Relevant, Timely Medical and Radiation Oncology News

Constant advancements in medical technology and healthcare regulations mean the oncology industry is dynamic and fast-changing. To keep clients on the leading edge of what's happening, Revenue Cycle Inc. maintains the news section of its website as a clearinghouse for oncology news, CPT® coding and/or business operations. Whether it's a legal change that could affect our industry or a tip about oncology coding, you'll find it here.

For more information about how our team of expert consultants can help your practice stay current on these industry changes, visit our medical and radiation oncology service page.

April 2016 Medical Oncology News

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InflectraTM (infliximab-dyyb)

Gigi Price, R.N., O.C.N., CHONC

Throughout the year, the FDA receives new data submitted by pharmaceutical manufacturers and research entities. After their intensive review of it, the FDA grants labeling changes to existing approved drugs, adds new indications for use, initiates an accelerated approval, proceeds with regular approval or decides more information is required from related research entities prior to granting approval for use in humans. The following is a synopsis of the new drug Inflectra, commonly provided in the Infusion setting. 

Inflectra is manufactured by Celltrion, Inc., based in Yeonsu-gu, Incheon, Republic of Korea, for Hospira, of Lake Forest, Illinois. Remicade® is marketed by Janssen Biotech, Inc., based in Horsham, Pennsylvania. It is the second company to receive approval of a biosimilar (a product similar to an FDA-approved drug) in the U.S. through the new FDA biosimilars pathway established under the Biologics Price Competition and Innovation Act. Recently, the FDA approved Inflectra, a biosimilar to Remicade, for multiple indications. The formulation of Inflectra differs from that of U.S.-licensed Remicade in one inactive component. The product is not yet available in the U.S. market due to ongoing patent litigation. Inflectra is utilized in:  

  • Adult patients and pediatric patients (ages six years and older) with moderately to severely active Crohn’s disease who have had an inadequate response to conventional therapy
  • Adult patients with moderately to severely active ulcerative colitis who have had an inadequate response to conventional therapy
  • Patients with moderately to severely active rheumatoid arthritis in combination with methotrexate
  • Patients with active ankylosing spondylitis (arthritis of the spine)
  • Patients with active psoriatic arthritis
  • Adult patients with chronic severe plaque psoriasis

Inflectra for injection is supplied in an accumulator carton containing 10 vials of 100 mg. Each single use vial contains 100 mg of infliximab-dyyb. Billing and coding includes the use of code Z51.12, indicating immunotherapy, followed by the diagnosis code. The CMS HCPCS update of April 6, 2016, indicated Q5102 per 10 mg will be effective July 1, 2016. More information can be found here.

Prior to July 1, 2016, it is best to check with individual payers for guidance when using the unclassified code J9999 chemotherapy or J3590 unclassified biologic, depending on payer requirements and the setting in which the drug is provided.

Keeping up-to-date with FDA approvals and accurate coding, and adhering to specific payer guidelines are important steps in every documentation and billing compliance plan. With timely staff education, proper documentation, and effective checks and balances, you can achieve your compliance goals. Revenue Cycle Inc. can help by implementing efficient processes. For more information regarding RCI’s services, please contact our consulting team at 512-583-2000.

April 2016 Radiation Oncology News

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Stereotactic Radiation Therapy Documentation

Adam Brown, BSRT(T), CMD

Stereotactic radiation therapy is a form of radiation therapy used to deliver higher doses of precisely targeted radiation in one to five fractions to small or uniquely positioned tumors, all while preserving surrounding healthy tissue. Two categories of stereotactic radiation therapy are typically used: stereotactic radiosurgery (SRS) or stereotactic body radiotherapy (SBRT). SRS is a non-surgical radiation therapy used to treat functional abnormalities and small tumors of the brain in one fraction. SBRT is used to treat body tumors and can range from one to five fractions.

With this advanced form of radiation therapy comes increased requirements for requesting and documenting the service. Over the years, stereotactic treatment has become increasingly common and questions regarding the requirements have followed suit. Nationwide, Revenue Cycle Inc. consultants are consistently questioned regarding stereotactic procedures and the documentation requirements necessary to support this advanced form of treatment. 

The following excerpt, which highlights just a few of the documentation requirements, can be found within the Noridian Healthcare Solutions local coverage determination (LCD) policy, Stereotactic Radiation Therapy: Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT) (L34151).

“The patient's record must support the necessity and frequency of treatment. The medical record must clearly indicate the critical nature of the anatomy or other circumstances necessitating the services. Medical records should include not only the standard history and physical but also the patient's functional status and a description of current performance status (Karnofsky Performance Status). See Karnofsky Performance Status listed under Indications and Limitation of Coverage and/or Medical Necessity above. 

Documentation should include the date and the current treatment dose. A radiation oncologist and a neurosurgeon must evaluate the clinical aspects of the treatment, and document and sign this evaluation as well as the resulting management decisions.

For CPT codes 77300 and 77334: Documentation must specify factors, such as, multiple isocenters, irregularity of target volume(s), proximity of critical structures or other reasons which justify the units of service for dosimetry or treatment devices. 

All documentation must be available upon request of the Medicare contractor.

When the documentation does not meet the criteria for the service rendered or the documentation does not establish the medical necessity for the services, such services will be denied as not reasonable and necessary under Section 1862(a)(1) of the Social Security Act.”

Thorough documentation processes should be maintained to ensure medical records meet payors’ documentation requirements for stereotactic radiation therapy. Bear in mind that the information above is an excerpt from one payor policy; similar information can be found in payor policies for other parts of the country, as well. 

Keeping your practice and facility on top of the latest updates and code changes can be a constant effort. For help, tap into Revenue Cycle Inc.’s online, 24/7 Client Resource Center for up-to-date, easily accessible news, resources and answers. For more information on an annual subscription and all of our consulting services, please contact us at