October 2018 Radiation Oncology News

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Industry News, October 2018

The summary of events and newsworthy items for the month of October is provided on the following pages.  In most instances, the link to the full document of information is provided for you.  Any of the contents may be further discussed by reaching out to Revenue Cycle Inc.  

340B Acquired Drug Payment is Final and Not Subject to Appeal

Wisconsin Physician Services released information for providers that drugs purchased under the 340B Drug Program and reimbursed at ASP -22.5% are final.  No administrative review is available for the drugs purchased under 340B program for hospitals (HOPPS).  Appeal requests about the reimbursement will be dismissed.

ASTRO Releases New Prostate Radiation Therapy Guidelines

ASTRO convened a task force to address several questions related to radiation therapy for prostate cancer.  After review of "high-quality" evidence, ASTRO indicated there was a strong consensus for offering moderate hypofractionation across risk groups choosing external beam radiation therapy.  As a result of the review, the task force conditionally recommends ultrahypofractionated radiation may be offered for low- and intermediate-risk prostate cancer but strongly encourages treatment of intermediate-risk patients on a clinical trial or multi-institutional registry.  For patients who are considered high-risk, the task force conditionally recommends against routine use of ultrahypofractionated external beam radiation therapy.  Additionally, the task force strongly recommended use of image guided radiation therapy (IGRT) and avoidance of nonmodulated 3D conformal technique.

The full text report can be found at https://www.practicalradonc.org/article/S1879-8500(18)30247-9/fulltext.

CMS Changes Local Coverage Determination Process

CMS received feedback about the Local Coverage Determination (LCD) process through the CY 2018 MPFS proposed rules by stakeholders and healthcare associations about the need and ways to modernize the whole process.  Much of the feedback was related to lack of ability for providers and stakeholders to provide feedback on LCDs, lack of non-physician representation on the Contractor Advisory Committee (CAC) and the fact the CAC meetings are not open to the public.

In 2016 the 21st Century Cares Act included changes to the LCD process.  Based on the all of the feedback and requirements by the Act, the following is a summary of some of the key changes, the full description can be found in MM10901 https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10901.pdf.

  • The New LCD Process may begin with informal meetings in which interested parties within the MAC's jurisdiction can discuss potential LCD requests.
  • The New LCD Request Process is a mechanism through which interested parties within a MAC's jurisdiction can request a new LCD.
  • During an LCD's development, MACs should (when applicable and available) supplement their research with clinical guidelines, consensus documents, or consultation by experts (recognized authorities in the field), medical associations or other health care professionals for an advisory opinion.
  • The CAC is to be composed of healthcare professionals, beneficiary representatives, and representatives of medical organizations; and is used to supplement the MAC's internal expertise, and to ensure an unbiased and contemporary consideration of "state of the art" technology and science. Additionally, all CAC meetings will be open to the public to attend and observe.
  • After the proposed LCD is made public, MACs will hold open meetings to discuss the review of the evidence and the rationale for the proposed LCD(s) with stakeholders in their jurisdiction.
  • The date the final LCD is published on the MCD, marks the beginning of the required notice period of at least 45 calendar days before the LCD can take effect.

One of the biggest changes from the standpoint of using the LCDs for determining coverage of services, is that the LCD itself will no longer contain CPT® or ICD-10-CM codes.  All codes are to be removed from LCDs and placed in billing and coding articles linked to the LCDs.

Full information can be found at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM10901.pdf

CMS Publishes Part B Drug Pricing, Medicare Programs: International Pricing Index Model for Medicare Part B Drugs

Medicare released a Part B drug price proposed ruling on October 23, 2018 which would align payments for select physician-administered drugs to levels more closely of those in other countries.  The expected overall savings is estimated to be approximately $17.2 billion over five years.  The entire 59 page proposed rule can be found at https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-23688.pdf.

CMS Activates System for Validating Edits under OPPS for Multiple Service Locations

CMS released MLN Matters SE18023 on October 12, 2018 to address hospitals operating multiple off-campus outpatient provider-based departments which may be in a different payment locale from the main provider.  The actual location of the off-campus outpatient provider-based department is used when determining payment rates under both MPFS and HOPPS.  When the location of services rendered differs from the location contracted or enrolled with Medicare this can create issues regarding reimbursement.

Medicare will be validating the service facility location to ensure the services are being provided in the Medicare enrolled location.  The validation will consist of matching claim forms to the enrollment application addresses to ensure compliance and appropriate reimbursement is applied per the services rendered.  The full transmittal can be found at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE18023.pdf.

Study Gives All Clear for Skin Cream During Radiation Therapy

Recent study published in JAMA Oncology indicated patients scheduled for radiation therapy are OK to apply skin creams in moderation before procedures.  The study asked providers how many tell patients to avoid topical agents, and of the nearly 105 respondents, 91% of physicians and nurses stated they advised against skin creams before radiation treatments.

In a study which placed OSLDs on the skin, one with nothing on it, one with Aquaphor and one with silver sulfadiazine cream; the results showed there was no increase in absorbed radiation dose as measured by the dosimeters.  The study was repeated with varying thicknesses of the creams applied and there was no increase in dose at the surface for the thick layer of cream.  There was however some increase for a very thick layer of the topical agent.  This leads to the advisement that skin creams prior to radiation therapy procedures are OK if used in moderation.

October Coding Corner

Within this section, current topics will be the focus.  In some cases, the Q&A could reflect common questions received by Revenue Cycle Inc. and in other cases, represent current issues encountered by Revenue Cycle Inc. professionals.

Question:  Is it possible to charge 77417 once per five treatments for non-IGRT palliative cases where planning charges billed were either 77306 or 77307?

Advice: Yes, port images are an option when the course is 2D or even 3D courses when there is not IGRT performed.

Question:  Is there a charge for the smit sleeve?  The physician inserts it in the OR at the time of the T&O insertion.

Advice:  The smit sleeve is a supply and not considered a billable device like the T&O applicator.