November 2018 Radiation Oncology News

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Industry News, November 2018

The summary of events and newsworthy items for the month of November 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.  

New Medicare Payment Models to be Released Soon

CMS indicated that new alternative payment models (APMs) are expected to be released by the end of 2018 or very early in 2019.  This is important for radiation oncologists to be aware of as CMS also indicated the week after the release of the CY 2019 MPFS final rule that a mandatory radiation oncology payment model would be released soon.  The APMs apply to reimbursement under the Medicare Physician Fee Schedule (MPFS).   

The APM for radiation oncology, as indicated by CMS, would be mandatory and expected to begin January 1, 2020.  This would be the answer to how radiation therapy treatments and IGRT are reimbursed in the future when the G-codes currently used for billing purposes expire December 31, 2019.  Stay tuned for more information!

FDA Approves Rituximab Biosimilar for Non-Hodgkin Lymphoma

The FDA approved the first rituxib biosimilar (rituximab-abbs, Truxima) earlier this month for treatment of adults with CD20-positive B-cell non-Hodgkin lymphoma (NHL).  The biosimilar biological can be used as a single agent or in combination with chemotherapy.

The FDA approval covered the following indications for rituximab-abbs:

  • Single-agent treatment of relapsed or refractory, low grade or follicular lymphoma
  • Combination therapy for previously untreated follicular lymphoma, followed by single-agent maintenance for patients who achieve a partial or complete response
  • Single-agent treatment of nonprogressing, low-grade, NHL after first-line chemotherapy

Of note, rituximab-abbs received approval "as a biosimilar, not as an interchangeable product" for the original rituximab (Rituxan) made by Roche's Genentech unit.  Additionally, this does not include many of the other indications that Rituxan is approved for which includes chronic lymphocytic leukemia (CLL), rheumatoid arthritis and other indications.

Wisconsin Physician Services Updates Drug Administration Coding Article

Medicare Administrative Contractor (MAC) Wisconsin Physician Services (WPS) has an updated Article, Drug Administration Coding (A54176) effective December 1, 2018.  The newest changes to the Article include, adding code J3490 OnpattroTM (patisiran) and NOC verbiage for billing and coding guidelines for guidance.

It is important to be aware of the billing guidelines provided by the individual MACs for drugs administrations.  The MACs will identify which drugs they consider to be chemotherapy drugs for billing purposes and which are not and many time this will vary between the MACs.  The Article can be found at, https://www.cms.gov/medicare-coverage-database/details/article-details.aspx?articleId=54176&ContrId=147 For providers under the WPS Jurisdictions the following is provided for reference:

The list below is not an all-inclusive list and may be subject to further revision.

The administration of the following drugs should not be billed using a chemotherapy administration code. Instead, the administration of the following drugs in their subcutaneous forms should be billed using CPT code 96372, (therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular). For the drugs that are administered IV the CPT codes for IV injection/infusion should be used codes 96365-96368 and 96374-96375.

 

Generic Name

Trade Name

HCPCS Code

abatacept

Orencia ®

J0129

bezlotoxumab

ZinplavaTM

J0565

canakinumab

Ilaris®

J0638

certolizumab pegol  

Cimzia®

J0717

denosumab

Prolia/Xygeva®  

J0897

eculizumab

Soliris®

J1300

edaravone

Radicava®

J3490

golimumab

Simponi aria®

J1602

mepolizumab

Nucala®

J2182

natalizumab

Tysabri

J2323

omalizumab

Xolair®

J2357

patisiran

 OnpattroTM

J3490

reslizumab

Cinqair®

J2786

rilonacept

Arcalyst®

J2793

tocilizumab

Actemra®

J3262

ustekinumab

Stelara®

J3357 for subcutaneous injection

ustekinumab

Stelara®

J3358 for intravenous injection

vedolizumab

Entyvio®

J3380

 

Palmetto GBA Updates Single Use Vial/Package Drug Waste Billing and Coverage

Palmetto GBA, Medicare Administrative Contractor, released notification of the update to billing and coverage guidelines for single use vial/package drug waste.  According to their website, Palmetto GBA will consider payment for the unused and discarded portion of a single-use drug/biological product, including single dose vial or single dose preparation of radiopharmaceuticals, after administration of the appropriate (reasonable and necessary) dosage for the patient's condition.

Palmetto is applying this to all drugs, even those considered Not Otherwise Classified.  In order for the waste to be reimbursed by CMS, modifier JW must be applied to the waste portion of the drug on the billing claim form.  Additionally, the drug waste must be documented in the patient's medical record with the date, time and quantity wasted.  If there are any discrepancies in the documentation between what was administered and what was billed, the billed amount will be denied, unless the drug wastage is clearly documented.  The drug waste cannot be administered to another patient and billed again to CMS.

OIG Releases Report of Improper Payments by Novitas for Radiation Therapy Services

The Office of Inspector General (OIG) released a report of findings under both Novitas Jurisdictions (H and L) of improper payments for services which they considered not separately billable and part of the IMRT plan (77301).  In review of report released by the OIG, the services were reviewed during CYs 2013 - 2015.  During this time there were policies in place by Novitas which allowed for billing for of some of these services when the course was IMRT. 

As identified in the OIG report, https://oig.hhs.gov/oas/reports/region2/21601006.asp, the OIG considers "simulations" to be included in IMRT planning as stated in other Medicare guidelines.  However, the Medicare guidelines do not differentiate as to which simulation is referenced in the transmittals as include in IMRT, from the report it appears the OIG interprets the simulation to be the initial simulation.   Interpretation by providers and industry experts has attributed the simulation referred to as the computer-aided simulation. 

When the transition to CT-based imaging for treatment planning happened, the work traditionally performed in the conventional simulator with fluoro and hard films now occurred in dosimetry on the computer.   It was understood this simulation process was not separately billable from the 3-D or IMRT treatment plan, but the initial simulation which is separate and used for treatment delivery, was still billable.

In CY 2013 Novitas had an LCD, Radiation Therapy Services (L27515), which was retired October 31, 2013 in preparation for the transition to ICD-10.  Beginning in CY 2016
Novitas had a new LCD, Intensity Modulated Radiation Therapy (IMRT) (L36711), which covered both Jurisdictions H and L.  The LCD in 2013 only covered Jurisdiction L and indicated the initial simulation as well as a verification simulation were billable, but only one immobilization device was billable per volume of interest.  The LCD which began in 2016, and is current now, only mentions the IMRT specific codes and refers to verification simulation and then the initial simulation as part of the process and that some services may be included in services and to refer to the Documentation Requirement Section of the LCD.

The report indicates Medicare overpaid a little more than $7 million dollars for the services reviewed.  Some of these findings included billing for immobilization devices, one case was a complex device and two intermediate devices, continuing physics services with code 77336 and simulation services prior to the IMRT plan.  Per the report it appears the OIG will also be reviewing other MACs and providers to identify overpayments.  The time period of review is prior to the CMS changes which further clarified which services were bundled into the IMRT plan in CY 2016.  In the years prior to CY 2016 there were many different transmittals and guidelines for providers from the individual MACs regarding services which were considered billable.

November 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:  CPT® 57156 can both the facility and the physician bill this code in an Outpatient hospital setting for HDR?

Advice: Yes, each entity can report the placement code for each brachytherapy fraction of treatment when the applicator is inserted into the patient.  Documentation is needed to support this work.

Question:  What documentation is needed for charging 77338 code?

Advice:  Either use documentation from the IMRT plan of the planned device or the fluence distribution from the QA.  Either one must be approved by the physician prior to treatment and whichever is used for documentation it is recommended to use consistently for all patients.

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