2016 billing and coding update for radiation & medical ... billing... · 2014 cpt code 2015...

2016 Billing and Coding Update for Radiation & Medical Oncology

January 29, 2016ACE

Copyright © 2016 RCI All Rights Reserved. Do Not Duplicate. Work product, information & guidance provided by RCI are subject to the terms & limitations provided at http://www.revenuecycleinc.com/disclaimer.

Contact Information

Revenue Cycle Inc.1817 W. Braker Lane

Bldg. F, Suite 200Austin, Texas 78758

www.revenuecycleinc.com(512) 583-2000


PresenterSally Eggleston, MBA, BSRT(T)VP Revenue Cycle Inc.


Disclaimer

This presentation was prepared as a tool to assist attendees in learning about documentation, chargecapture and billing processes. It is not intended to affect clinical treatment patterns. While reasonableefforts have been made to assure the accuracy of the information within these pages, the responsibilityfor correct documentation and correct submission of claims and response to remittance advice lies withthe provider of the services. The material provided is for informational purposes only.

Efforts have been made to ensure the information within this document was accurate on the date ofpresentation. Reimbursement policies vary from insurer to insurer and the policies of the same payormay vary within different U.S. regions. All policies should be verified to ensure compliance.

CPT® codes, descriptions and other data are copyright 2016 American Medical Association (or suchother date of publication of CPT®). All Rights Reserved. CPT® is a registered trademark of theAmerican Medical Association. Code descriptions and billing scenarios are references from the AMA,CMS local and national coverage determinations (LCD/NCD), the ASTRO/ACR Guide to RadiationOncology Coding, the ACRO Practice Management Guide and common practice standards nationwide.


Objectives

Basic Review of HOPPS and MPFSBasic Review of HOPPS and MPFS

• Final Rule Items• Final Payment Rates

MPFSMPFS

• Final Rule Items• Final Payment Rates

HOPPSHOPPS

• New Brachytherapy Codes• Provider Based Department Changes• Codes 77295 and 77300 in 2016

Coding Changes Impacting CY 2016Coding Changes Impacting CY 2016

Q&AQ&A


HOPPS and MPFS Payment Systems

HOPPS• Payments based on costs• Adjusted by a wage index• Grouped into APC’s• Example : Tx Devices

– 77332, 77333 and 77334• Historically the same

payment rate under HOPPS• Changed for 2016

MPFS• Codes have RVUs • CF is applied to all RVUs• GPCI’s• Codes can be split into Global, TC,

26 payment• Example: Tx Devices

– 77332, 77333, 77334• Historically different payment

rates under MPFS


Billing Scenarios

Hospital Outpatient

Technical Services

UB04

Physician Services (-26)

CMS 1500

Freestanding Facility

Global Billing

Pro & Tech Services CMS1500

Split Billing

Physician Services (-26)

CMS 1500

Technical Services (TC)

CMS 1500


Annual Updates to Rules

Hospital Outpatient: Hospital Billing

Technical Charges

Hospital Outpatient: Hospital Billing

Technical ChargesPhysician/Facility:

Physician Practicing in a Hospital Setting &

Freestanding Facilities

Physician/Facility: Physician Practicing in a

Hospital Setting & Freestanding Facilities

http://www.gpoaccess.gov/index.html

• Stay up to date• Stay informed• Get involved


Proposed vs. Final

ProposedCMS’s plan, intent, thoughts for rules, regulations and reimbursement for upcoming year

FinalDetermined after consideration and debate occurs based on comments received

Proposed Rules Consideration of Comments Final Rule


MEDICARE PHYSICIAN FEE SCHEDULE (MPFS)

2016 Final Rule


Conversion Factor (CF) Update• The Medicare Access and CHIP Reauthorization Act of 2015

(MACRA) put into law April 16, 2015– Repealed sustainable growth rate (SGR)– Revised and established PFS updates for several years– Established a Merit-based Incentive Payment System (MIPS)

• CY 2016 CF proposed to be $36.1096 & finalized at $35.8279 – 0.5% increase over CY 2015 CF of $35.9335, but…– Decrease of Budget Neutrality Factor– Decrease of Target Recapture Amount– BUT WAIT!...CMS published MPFS correction notice on

1/5/16 new conversion factor 2016 CF = $35.8043Copyright © 2016 RCI All Rights Reserved. Do Not Duplicate.

Work product, information & guidance provided by RCI are subject to the terms & limitations provided at http://www.revenuecycleinc.com/disclaimer.

Calculating Conversion Factor• Budget Neutrality keeps CMS budget in expected range, factor

subtracted from CF of 2015 + the 0.5% update factor• Target Recapture Amount

– Factor applied if due to misvalued codes in previous years, expenditure reduction does not meet the 1% target

– Pathology had high number of misvalued codes that are now impacting reimbursement for all specialties in 2016


New 2016 Conversion Factor = $35.8043!

MPFS Equation

Work RVU * Work GPCI

PE RVU * PE GPCI

MP RVU * MP GPCI

Conversion Factor+ + *

Physician work

provided per service

Practice expense, overhead etc. for service

Malpractice is

professional liability

insurance

Used to convert

RVUs into $$$

GPCI = Geographic Practice Cost Index (adjusts each different type of RVU) for a particular locality in the country


MPFS Payment Impact Table

TABLE 62: CY 2016 PFS Estimated Impact on Total Allowed Charges by Specialty*

(A)Specialty

(B) AllowedCharges (mil)

(C)Impactof Work

RVUChanges

(D)Impact

of PERVU

Changes

(E)Impactof MPRVU

Changes

(F)Combined

Impact**

Radiation Oncology $1,776 0% -2% 0% -2%

Radiation Therapy Centers $52 0% -2% 0% -1%

** Column F may not equal the sum of columns C, D, and E due to rounding.

Proposed conversion to AMA CPT codes was not finalized, G-codes continued, this will decrease the overall negative impact from what was proposed.


Global RVU Changes Snapshot


Service Description TOTAL NON-FACILITY RVUs

HCPCS DESCRIPTION 2015 RVU Totals2016 RVU Totals Diff

77263 Radiation therapy planning 4.64 4.68 0.04 77280 Set radiation therapy field 7.59 7.71 0.12 77285 Set radiation therapy field 11.96 12.16 0.20 77290 Set radiation therapy field 14.29 14.54 0.25 77295 3-d radiotherapy plan 13.68 13.85 0.17 77300 Radiation therapy dose plan 1.77 1.88 0.11 77301 Radiotherapy dose plan imrt 54.29 55.16 0.87 77306 Telethx isodose plan simple 4.07 4.22 0.15 77307 Telethx isodose plan cplx 7.97 8.15 0.18 77316 Brachytx isodose plan simple 5.22 5.33 0.11 77317 Brachytx isodose intermed 6.83 6.94 0.11 77318 Brachytx isodose complex 9.87 10.01 0.14 77321 Special teletx port plan 2.58 2.62 0.04 77331 Special radiation dosimetry 1.79 1.80 0.01 77332 Radiation treatment aid(s) 2.31 2.34 0.03 77334 Radiation treatment aid(s) 4.26 4.31 0.05 77338 Design mlc device for imrt 14.15 14.34 0.19 77427 Radiation tx management x5 5.22 5.24 0.02 77431 Radiation therapy management 2.86 2.88 0.02 77432 Stereotactic radiation trmt 11.71 11.81 0.10 77435 Sbrt management 17.67 17.81 0.14 77470 Special radiation treatment 4.36 4.41 0.05 77778 Apply interstit radiat compl 24.43 22.04 (2.39)G6002 Stereoscopic x-ray guidance 2.1 2.12 0.02 G6012 Radiation treatment delivery 6.37 7.42 1.05 G6013 Radiation treatment delivery 7.17 7.43 0.26 G6015 Radiation tx delivery imrt 11.19 9.70 (1.49)G6016 Delivery comp imrt 11.16 9.67 (1.49)

2015 - 2016 MPFS Global Compare


CY2015 Final Rule MPFS Global Non-Facility Course Compare

Type 2015 Global - CF = $35.9335

2016 Global - CF = $35.8043

2015 - 2016 Variance

Global GLOBAL % Change

2D 10 fxs $4,961.34 $5,228.50 $267.16 5%

3D w/IGRT 35 fxs $16,948.39 $18,119.84 $1,171.45 7%

IMRT 42 fxs $25,723.71 $23,522.71 -$2,201.01 -9%

SRS - Linac $5,039.67 $4,452.62 -$587.05 -12%

SBRT Linac 5 Fxs $10,848.32 $10,480.63 -$367.69 -3%

Prostate - HDR $5,066.98 $5,307.27 $240.29 5%

Prostate - LDR $3,364.09 $3,157.94 -$206.16 -6%

GYN T&O - HDR $5,138.13 $5,309.42 $171.29 3%

GYN Cyl 1 Chan HDR $4,750.05 $5,138.63 $388.58 8%

GYN Multi Chan HDR $6,258.54 $6,592.65 $334.11 5%

Potentially Misvalued Codes• High expenditure screening tool identified codes which may be potentially

misvalued.

• Codes have not been reviewed since 2009 or earlier and have a significant impact on PFS payments at a specialty level, >$10 million allowed charges.

TABLE 8: List of Potentially Misvalued Codes Identified Through High Expenditure by Specialty Screen

HCPCS Short Descriptor31575 Diagnostic laryngoscopy77263 Radiation therapy planning77334 Radiation treatment aid(s)77470 Special radiation treatment


Treatment Delivery Coding in CY 2016

• Implementation of AMA codes delayed again for MPFS– Treatment delivery and image guidance codes will continue to be

reported with CMS created G-codes• CMS indicated new IMRT tx codes were good based on diagnosis

compared to single code to encompass all IMRT services.• The overall high potential impact to reimbursement for IMRT courses

major reason for delay.• Seeking more information and input to value codes in future• CMS is engaging market research to develop independent estimates

on utilization of linear accelerators and image guidance used to deliver radiation treatments to patients

• CMS to review how to collect data from hospital based systems to assist in establishing rates for txs and other technical services


Treatment Delivery Coding 2016 cont.

• Before accurate rates can be developed following changes needed, per CMS– “Developing a code set that recognizes the difference in

costs between kinds of imaging guidance modalities; – Making sure that this code set facilitates valuation that

incorporates the cost of imaging based on how frequently it is actually provided; and

– Developing treatment delivery codes that are structured to differentiate payment based on the equipment resources used.”

• Table on following slide outlines the G-codes to use for MPFSCopyright © 2016 RCI All Rights Reserved. Do Not Duplicate.


2014 CPT Code 2015 & 2016 MPFS

Code2015 & 2016 Description

77014 (IGRT) 77014 Computed tomography guidance for placement of radiation therapy fields77401 77401 Radiation treatment delivery, superficial and/or orthovoltage, per day76950 G6001 Ultrasonic guidance for placement of radiation therapy fields77421 G6002 Stereoscopic X-ray guidance for localization of target volume for the delivery of radiation therapy

77402 G6003 Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks; up to5 MeV

77403 G6004 Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks; 6-10 MeV

77404 G6005 Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks; 11-19 MeV

77406 G6006 Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks; 20 MeV or greater

77407 G6007 Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks; up to 5 MeV

77408 G6008 Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks; 6-10 MeV

77409 G6009 Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks; 11-19 MeV

77411 G6010 Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks; 20 MeV or greater

77412 G6011 Radiation treatment delivery, 3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; up to 5 MeV

77413 G6012 Radiation treatment delivery, 3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 6-10 MeV

77414 G6013 Radiation treatment delivery, 3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 11-19 MeV

77416 G6014 Radiation treatment delivery, 3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 20 MeV or greater

77418 G6015 Intensity modulated treatment delivery, single or multiple fields/arcs, via narrow spatially and temporally modulated beams, binary, dynamic MLC, per treatment session

0073T G6016 Compensator-based beam modulation treatment delivery of inverse planned treatment using 3 or more high resolution (milled or cast) compensator convergent beam modulated fields, per treatment session

0197T G6017 Intra-fraction localization and tracking of target or patient motion during delivery of radiation therapy (eg, 3D positional tracking, gating, 3D surface tracking), each fraction of treatment


Reimbursement Snapshot of TXs 2016


HCPCS Description2015 Final Payment

Rate (CF $35.9335)

2016 Final Payment Rate (CF$35.8043)

Variance % Change

77401 Radiation treatment delivery $ 20.84 $ 24.35 $ 3.51 16.8%

G6004 Radiation treatment delivery $ 125.77 $ 145.72 $ 19.96 15.9%




G6015 Radiation tx delivery imrt $ 402.10 $ 347.30 $ (54.79) -13.6%

G6016 Delivery comp imrt $ 401.02 $ 346.23 $ (54.79) -13.7%

Image guidance• On-board imaging calculated as part of capital expense of treatment

machines, could not accurately calculate separately for image guidance codes per the RUC data.

• Time value of image guidance was accepted as correct, 16 minutes total at time of treatment.– 3 mins pre-service, 10 mins intraservice and 3 mins post service

• The RUC assumed the most used imaging code was 77014, when setting values for 77387 it used these values– Most used imaging code was 77421 with lower RVUs

• CMS did not agree with imaging bundled into IMRT txs and then allowing imaging to be billed with 3D txs. Creates issues with the hierarchy of codes; 3D would be higher than IMRT if it was accepted

• As a result, image guidance codes for 2016 are 77014 and G-codesCopyright © 2016 RCI All Rights Reserved. Do Not Duplicate.


Equipment Utilization Rate for Linear Accelerators• Capital equipment cost is the primary determining factor in payment

rates for treatment delivery.• Estimated Cost = # mins of equipment use x per minute cost of

equipment• CMS has two default equipment usage assumptions 50% and 90%

– Rad Onc default calculation• Typical business hours10 hrs/day x 5 days/week = 50 hour

work week, 50% of that = 25 hrs/week that linacs are used for treatment

• CMS claims data supports single linac used 11.2 hrs/day or 7 out of 10 business hrs/day, not 5 of 10 hrs/day

• A 45% aggregate time increase in utilization over current default


Equipment Utilization Rate for Linear Accelerators cont.• Treatment times had issues

– The RUC stated IMRT is 60 mins/treatment– Data and public info said IMRT is 5-30 mins/treatment

• CMS adjusting utilization for Rad Onc from 50% to 70% over 2 years– CMS calculated utilization to be higher, but limiting the increase to

only 70%, rather than the 90% used for Diagnostic Radiology – Increase to 60% in 2016 and increase to 70% in 2017– Increase in utilization = decrease in Practice Expense (PE) RVUs =

potential decrease in payment for treatments• This is reason for overall negative impact in 2016


Superficial Radiation Treatment Delivery

• CMS did not make major changes as requested per comments. Feedback was conflicting

• Considering creating a code to describe the work associated with code 77401 due to all other codes bundling into tx– CMS is seeking input

• CMS did finalize equipment is now named “superficial radiation therapy system”

• Equipment pricing raised from $140,000 to $216,000


Incident to Changes• CMS finalizing changes to incident to definition and guidelines.• Incident to services continue to require direct supervision of auxiliary

personnel providing the service by physician or NPP• CMS adjusting language to include supervising is billing physician

– “To be certain that the incident to services furnished to a beneficiary are in fact an integral, although incidental, part of the physician’s or other practitioner’s personal professional service that is billed to Medicare, we believe that the physician or other practitioner who bills for the incident to service must also be the physician or other practitioner who directly supervises the service. It has been our position that billing practitioners should have a personal role in, and responsibility for, furnishing services for which they are billing and receiving payment as an incident to their own professional services.”

• Statement matches attestation statement on back of CMS1500 claim form


Incident to Changes cont.

• Revising last sentence from what was proposed to state, – “that the physician (or other practitioner) supervising the

auxiliary personnel need not be the same physician (or other practitioner) treating the patient more broadly.”

• Also stating the following,– “that only the physician or other practitioner under whose

supervision the incident to service(s) are being provided is permitted to bill the Medicare program for the incident to services.”


Incident to Changes cont.

• Auxiliary personnel who have been excluded from Medicare, Medicaid and all other federally funded health care programs by the OIG cannot provide services under incident to (direct supervision) of the physician

• “As a condition of Medicare payment, auxiliary personnel who, under the direct supervision of a physician or other practitioner, provide incident to services to Medicare beneficiaries must comply with all applicable federal and state laws. This includes not having been excluded from Medicare, Medicaid and all other federally funded health care programs.”


Biosimilar Biological Products• Created by using living cells that treat disease by genetically modifying the

cells being treated– Due to the size and complexity of the molecules, highly sensitive in the

manufacturing process and how they are handled. – Generic drugs follow a known recipe that is typically comprised of

standard ingredients. – A biosimilar is trying to match the outcome of an already known and FDA

approved drug, but the make-up of the biosimilar is different than the biologic. They are both made to achieve the same outcome with different recipes.

• Approval process can be lengthy since clinical trials must be run to prove the outcome matches the known biologic. Generic drugs are approved based simply on the fact the chemical structure matches the biologic it is replacing.


Biosimilar Licensing

• Affordable Care Act – reduced pathway for licensing for biosimilar products established– Allows proposed biological product demonstrated to be

biosimilar to a reference product can rely on certain existing scientific knowledge about the safety, purity, and potency of the reference product to support licensure

– Also defined payment methodology & outlined in CY 2011 MPFS final rule

– Provide for Medicare payment of biosimilar biological products using the average sale price (ASP) methodology


Biosimilar Approvals

• Section 1847A(b) of the Affordable Care Act was also amended by adding a new paragraph to specify the payment amount for a biosimilar biological product will be the sum of the ASP and 6% of the payment amount determined using the methodology in section 1847A(b)(4) of the Act for the corresponding reference biological product.

• Effective date was July 1, 2010 – at time unsure of FDA pathway for approvals or when one would be approved

• March 6, 2015 FDA approved first biosimilar product– CMS expects additional ones to be approved


Need For Review• As the biosimilars are emerging, CMS has reviewed the existing

guidance on payment and realized potential inconsistencies between the interpretation of the statutory language

• Comments received pertinent to the proposed changes were received from individuals, pharmaceutical manufacturers, patient advocate groups, providers and members of the House of Representatives

• Many requested a different payment amount for each biosimilar product and recommendations were made to be mindful of the policy as the marketplace evolves


Proposed Rule Comments

• Commenters expressed concern over the appropriate clinical use of the drugs and medical recordkeeping issues that might result

• CMS responded that these concerns were outside the scope of the final rule

• CMS did indicate they were not aware of provider confusion resulting from the drug groupings and provided an example– HCPCS J3489 includes drugs Reclast, Zometa and

generic versions of both zoledronic acid products


Finalized Amendments

• CMS has finalized the proposal to amend the regulation text and specify the payment amount will be based on the ASP of all NDCs assigned to the biosimilar biological products included within the same billing and payment code– Effective January 1, 2016

• CMS indicated due to the similarity biosimilars share with their reference products, they should be priced in groups similar to how multiple source or generic drugs are priced

• CMS will have the discretion to calculate the ASP-based payment for grouped biosimilars in same manner and methodology used for grouped multiple drugs


Biosimilar Payments• New payments for approved biosimilars will be determined by

involving the receipt of the manufacturers’ ASP sales data through the ASP data submission process and publication of national payment amounts consistent with pricing for other drugs and biologicals

• CMS anticipates biosimilar products will have lower ASP than corresponding reference products = Medicare savings

• As of final rule release CMS had not received ASP data for any biosimilars approved under FDA’s biosimilar approval pathway

• CMS unaware of how many biosimilar products will be approved, expects some degree of savings to be realized


MPFS NON-FACILITYCY 2016 Reimbursement Rates with $35.8043 CF



$-

$100.00

$200.00

$300.00

$400.00

$500.00

$600.00

77280 77280-TC 77280-26 77285 77285-TC 77285-26 77290 77290-TC 77290-26

MPFS Simulation

2015 Final Payment Rate (CF $35.9335) 2016 Final Payment Rate (CF$35.8043)


$-

$100.00

$200.00

$300.00

$400.00

$500.00

$600.00

77332 77332-26 77333-TC 77334 77334-26 77338-TC

MPFS Treatment Devices



$1.00

$10.00

$100.00

$1,000.00

$10,000.00

MPFS Dosimetry



$-

$20.00

$40.00

$60.00

$80.00

$100.00

$120.00

$140.00

$160.00

$180.00

77331 77331-TC 77331-26 77336 77370 77470 77470-TC 77470-26

MPFS Special Dosimetry, Physics & Special Trmt Procedure



$-

$50.00

$100.00

$150.00

$200.00

$250.00

$300.00

$350.00

$400.00

$450.00

77401 G6004 G6008 G6012 G6013 G6015 G6016

MPFS Treatment Delivery - EBRT & IMRT



$-

$200.00

$400.00

$600.00

$800.00

$1,000.00

$1,200.00

$1,400.00

$1,600.00

77372 77373

MPFS Stereotactic Treatment Delivery - SRS & SBRT



$-

$100.00

$200.00

$300.00

$400.00

$500.00

$600.00

$700.00

77427 77431 77432 77435

MPFS Physician Treatment Management



$-

$20.00

$40.00

$60.00

$80.00

$100.00

$120.00

$140.00

77014 77014-26 G6001-TC G6002 G6002-26

MPFS Image Guidance


2016 MPFS Medical Oncology Rates


HCPCS Code Short Descriptor

Non-Facility Payment Rate Facility Payment Rate Non-Facility

VarianceFacility

Variance2015 Final 2016 Final 2015 Final 2016 Final36415 Routine venipuncture $0.00 $0.00 $0.00 $0.00 $0.00 $0.0036430 Blood transfusion service $35.21 $35.09 $35.21 NA -$0.13 $0.0036591 Draw blood off venous device $23.72 $23.63 $23.72 NA -$0.09 $0.0036593 Declot vascular device $31.26 $31.51 $31.26 NA $0.25 $0.0038220 Bone marrow aspiration $167.81 $167.56 $63.60 $63.37 -$0.25 -$0.2338221 Bone marrow biopsy $171.04 $170.43 $77.62 $76.98 -$0.61 -$0.6496360 Hydration iv infusion init $58.21 $57.64 $58.21 NA -$0.57 $0.0096361 Hydrate iv infusion add-on $15.45 $15.40 $15.45 NA -$0.06 $0.0096365 Ther/proph/diag iv inf init $70.43 $69.82 $70.43 NA -$0.61 $0.0096366 Ther/proph/diag iv inf addon $19.04 $18.98 $19.04 NA -$0.07 $0.0096367 Tx/proph/dg addl seq iv inf $30.54 $30.79 $30.54 NA $0.25 $0.0096368 Ther/diag concurrent inf $20.84 $20.77 $20.84 NA -$0.07 $0.0096372 Ther/proph/diag inj sc/im $25.51 $25.42 $25.51 NA -$0.09 $0.0096374 Ther/proph/diag inj iv push $57.49 $57.29 $57.49 NA -$0.21 $0.0096375 Tx/pro/dx inj new drug addon $22.64 $22.56 $22.64 NA -$0.08 $0.0096376 Tx/pro/dx inj same drug adon $0.00 $0.00 $0.00 $0.00 $0.00 $0.0096401 Chemo anti-neopl sq/im $75.46 $75.19 $75.46 NA -$0.27 $0.0096402 Chemo hormon antineopl sq/im $32.70 $32.58 $32.70 NA -$0.12 $0.0096409 Chemo iv push sngl drug $111.75 $111.71 $111.75 NA -$0.04 $0.0096411 Chemo iv push addl drug $62.52 $62.66 $62.52 NA $0.13 $0.0096413 Chemo iv infusion 1 hr $136.55 $136.41 $136.55 NA -$0.13 $0.0096415 Chemo iv infusion addl hr $28.39 $28.64 $28.39 NA $0.26 $0.00

Medical Oncology Rates cont.


HCPCS Code Short Descriptor

Non-Facility Payment Rate Facility Payment Rate Non-Facility

VarianceFacility

Variance2015 Final 2016 Final 2015 Final 2016 Final

96416 Chemo prolong infuse w/pump $141.58 $141.79 $141.58 NA $0.21 $0.00

96417 Chemo iv infus each addl seq $63.24 $63.02 $63.24 NA -$0.23 $0.0096450 Chemotherapy into cns $184.34 $184.03 $82.29 $82.35 -$0.30 $0.0696521 Refill/maint portable pump $139.42 $139.28 $139.42 NA -$0.14 $0.0096523 Irrig drug delivery device $25.15 $25.06 $25.15 NA -$0.09 $0.0099195 Phlebotomy $101.69 $100.97 $101.69 NA -$0.72 $0.00G0364 Bone marrow aspirate &biopsy $12.58 $12.53 $8.98 $8.95 -$0.05 -$0.0399201 Office/outpatient visit new $44.20 $44.04 $26.95 $26.85 -$0.16 -$0.1099202 Office/outpatient visit new $75.46 $75.19 $50.67 $50.84 -$0.27 $0.1899203 Office/outpatient visit new $109.60 $108.85 $77.98 $77.70 -$0.75 -$0.2899204 Office/outpatient visit new $166.73 $166.13 $131.88 $131.40 -$0.60 -$0.4799205 Office/outpatient visit new $209.49 $208.38 $171.40 $170.79 -$1.11 -$0.6299211 Office/outpatient visit est $20.12 $20.05 $9.34 $9.31 -$0.07 -$0.0399212 Office/outpatient visit est $44.20 $43.68 $25.87 $25.42 -$0.52 -$0.4599213 Office/outpatient visit est $73.30 $73.40 $51.38 $51.56 $0.09 $0.1799214 Office/outpatient visit est $108.88 $108.13 $79.41 $79.13 -$0.75 -$0.2999215 Office/outpatient visit est $146.97 $145.72 $112.83 $112.07 -$1.24 -$0.76

HOSPITAL OUTPATIENT PROSPECTIVE PAYMENT SYSTEM (HOPPS)

2016 Final Rule


HOPPS Payments • After last few years of increases, decrease in overall

payments for hospitals of -0.3%• Continue 2% adjustment for hospitals who fail to meet

the hospital Outpatient Quality Reporting (OQR) requirements

• Cancer Hospital Payment Adjustment – continue to provide payment-to-cost ratio (PCR) = 0.92 for each of 11 specified cancer hospitals


Payment for Hospital Outpatient Visits

• G0463 (clinic visit) moving from APC 0634 to APC 5012• APC 5012 will continue to be base setting APC for all other

APCs• G0463 is the most frequently furnished service in the

hospital outpatient settingHCPCS Code

Short Descriptor2015 APC

2015 Nat. Avg.

Payment2016 APC

2016 Nat. Avg.

PaymentVariance

G0463 Hospital outpt clinic visit 0634 $96.22 5012 $102.12 6%


APC Restructuring• Finalized restructuring of APCs into 9 individual clinical families

and based on the following principles:– Improved clinical homogeneity;– Improved resource homogeneity;– Reduced resource overlap in APCs within a clinical family;

and– Greater simplicity and improved understanding of the

structure of the APCs. • APCs also renumbered to provide consecutive APC numbers

within a clinical family. • Every code in same APC is reimbursed the same amount,

regardless of complexity or modality.Copyright © 2016 RCI All Rights Reserved. Do Not Duplicate.


New CY 2016 APC Number

New CY 2016 APC Title HCPCS Codes in APC

5611 Level 1 Therapeutic Radiation Treatment Preparation 77299, 77300, 77316, 77331, 77332, 77336 & 77399

5612 Level 2 Therapeutic Radiation Treatment Preparation 77280, 77306, 77333 & 77370

5613 Level 3 Therapeutic Radiation Treatment Preparation 77285, 77290, 77307, 77317, 77318, 77321, 77334 & 77338

5614 Level 4 Therapeutic Radiation Treatment Preparation 32553, 49411, 55876, 77295, 77301 & C9728

5621 Level 1 Radiation Therapy 77401, 77402, 77407, 77789 & 77799

5622 Level 2 Radiation Therapy 0394T, 77412, 77422, 77600, 77750, 77767 & 77768

5623 Level 3 Radiation Therapy 77385, 77386, 77423, 77470, 77520, 77610, 77615, 77620, 77761 & 77762

5624 Level 4 Radiation Therapy 0395T, 77605, 77763, 77770, 77771, 77772 & 77778

5625 Level 5 Radiation Therapy 77522, 77523 & 77525

5626 Level 6 Radiation Therapy 77373

5627 Level 7 Radiation Therapy 77371 & 77372

5661 Therapeutic Nuclear Medicine 79005, 79101, 79445 & 79999Brachytherapy sources are in APC that matches the number in HCPCS billing code


APC Restructuring cont.• Variances >20% finalized for Rad Onc codes in 2016

HCPCS Code

Short Descriptor 2015 APC2015 Nat.

Avg. Payment

2016 Proposed

APC

2016 Proposed Nat. Avg. Payment

Variance

57155 Insert uteri tnadem/ovoids 0192 $487.06 5412 $1,861.18 282%

77280 Set radiation therapy field 0304 $113.12 5612 $166.65 47%

77306 Telethx isodose plan simple 0304 $113.12 5612 $166.65 47%

77307 Telethx isodose plan cplx 0304 $113.12 5613 $291.77 158%

77332 Radiation treatment aid(s) 0303 $215.54 5611 $107.40 -50%

77334 Radiation treatment aid(s) 0303 $215.54 5613 $291.77 35%

77370 Radiation physics consult 0304 $113.12 5612 $166.65 47%

77778 Apply interstit radiat compl 0651 $952.11 5624 $696.21 -27%

77763 Apply intracav radiat complx 0312 $395.77 5624 $696.21 76%


Comprehensive APCs (C-APC) for SRS

• Services which are as integral, ancillary, supportive, dependent, and adjunctive to the primary service and reported on the same claim as SRS treatment codes 77371 (Cobalt-60 based) or 77372 (Linac based) is packaged and not separately reimbursed

• All ancillary services are reported on the claim to assist in cost reporting for the service in setting C-APC future payments, but not separately reimbursed

• Upon review of CY 2014 claims data for SRS procedures and the codes ancillary to 77371 and 77372 - issues identified which can and do impact the C-APC for SRS

• Changes made to C-APC – removing codes to be reimbursed separately


Cobalt-60 vs. Linac Variances • Analysis of CY 2014 claims revealed that billing practices for Cobalt-60 based

vs. Linac based technologies varied• SRS delivery with Cobalt-60 typically had all services (specifically imaging,

simulation, treatment plan and physics services) related to the procedure billed on the same date and claim as the treatment itself.

• Linac based services were found to have services such as imaging, simulation, treatment plan and physics services reported on different dates of service and separate claims. – Services such as simulation and planning reported up to a month prior to

Linac based SRS tx on different claim forms• Regulation passed in 2013 requires both 77371 and 77372 be reimbursed the

same amount. Changes finalized to account for possible increased reimbursement of linac based services performed over multiple dates vs. Gamma Knife which are performed on single date.


C-APC Changes 2016 & 2017• CMS removing some services from the C-APC and provide payment to these

separately, even when billed with the SRS treatment code which has a status indicator of “J1” in CYs 2016 & 2017

• The following codes will be removed from the SRS C-APC and reimbursed separately (up to 30 days prior to tx only), when reported on the same or claim 30 days prior as the SRS treatment code 77371 or 77372– CT localization (HCPCS codes 77011 and 77014);– MRI imaging (HCPCS codes 70551, 70552, and 70553);– Clinical treatment planning (HCPCS codes 77280, 77285, 77290, and

77295);– Physics consultation (HCPCS code 77336)

• Modifier “CP” to be reported on above codes when billed for services related in the preparation and delivery of SRS treatment, both Cobalt-60 and Linac based, but only when performed on different date than treatment

• After collection of data, plan to repackage codes back into C-APC in 2018Copyright © 2016 RCI All Rights Reserved. Do Not Duplicate.


C-APC Changes cont.

• SRS C-APC 0067 changed to C-APC 5627HCPCS Code


2015 Nat. Avg.

Payment2016 APC

2016 Nat. Avg.

PaymentVariance

77371 Srs multisource 0067 $9,765.40 5627 $7,300.24 -25%

77372 Srs linear based 0067 $9,765.40 5627 $7,300.24 -25%

Remember, the new C-APC has removed codes which may be separately reimbursed when appropriate and due to edits. The negative impact for CY 2016 cannot be compared equally to CY 2015.


Frameless SRS Course Performed Over Multiple Dates of Service (Co-60 and Linac based)

Category CPT CPT Description2015

Quantity Paid

2016 Quantity Paid

2015 Total APC Pmt

2016 Total APC Pmt

Pre-SimG0463 Hospital outpt clinic visit $ - $ -

77470 Special radiation treatment $ - $ -

Simulation

70552 Mri brain stem w/dye 1 $ - $ 454.32

77290 Set radiation therapy field 1 $ - $ 291.77

77334 Radiation treatment aid(s) $ - $ -

Planning

77370 Radiation physics consult $ - $ -

77295 3-d radiotherapy plan 1 $ - $ 1,026.81

77300* Radiation therapy dose plan $ - $ -


Treatment77371 or 77372 Srs linear based 1 1 $ 9,765.40 $ 7,300.24

77336 Radiation physics consult 1 $ - $ 107.40

*MU Calculations are cannot be reported on the claim form in 2016 due to an edit with the planning code 77295. The course scenario has the simulation taking place on a date separate than the treatment plan and treatment delivery.

$ 9,765.40 $ 9,180.54

$ (584.86)

-5.99%


Headframe SRS Course Performed on Single Date of Service (Co-60 and Linac based)

Category CPT CPT Description2015

Quantity Paid

2016 Quantity Paid

2015 Total APC Pmt

2016 Total APC Pmt

Pre-SimG0463 Hospital outpt clinic visit $ - $ -

77470 Special radiation treatment $ - $ -

Simulation

70552 Mri brain stem w/dye 1 $ - $ 454.32

77290* Set radiation therapy field 0 $ - $ -


Planning

77370 Radiation physics consult $ - $ -

77295 3-d radiotherapy plan 1 $ - $ 1,026.81

77300** Radiation therapy dose plan $ - $ -


Treatment77371 or 77372 Srs linear based 1 1 $ 9,765.40 $ 7,300.24

77336 Radiation physics consult 1 $ - $ 107.40

*Code 77290 is lost to edit with treatment planning code 77295 on same date of service. *MU Calculations are cannot be reported on the claim form in 2016 due to an edit with the planning code 77295

$ 9,765.40 $ 8,888.77

$ (876.63)

-8.98%


LDR Brachytherapy C-APC 8001

• No changes in CY 2016• In place since 2008, continuing C-APC 8001 for LDR

prostate brachytherapy services • Includes codes 55875 and 77778

– If reported together then under C-APC payment, if performed separately then reimbursed under individual APCs – very different than other C-APCs

• In ASC continue to report G0458 (low dose rate (LDR) prostate brachytherapy services, composite rate) when services on same date of service


Hospital OQR Measure for CY 2018

• CMS finalized new Hospital Outpatient Quality (OQR) Reporting Measure for CY 2018 and subsequent years specific to Radiation Oncology

• NQF# 1822, OP-33: External Beam Radiotherapy (EBRT) for Bone Metastases – 2009 Task Force organized by ASTRO assessed existing

recommendations for palliative care in order to better address and evaluate any lack of guidelines

– Established 4 sets of recommendations for treating bone metastases in previously un-irradiated patients

• Goal is to reduce the rate of EBRT overuse and promote patient safety.


Hospital OQR Bone Mets cont.• Designed to address concerns with unnecessary exposure to EBRT for bone

pain and reduce overuse of EBRT services, also address treatment gaps in the variations of courses used to treat the similar patients

• Measure to address all patients (all payors) using following dosing schedules– 30 Gy over course of 10 fractions– 24 Gy over course of 6 fractions– 20 Gy over course of 5 fractions– Single 8 Gy fraction

• Measure is not open to following patients– Patients who have had previous radiation to the same site; – Patients with femoral axis cortical involvement greater than 3 cm in length; – Patients who have undergone a surgical stabilization procedure; – Patients with spinal cord compression, cauda equina compression or

radicular painCopyright © 2016 RCI All Rights Reserved. Do Not Duplicate.


Initial Simulation with IMRT Course

• Physicians and freestanding cancer centers cannot bill for initial simulation with course of IMRT in 2015.

• In 2016 hospitals cannot bill for initial simulation with course of IMRT.

• CMS requested by commenters to address questions about billing for initial simulation with IMRT course for hospitals.

• CMS cited two sources/transmittals to support their stance that the initial simulation is not billable.


Initial Simulation with IMRT Course cont.

• Medicare Claims Processing Manual, Chapter 4, Section 200.3.2

“Payment for the services identified by CPT codes 77014, 77280-77295, 77305-77321, 77331, 77336, and 77370 is included in the APC payment for IMRT planning when these services are performed as part of developing an IMRT plan that is reported using CPT code 77301. Under those circumstances, these codes should not be billed in addition to CPT code 77301 for IMRT planning.”


Initial Simulation with IMRT Course cont.• National Correct Coding Initiative (NCCI) guidance in the

NCCI Policy Manual for Medicare Services, Chapter 9, page IX-17

“12. Intensity modulated radiotherapy (IMRT) plan (CPT code 77301) includes therapeutic radiology simulation-aided field settings. Simulation field settings for IMRT should not be reported separately with CPT codes 77280 through 77295. Although procedure-to-procedure edits based on this principle exist in NCCI for procedures performed on the same date of service, these edits should not be circumvented by performing the two procedures described by a code pair edit on different dates of service.”


Initial Simulation with IMRT Course cont.• CMS provided the following statement to support their rationale for this

decision.“…We believe that the types of services included in IMRT treatment planning include simulation…we believe CMS’ longstanding Manual and coding guidance issued in CY 2008 has been precise in conveying its policy and instructions regarding coding for IMRT services and that, generally, IMRT services have been properly reported by hospitals.

It is our policy that payments for the services identified by CPT codes 77280 through 77295 are included in the APC payment for IMRT planning services, and that the services described by these CPT codes should not be reported separately from services described by CPT code 77301, regardless of when the various services that comprise CPT code 77301 are performed. If a hospital submits a claim that separately reports services described by one of these simulation CPT codes in addition to separately reporting IMRT planning services that are performed, we would consider this reporting to constitute unbundling of the APC payment, which is prohibited. We will revise and update the Medicare Claims Processing Manual and coding guidance in the near future to ensure that this policy is more directly stated. The clarified coding guidance will state the following:

“Payment for the services identified by CPT codes 77014, 77280 through 77295, 77305 through 77321, 77331, and 77370 is included in the APC payment for CPT code 77301 (IMRT planning). These codes should not be reported in addition to CPT code 77301 (on either the same or a different date of service) unless these services are being performed in support of a separate and distinct non-IMRT radiation therapy for a different tumor.”


Initial Simulation with IMRT Course cont.• However…codes 77301 and 77295 will continue to be

reimbursed the same amount in 2016! A 3D course of treatment does not have the simulation bundled into the planning.

• The final geometric mean cost of the services described by CPT code 77301 is approximately $1,125.

• CMS stated “if the clarification of our coding guidance for IMRT planning services results in a significant change in the geometric mean cost of services described by CPT code 77301 in future years, we will consider an alternative APC assignment for the code other than APC 5614.”


Packaged Oncology Codes• The following codes are designated with a Status Indicator (SI) of

Q1, which defines the code as conditionally packaged. When reported with another service paid under HOPPS with a Status Indicator of S, T or V, the payment will be packaged; however, when furnished alone, payment will be made separately. – CPT 96523 Irrigation of implanted venous access device for

drug delivery systems– CPT 36591 Collection of blood specimen from a completely

implantable venous access device– CPT 36592 Collection of blood specimen using established

central or peripheral catheter, venous, not otherwise specified


Payments of Drugs, Biologicals, and Radiopharmaceuticals

• Payments for those drugs and biologicals which do not have pass-through status are proposed to be set at the statutory default Average Sales Price (ASP) plus 6%

• Medicare finalized the proposal to expire pass-through status of twelve (12) drugs and biologicals on December 31, 2015

• Includes drugs and biologicals that have received OPPS pass-through payment for at least two (2) years and no longer than three (3) years by this expiration date


Pass-through Status Removed


Table 43 – Drugs and Biologicals For Which Pass-Through Payment Status Expires December 31, 2015

CY 2016 HCPCS Code

CY 2016 Long DescriptorFinal CY 2016 SI

Final CY 2016 APC

J1556 Injection, immune globulin (Bivigam), 500 mg K 9130

J9047 Injection, carfilzomib, 1 mg K 9295

J9354 Injection, ado-trastuzumab emtansine, 1 mg K 9131

J9400 Injection, Ziv-Aflibercept, 1 mg K 9296

Pass-through Status• Medicare has finalized to continue pass-through status in CY 2016 for 38 drugs and biologicals.• For CY 2016, CMS will pay for pass-through drugs and biologicals at the Average Sales Price

(ASP) plus 6 percent and continue to update pass-through payment rates on a quarterly basis through the CMS website.


Table 44 –Drugs and Biologicals With Pass-Through Payment Status In CY 2016

CY 2015 HCPCS Code

CY 2016 HCPCS Code

CY 2016 Long Descriptor CY 2016 SICY

2016 APC*

C9025 J9035 Injection, ramucirumab, 5 mg G 1488C9027 C9027 Injection, pembrolizumab, 1 mg G 1490C9442 J9032 Injection, belinostat, 10 mg G 1658C9449 J9039 Injection, blinatumomab, 1 mcg G 9449C9453 J9299 Injection, nivolumab, 1 mg G 9453Q9970 J1439 Injection, ferric carboxymaltose, 1 mg G 9441J1446 J1446 Injection, TBO-Filgrastim, 5 micrograms G 1477C9021 J9301 Injection, obinutuzumab, 10 mg G 1476J9371 J9371 Injection, Vincristine Sulfate Liposome, 1 mg G 1466

Q5101 Q5101 Injection, Filgrastim (G-CSF), Biosimilar, 1 microgram G 1822

Packaged Payment Rate• CMS finalized the packaged threshold payment in CY 2016 to have a

cost per day less than $100.00, slight increase from CY 2015 which was $95

• CMS will continue to pay separately for items with an estimated per day cost greater than $100 with the exception of diagnostic radiopharmaceuticals, contrast agents, anesthesia drugs, drugs, biologicals and radiopharmaceuticals that function as supplies when used in a diagnostic test or procedure, and drugs and biologicals that function as supplies or devices when used in a surgical procedure.

• CMS will continue the policy of making packaging determinations on a drug-specific basis rather than by HCPCS code for those codes that describe the same drug or biological but in different dosages.


Packaged Payment Rate

• Policy and packaging determinations on drug-specific basis, rather than HCPCS code – For codes that describe the same drug or biological, but in different

dosages• HCPCS codes describing different doses, est. cost/day of each drug or

biological is calculated by, – Weighted avg. ASP+6%/unit payment amount for all dosage levels

of specific drug or biological x est. units/day for all HCPCS codes that describe each drug or biological claims data

• HCPCS codes for the same drug or biologicals at less than or equal to $100 would be packaged as described above and those codes greater than $100 would be separately payable



Table 51– HCPCS Codes To Which The CY 2016 Drug-Specific Packaging Determination Methodology Applies

CY 2016 HCPCS Code

CY 2016 Long Descriptor CY 2016 SI

J9035 Injection, bevacizumab, 10 mg KJ1642 Injection, heparin sodium, (heparin lock flush), per 10 units NJ1644 Injection, heparin sodium, per 1000 units NJ7050 Infusion, normal saline solution , 250 cc NJ7040 Infusion, normal saline solution, sterile (500 ml=1 unit) NJ7030 Infusion, normal saline solution , 1000 cc NJ9250 Methotrexate sodium, 5 mg NJ9260 Methotrexate sodium, 50 mg N

Drug Packaging Payment Rate

• CMS also addresses drugs and biologicals lacking claims data and pricing information for ASP methodology

• CSM will continue to assign status indicator “E” (not paid by Medicare when submitted on outpatient claims [any outpatient bill type]) see Table 53

• CMS will continue to utilize status indicator “K” and pay for these codes separately for the remainder of CY 2015, if pricing information is available, which are represented within Table 52



Table 52 – Drugs And Biologicals Without CY 2014 Claims Data

CY 2016 HCPCS Code

CY 2016 Long DescriptorEstimated Average

Number of Units Per Day

CY 2016 SICY 2016

APC

J3489 Injection, Zoledronic Acid, 1mg 4 K 1356

J9047 Injection, carfilzomib, 1 mg 57 K 9295

J9306 Injection, pertuzumab, 1 mg 450 K 1471

J9354 Inj, Ado-trastuzumab Emt 1mg 262 K 9131

J9400 Inj, ziv-aflibercept, 1mg 326 K 9296

Q2050Injection, Doxorubicin Hydrochloride, Liposomal, Not Otherwise Specified, 10 mg

7 K 7046


Table 53 – Drugs And Biologicals Without CY 2014 Claims Data And Without Pricing Information For The ASP Methodology

CY 2016 HCPCS Code

CY 2016 Long Descriptor CY 2016 SI

J9160 Injection, denileukin diftitox, 300 micrograms E

J9215 Injection, interferon, alfa-n3, (human leukocyte derived),250,000 iu E

J9300 Injection, gemtuzumab ozogamicin, 5 mg E

Self-Administered Drugs (SADs) Technical Correction• The Affordable Care Act defines covered “medical and other

health services” to include both “services and supplies” and “hospital services” including drugs and biologicals not usually self-administered by the patient.

• CMS identified a paragraph which excludes payment for any drug or biological that can be self-administered

• CMS made a technical correction to amend the description of these drugs and biologicals, to reflect the statutory language. – Deletion of the phrase “any drug or biological that can be

self-administered” and replace it with the phrase “any drug or biological which is usually self-administered by the patient”.


HOPPS 2016 Payment Rates


$0.00

$50.00

$100.00

$150.00

$200.00

$250.00

$300.00

$350.00

77280 77285 77290

HOPPS Simulation

2015 Final HOPPS Rates 2016 Final HOPPS Rates


$0.00

$50.00

$100.00

$150.00

$200.00

$250.00

$300.00

$350.00

77332 77333 77334 77338

HOPPS Treatment Devices



$-

$200.00

$400.00

$600.00

$800.00

$1,000.00

$1,200.00

77293 77295 77300 77301 77306 77307 77321

HOPPS Dosimetry



$-

$100.00

$200.00

$300.00

$400.00

$500.00

$600.00

77401 77402 77407 77412 77385 77386

HOPPS Radiation Treatment Delivery - EBRT & IMRT



$0.00

$100.00

$200.00

$300.00

$400.00

$500.00

$600.00

77331 77336 77370 77470

HOPPS Special Dosimetry, Physics & Special Trmt Procedure



$-

$2,000.00

$4,000.00

$6,000.00

$8,000.00

$10,000.00

$12,000.00

77371 77372 77373

HOPPS Stereotactic Treatment Delivery - SRS & SBRT



$-

$50.00

$100.00

$150.00

$200.00

$250.00

$300.00

$350.00

77316 77317 77318

HOPPS Brachytherapy Planning Codes



$0.00$100.00$200.00$300.00$400.00$500.00$600.00$700.00$800.00$900.00

$1,000.00

77761 77762 77763 77767 77768 77770 77771 77772 77776 77777 77778 77785 77786 77787 0394T 0395T 0182T

HOPPS Brachytherapy Treatments:LDR, HDR & Electronic Brachytherapy



$7,400.00

$7,420.00

$7,440.00

$7,460.00

$7,480.00

$7,500.00

$7,520.00

$7,540.00

$7,560.00

$7,580.00

77424 77425

HOPPS Intraoperative Radiation Treatment Delivery



$-

$200.00

$400.00

$600.00

$800.00

$1,000.00

$1,200.00

$1,400.00

77520 77522 77523 77525

HOPPS Proton Therapy Treatments



2016 Medical Oncology Rates


HCPCS Code Short DescriptorNational Payment Rate

Variance2015 Final 2016 Final

36415 Routine venipuncture $0.00 $0.00 $0.00 36430 Blood transfusion service $297.18 $349.14 $51.96 36591 Draw blood off venous device $78.79 $91.18 $12.39 36593 Declot vascular device $195.12 $199.80 $4.68 38220 Bone marrow aspiration $826.26 $941.98 $115.72 38221 Bone marrow biopsy $826.26 $1,414.28 $588.02 96360 Hydration iv infusion init $108.20 $92.40 ($15.80)96361 Hydrate iv infusion add-on $32.57 $30.87 ($1.70)96365 Ther/proph/diag iv inf init $173.53 $173.18 ($0.35)96366 Ther/proph/diag iv inf addon $32.57 $30.87 ($1.70)96367 Tx/proph/dg addl seq iv inf $53.52 $42.31 ($11.21)96368 Ther/diag concurrent inf $0.00 $0.00 $0.00 96372 Ther/proph/diag inj sc/im $53.52 $42.31 ($11.21)96374 Ther/proph/diag inj iv push $108.20 $92.40 ($15.80)96375 Tx/pro/dx inj new drug addon $32.57 $42.31 $9.74 96376 Tx/pro/dx inj same drug adon $0.00 $0.00 $0.00

Medical Oncology Rates cont.


HCPCS Code Short DescriptorNational Payment Rate

Variance2015 Final 2016 Final

96401 Chemo anti-neopl sq/im $108.20 $92.40 ($15.80)96402 Chemo hormon antineopl sq/im $53.52 $42.31 ($11.21)96409 Chemo iv push sngl drug $173.53 $173.18 ($0.35)96411 Chemo iv push addl drug $53.52 $92.40 $38.88 96413 Chemo iv infusion 1 hr $285.00 $280.27 ($4.73)96415 Chemo iv infusion addl hr $53.52 $42.31 ($11.21)96416 Chemo prolong infuse w/pump $285.00 $280.27 ($4.73)96417 Chemo iv infus each addl seq $53.52 $42.31 ($11.21)96450 Chemotherapy into cns $285.00 $280.27 ($4.73)96521 Refill/maint portable pump $173.53 $173.18 ($0.35)96523 Irrig drug delivery device $78.79 $55.94 ($22.85)99195 Phlebotomy $78.79 $91.18 $12.39 G0364 Bone marrow aspirate &biopsy $0.00 $0.00 $0.00 G0463 Hospital outpt clinic visit $96.22 $102.12 $5.90

CODING CHANGES IMPACTING 2016


Radionuclide Brachytherapy Codes

• Codes 77785, 77786 & 77787 deleted in 2016• New codes added - Skin Surface HDR Radionuclide

Treatments– 77767 – Remote afterloading high dose rate radionuclide

skin surface brachytherapy; includes basic dosimetry, when performed; lesion diameter up to 2.0 cm or 1 channel

– 77768 - Remote afterloading high dose rate radionuclide skin surface brachytherapy; includes basic dosimetry, when performed; lesion diameter over 2.0 cm and 2 or more channels, or multiple lesions


Radionuclide Brachytherapy Codes cont.• Codes 77785, 77786 & 77787 deleted in 2016• New codes added - Interstitial or Intracavitary HDR Radionuclide

Treatments– 77770 - Remote afterloading high dose rate radionuclide

interstitial or intracavitary brachytherapy; includes basic dosimetry, when performed; 1 channel

– 77771 - Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy; includes basic dosimetry, when performed; 2 to 12 channels

– 77772 - Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy; includes basic dosimetry, when performed; over 12 channels


Interstitial LDR Brachytherapy Txs

• Codes 77776 & 77777 deleted in 2016• Changes to code 77778

– 77778 - Interstitial radiation source application, complex, includes supervision, handling, loading of radiation source, when performed

• Code 77790 not billed with code 77778; work of code 77790 is not factored into 77778

• When using <10 sources for any procedure, report 77799 since codes 77776 & 77777 deleted


Electronic Brachytherapy Treatments

• Code 0182T deleted• New codes - Electronic Brachytherapy Treatments

– 0394T - High dose rate electronic brachytherapy, skin surface application, per fraction, includes basic dosimetry, when performed

– 0395T - High dose rate electronic brachytherapy, interstitial or intracavitary treatment, per fraction, includes basic dosimetry, when performed

• When reporting codes 0394T or 0395T the following codes cannot be reported: 77261-77263, 77300, 77306 – 77307, 77316 – 77318, 77332 – 77334, 77336, 77427, 77431, 77432, 77435, 77469, 77470, 77499, 77761 – 77763, 77770 – 77772, 77778 and 77789


Spacer Gel HCPCS Code Prostate Pts.• C9743 - Injection/implantation of bulking or spacer material

(any type) with or without image guidance (not to be used if a more specific code applies); hospitals only

• 45999 - Unlisted procedure; physicians and freestanding/offices only

• Gel billed as A4649 - Surgical supply; miscellaneous– Hospital packaged into placement– Offices paid at invoice cost

HCPCS Code


2015 Nat. Avg.

Payment2016 APC

2016 Nat. Avg.

PaymentVariance

C9743 Bulking/spacer material impl 0310 $1,038.12 5374 $2,243.49 116%


Provider Based Department Changes

• Bipartisan Budget Act of 2015 signed into law 11/2/15• SEC. 603. Treatment of Off-campus Outpatient Departments of a Provider

references 42 CFR 413.65 - Requirements for a determination that a facility or an organization has provider-based status within the law.

• MedPAC (Medicare Payment Advisory Commission) concerned that CMS pays varying payments based on location or designation of an entity for the same services and hospitals are acquiring practices to increase payments– Procedure in office/freestanding cancer center paid under MPFS– Procedure in hospital setting, pay facility fee under HOPPS and

professional fee under MPFS, typically results in higher amount paid than just for procedure in an office

– Procedure in ASC reimbursement is less than if receives same service in a hospital


Provider Based Department Changes cont.• Bipartisan Budget Act of 2015, Section 603, effective January 1,

2017 when a service is provided in an off-campus outpatient department of a hospital, unless they were billing as a dept. of the hospital prior to January 1, 2017, CMS will reimburse services under either the MPFS or ASC fee schedule.

• Off-campus departments billing for services prior to 1/1/17 are exempt, but CMS could change or adjust future rules to add further limitations

• Hospitals will be required to report as requested per the HHS Secretary info appropriate to implement means of collecting data, which may include use of a modifier or code


On-campus vs. Off-campus

• On-campus vs. off-campus, what’s the difference?– Per 42 CFR 413.65, “Campus means the physical area immediately

adjacent to the provider's main buildings, other areas and structures that are not strictly contiguous to the main buildings but are located within 250 yards of the main buildings, and any other areas determined on an individual case basis, by the CMS regional office, to be part of the provider's campus.”

• Locations not on-campus are considered off-campus– Hospitals need to evaluate their campuses and how they defined the

locations with CMS• Remote locations of a hospital will be considered on-campus• Any new acquisitions or off-campus locations need to be evaluated for

financial impact if created after 1/1/17


New POS Code for Provider Based

• POS codes to identify services provided in on-campus outpatient hospital vs. off-campus outpatient hospital

New and Revised POS Codes Effective January 1, 2016Code Descriptor

POS 19 Off Campus-Outpatient Hospital

Descriptor: A portion of an off-campus hospital provider based department which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.

POS 22 On Campus-Outpatient Hospital

Descriptor: A portion of a hospital’s main campus which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.


Codes 77295 and 77300 in 2016

• Effective January 1, 2016 CPT code 77300 will edit with Code 77295!

• Code 77300 would be billable with following possible scenarios– IMRT, IORT, SIRT, Radiopharmaceuticals & Superficial– Nomograms for PSI– Hand calculations– Re-calculating dose later during course due to changes

• Code 77300 is a column 2 code to the following primary codes• 77295, 77306 & 77307 & 77316 – 77318• 77767, 77768, 77770, 77771 & 77772• 0394T & 0395T


Questions?


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