Oncology News Archives

PRESIDENT TRUMP SIGNS COVID RELIEF BILL INTO LAW

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On December 21, Congress passed a comprehensive bi-partisan year-end bill that funds the federal government through FY 2021, provides additional COVID relief and economic stimulus funds, and includes important changes to the 2021 Medicare Physician Fee Schedule. The legislation was finally signed into law by President Trump late Sunday, December 27, averting a government shutdown on Tuesday.Along with the COVID-19 relief and economic stimulus funds, the bill includes provisions which will help to alleviate the 10.2% reduction in Medicare’s payment rates (due to the 10.2% decrease in the conversion factor for 2021) included in the CMS 2021 Medicare Physician Fee Schedule (PFS) final rule. The bill provides: An increase of 3.75% to the PFS conversion factor for all specialties and services in 2021. A three-year delay in payments for a new add-on evaluation and management (E/M) code G2211 for visit complexity inherent in E/M visits. An extension of the 2%…

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CMS Delays Radiation Oncology Start Date

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On October 21, 2020, CMS announced they received feedback from a number of stakeholders about the challenges of preparing to implement the Radiation Oncology (RO) Model by January 1, 2021 and as a result, they would delay the RO Model start date to July 1, 2021. The RO Model tests whether bundled, prospective, site neutral, modality agnostic, episode-based payments to physician group practices (PGPs), hospital outpatient departments (HOPD), and freestanding radiation therapy centers for radiotherapy (RT) episodes of care reduces Medicare expenditures while preserving or enhancing the quality of care for Medicare beneficiaries. The design of the RO Model includes several key programmatic elements: Alternative Payment: Episode Payments:CMS makes prospective, episode-based (i.e., bundled) payments, based on a patient’s cancer diagnosis, that cover RT services furnished in a 90-day episode for the 16 cancer types meeting the included cancer type criteria described in the final rule; Site-neutrality:The Model uses site-neutral payment…

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Medicare 2021 Proposed Physician Fee Schedule and OPPS Rules

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CMS RELEASES CY 2021 PROPOSED RULES On August 4, 2020, the Centers for Medicare and Medicaid Services (CMS) released the proposed 2021 Medicare Physician Fee Schedule (PFS), and Hospital Outpatient Prospective Payment System (OPPS) rules. Below are some of the highlights of the rules. PHYSICIAN FEE SCHEDULE PROPOSED RULE (PFS) CY 2021 Under the PFS proposed rule, physicians would see a reduced conversion factor (CF) from $36.09 in 2020, to $32.26, effective Jan. 1, 2021. Table 90 of the proposed PFS rule shows the estimated impact on total allowed charges by specialty. If the rule is finalized as proposed, CMS estimates the following payment rate changes: Hematology/Oncology +14% Radiation Oncology and Radiation Therapy -6%, Rheumatology +16% Physician Assistants +8% Nurse Practitioners +8% The PFS proposed 2021 rule includes changes to previously finalized billing and coding requirements for office and outpatient visits by incorporating revisions recommended by the American Medical Association (AMA). Among the…

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Audit Activity

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Audits In response to the recent increase in providers reaching out to us regarding audits, we want to remind you of a few basics. First, the Centers for Medicare and Medicaid Services (CMS) healthcare audit programs include the Unified Program Integrity Contractors (UPICs) audit program, the Recovery Audit Contractor (RAC) program, and the Comprehensive Error Rate Testing (CERT) program. It is important to identify the entity that is auditing you. E/M Services Billed with Modifier 25 There has been an increase in audits on evaluation and management (E/M) services billed on the same day as chemotherapy. We know that the American Medical Association (AMA) CPT and Medicare guidelines state that medically necessary, significant and separately identifiable E/M services are payable when billed on the same day as drug administration services.  What is less clear is the criteria payers use to determine that the E/M service is significant and separately identifiable….

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January 8, 2020 News

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NEW RAC AUDIT – ESA On December 10, 2019, CMS approved a new RAC audit – Issue Number 0171 Erythropoiesis Stimulating Agents for Cancer Patients: Medical Necessity and Documentation Requirements, this RAC audit will apply to all A/B MACs for physicians/non-physician practitioners and hospital outpatient claims. This RAC audit is a complex review, which almost always involves a request for medical records from the contractor. Under the audit issue description, CMS states, “Medical records will be reviewed to determine if the use of ESA in cancer and related neoplastic conditions meets Medicare coverage criteria. Affected Codes J0881 and J0885 that were billed with modifiers EA and EB.” Dates of service to be audited are claims having a “claim paid date” which is less than 3 years prior to the Demand Letter date. The National Coverage Determination (NCD) for ESAs can be accessed here: National Coverage Determination Manual, Chapter 1, Section 110.21: Erythropoiesis…

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CMS RELEASES 2020 FINAL RULES

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On Friday, November 1, 2019 the Centers for Medicare and Medicaid Services (CMS) released the 2020 Medicare Physician Fee Schedule (PFS) final rule, which includes updates to the Quality Payment Program (QPP), and the 2020 Medicare Hospital Outpatient Prospective Payment System final rule. The final rules are effective on January 1, 2020. Medicare Physician Fee Schedule 2020 Final Rule  The finalized Calendar Year (CY) 2020 PFS conversion factor is $36.09, up slightly from the CY 2019 PFS conversion factor of $36.04. Below are some of the key changes for CY 2020 and CY 2021. CMS Reported Estimates of Payment Impact on PFS Services: Hematology/Oncology 0% Nurse Practitioner 0% Physician Assistant 0% Radiation Oncology 0% Rheumatology 0% Documentation – Evaluation and Management (E/M) Services for CY 2020 Physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse-midwives can review and verify (sign and date), rather than re-document, notes made in…

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ASCO’s PracticeNET Monthly Calls

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Starting in August 2019, the ASCO PracticeNET program began hosting monthly calls. Every month PracticeNET hosts an hour-long call for physicians and administrative practice leaders. Below is the information from the recent and upcoming PracticeNET calls. December PracticeNET Call Register for the December 2019 PracticeNET call. December 19, 2019 at 4:00 PM Eastern. Agenda will be forthcoming November PracticeNET Call Register for the November 2019 PracticeNET call. November 21, 2019 at 4:00 PM Eastern. Agenda will be forthcoming October PracticeNET Call: Slides from the October 17 PracticeNET Call. Read and Track S.2543 – Prescription Drug Pricing Reduction Act of 2019. Read and Track H.R.3 – Lower Drug Costs Now Act of 2019. Visit CMMI to read the Radiation Oncology Model proposed rule and fact sheet. Read ASTRO’s comment letter to CMMI on the RO Model. September 19 PracticeNET Call: Slides from the September 19, 2019 PracticeNET call – Quality Payment Program and Hospital Outpatient Reporting Program proposed changes for 2020…

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CMS PUBLIC LISTENING SESSION ON ONCOLOGY PAYMENT MODEL

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The Center for Medicare and Medicaid Innovation (CMMI – the Innovation Center) is announcing a Public Listening Session to gather feedback on value-based payment to support high-quality oncology care.  The Innovation Center says they are seeking to develop a potential new oncology payment and service delivery model that builds on the Oncology Care Model (OCM). The Innovation Center will release additional materials before the November 4, 2019 Public Listening Session. The Public Listening Session will take place on Monday, November 4, 2019 from 1:00 to 4:00 pm EST at the Hubert H. Humphrey Building (Great Hall) 200 Independence Avenue, SW Washington DC 20201. You can participate in person, via livestream video, or via teleconference.  Registration for the Public Listening Session is required. For additional information on the Public Listening Session visit https://innovation.cms.gov/resources/oncology-listening-session.html.  

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CMS QUARTERLY UPDATE TO HCPCS CODE SET

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MLN Matters Number: MM11296  provides the updates on the HCPCS code set for codes related to drugs and biologicals. The HCPCS code set is updated quarterly. On May 19, 2019 CMS announced a change in the current process of allowing only one opportunity per year to apply for new Level II codes. CMS is moving to a process with quarterly opportunities to apply for drugs, and semi-annual opportunities to apply for devices. Administrator Verma’s speech can be viewed at: https://www.cms.gov/newsroom/press-releases/speech-remarks-administrator-seema-verma-medical-device-manufacturers-association. CMS HCPCS Quarterly Updates including C-Codes, G-Codes, Q-Codes and J-Codes are available on the CMS website at: https://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/HCPCS-Quarterly-Update.html

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LATEST FDA APPROVALS

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FDA approved ado-trastuzumab emtansine (KADCYLA, Genentech, Inc.) for the adjuvant treatment of patients with HER2-positive early breast cancer (EBC) who have residual invasive disease after neoadjuvant taxane and trastuzumab based treatment. May 3, 2019. FDA Announcement: https://www.fda.gov/drugs/resources-information-approved-drugs/fda-approves-ado-trastuzumab-emtansine-earlybreast-cancer. KADCYLA was granted breakthrough therapy designation for the adjuvant treatment of patients with HER2-positive early breast cancer who have residual disease after pre-operative systemic treatment. A description of FDA expedited programs is in the Guidance for Industry: Expedited Programs for Serious Conditions-Drugs and Biologics.  

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