Improving Health Through Medical Physics

AAPM Newsletter — Volume 42 No.6 — November|December 2017


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AAPM Submits Comments on 2018 Medicare Proposed Rules

AAPM recently submitted comments to the Centers for Medicare and Medicaid Services (CMS) regarding the 2018 Medicare proposed rules for payments to hospital outpatient departments, freestanding cancer centers and physicians.

CMS will address public comments in the 2018 final rules, was published on the first of November. AAPM's full comments to CMS can be found here.

Medicare Hospital Outpatient Prospective Payment System

AAPM provided written comments to CMS regarding the 2018 Medicare Hospital Outpatient Prospective Payment System (HOPPS) proposed rule, which provides facility payments to hospital outpatient departments.

In the 2018 Medicare hospital outpatient proposed rule, CMS proposes to continue the existing Comprehensive APC (C-APC) payment methodology and proposes a new code edit that requires a brachytherapy treatment delivery code when a brachytherapy insertion code is billed.

CMS defines a Comprehensive APC as a classification for the provision of a primary service and all adjunctive services and supplies provided to support the delivery of the primary service. The primary service is assigned a J1 or J2 status indicator. Under this policy, CMS calculates a single payment for the entire outpatient encounter, defined by a single claim, regardless of the date of service span.

The episode of care for cancer is complex, especially as it relates to brachytherapy treatment. We agree that most brachytherapy insertion procedures and brachytherapy treatments occur on the same day or within the same week and therefore the services should appear on the same claim. However, in other cases, the needles or catheters are surgically placed prior to the brachytherapy treatment delivery, which often consists of multiple fractions over several days or weeks and may be delivered at a different site of service than the needle or catheter insertion. Adding to the uncertainty, some outpatient facilities may submit daily outpatient claims, some weekly and some on another schedule.

AAPM and other stakeholders contracted with Christopher Hogan, Ph.D. of Direct Research to conduct analysis of 2016 outpatient claims regarding the 2018 CMS proposal to require a code edit for select brachytherapy insertion codes. Based on previous research and our comments regarding the 2017 HOPPS proposed rule, we initially thought that implementing a code edit would improve hospital coding and ensure more accurate payment for some C-APCs related to brachytherapy. Based on the data analysis, and given the complexity of coding, serial billing for cancer care, and potentially different sites of service for the initial surgical device insertion and subsequent brachytherapy treatment delivery, AAPM opposes the proposed mandatory code edit for brachytherapy insertion procedures.

Other AAPM recommendations include:

  • Discontinue the Comprehensive APC payment policy for all brachytherapy insertion codes. Alternatively, modify the C-APC methodology to pay for "J1" brachytherapy insertion but exclude all radiation oncology codes on the claim, defined as CPT codes 77261 through 77799, and make separate payment for the brachytherapy treatment delivery and related planning and preparation services in addition to the C-APC payment.
  • Discontinue the Comprehensive APC payment policy for Single Session Cranial Stereotactic Radiosurgery codes 77371 and 77372.
  • Continue the Composite APC payment methodology in 2018 for APC 8001 Low Dose Rate Prostate Brachytherapy Composite.

Since the inception of the Comprehensive APC methodology, AAPM has commented on concerns around the accuracy of claims data, as there is a great deal of discrepancy around how hospitals submit these claims. AAPM is also uncertain as to whether the rates associated with C-APCs adequately or accurately reflect all of the procedures and costs associated with those APCs. Claims data analysis suggests that the Comprehensive APCs result in significant Medicare payment reductions for complex radiation oncology treatments.

Medicare Physician Fee Schedule

AAPM also provided written comments to CMS regarding the 2018 Medicare Physician Fee Schedule (MPFS) proposed rule, which impacts physician payment and payments to freestanding radiation oncology centers.

AAPM notes that 2018 Medicare proposals have minimum impact to radiation oncology procedures and services. The Association did comment on several new and revalued radiation oncology codes proposed by CMS. For 2018, CMS is proposing to accept the RUC-recommended work relative value units (RVUs) based on the understanding that the RUC generally considers the kinds of concerns CMS has historically raised regarding appropriate valuation of work RVUs. AAPM agrees with this proposal. We believe that the CPT/RUC process is rigorous and generally results in fair and equitable valuation of services.

CPT 77263 Therapeutic radiology treatment planning; complex was identified through a screen of high expenditure services across specialties as a potentially misvalued code. CPT codes 77261 and 77262 were also included for review. These are professional component only codes. For 2018, CMS is proposing the RUC-recommended work RVUs of 1.30 for CPT 77261 (current RVU 1.39), 2.00 for CPT 77262 (current RVU 2.11), and 3.14 for CPT 77263 (current RVU 3.14).TheAAPM supports the RUC-recommended and CMS approved RVUs for radiation therapy planning codes.

In October 2016, the CPT Editorial Panel deleted Category III code 0438T and created a new CPT code 55X87 Transperineal placement of biodegradable material, peri-prostatic, single or multiple injection(s), including image guidance, when performed. For 2018, CMS is proposing the RUC-recommended work RVU of 3.03 for CPT 55X87. AAPM supports the RUC-recommended and CMS approved RVUs for a new peri-prostatic implantation of biodegradable material code.

AAPM opposes the CMS-proposed code description and related work RVU for new superficial radiation treatment (SRT) planning and management code GRRR1. CMS intends for this code to describe the range of professional services associated with a course of SRT, including services similar to those not otherwise separately reportable under CPT guidance and the NCCI manual. For 2018, CMS is proposing a work RVU of 7.93 for HCPCS code GRRR1. AAPM recommends that the newly proposed service be subject to the AMA Current Procedural Terminology (CPT) Editorial Panel and Relative Value Scale Update Committee (RUC) processes.

Radcal RSNA Adv

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