AMA Rejects Request For New Hem/Onc CPT Codes

Neltner Billing and Consulting recently submitted documents to the AMA suggesting that the infusion coding oncology and hematology rely on for appropriate payment of professional physician work and practice expense is failing in its purpose. Along with those documents we made requests for revised CPT coding to better reflect the work physicians are truly performing.

Unfortunately, the CPT Panel rejected our requests for the following reasons – with which we disagree:
1) They feel the existing E/M codes adequately describe physician services.
2) They feel our proposal lacked specialty society support.

1) We disagree and maintain that the existing E/M codes do not represent the professional work value associated with oncology/hematology treatment planning. They do not include specific bullet points or measures which can be scored to attribute to the level of service indicated. We have evidence that auditors continually fail to recognize the physician work associated with oncology/hematology planning in that levels of service are down-coded because credit is not properly attributed to the medical decision making. Auditors use medical necessity as the overarching criteria for down-coding the level of service, relying on the incorrect premise that a new problem, diagnosis or complication must be present in order to bill a level five service.

Auditors fail to recognize that a comprehensive review and exam combined with the high medical decision-making elements associated with administering drugs that cause extensive toxicity qualify as a level five service – even in a stable, chronically ill patient. The misunderstanding associated with what truly constitutes a level five service provides additional evidence that there is a need for separately reportable codes to identify the treatment planning elements of oncology and hematology encounters. The AMA coding in the infusion coding preamble discusses the highly complex nature of oncology care. Therefore, one code cannot come close to offering evidence of the different levels of care required to identify the correct treatment planning code for different levels of care.

2) With respect to a lack of support from specialty societies, we did receive and review the comments provided by the American Society of Clinical Oncology and the American Society of Hematology. While these societies ultimately don’t support the specific code requests, both expressed agreement with our contention that the physician work is not adequately captured with the existing E/M codes, nor is it included in the drug infusion codes. (Both societies indicated that a single code to represent oncology treatment planning would be more favorable rather than the proposed tiered set of codes.) With due respect, we do not believe that either ASCO or ASH understand what is happening in the community. After all if 95% of their members are under-coding – and hence, devaluing their service – who is going to complain? What we are experiencing is that auditors are looking at level five notes and calling them level three services.

Physicians across the US continue to down-code for fear of audits, and the work to defend their choice of high complex coding is under attack by carriers who use tactics of three formal reviews that will result in a lot work to defend an additional $40 payment per code. Also, these auditors and their processes do not allow a change in policy if you do actually win at the highest appeal. We have specific documentation to support this concern.

That is why we believe new coding with better definitions will resolve the concern.

Where do we go from here?
What we have done is ask the AMA to synchronize our coding request with the coding request proposed in 2004 by the Drug Administration work group (as suggested by ASCO and ASH). We would be pleased to have the Panel consider the proposed codes in a condensed format, represented by some variation of codes, rather than the series of codes originally requested. This would also be more consistent with the perspectives of ASCO and ASH.

We are hoping to hear back from the AMA and request reconsideration for this coding effort to be placed on the February 2010 agenda of the CPT Panel Executive Committee.

Stay tuned.

Reality is in the Results, and It is No Surprise

In our previous post, “Considering Solutions for Oncology Drug Purchasing”, we asked for you to fill out our short “worksheet” in the News area of our website. We had several responses from oncology/hematology practices, comparing what they are paying to the Medicare allowable. No surprise: most physicians are paying way too much. We have posted these current results on our Neltner Billing website, and will update this as we get more data from hematologists/oncologists across the country.

Now that you see the data, is it reality or myth that:

• Oncologists cannot purchase drugs at ASP or lower.
• Oncologists have been misled by industry representatives that oncologists are purchasing drugs at or below ASP.

The answer is reality, and you are proving it in your numbers. The table shows that most payments are red and blue. Red numbers denote payments of ASP+6% or higher; blue numbers denote payments between ASP and ASP+6%. There are few numbers in black which actually fall below ASP.

Thank you for the responses we have received so far and please keep them coming. It is clear from what we have collected so far, that ASP is flawed. The more data we can collect, the stronger we will be in lobbying for change. The data, the reality, cannot be ignored.

If any of you would be interested in attending pre-scheduled airport meetings, please comment back to us as we have considered this as a venue to discuss the ASP issue together in person.

Considering Solutions for Oncology Drug Purchasing

Thank you for your comments on the recent ASP post. Oncologists need to band together and find a solution to this problem.

Yes, this is doable. We need to create and engage in a process that suggests finding a solution in a free market system.

Medicare will never hear our plea for better reimbursement unless we can prove with documentation and examples that:
1. ASP is not working and why.
2. The current coding system is not properly reimbursing you for your cost.

How do we prove this to Medicare?

Who can purchase drugs at ASP or lower? You know that many of you are unfairly purchasing at ASP or higher. Following are some points to investigate in proving our case to Medicare:

1. How can we determine that the ASP formula is flawed?
2. Are distributors, GPO (Government Printing Office) and manufacturers taking more profit from the ASP formula than what they should be taking? Would the government agree?
3. Is it true that distributors obtain 2% plus from the manufacturers that are not counted in the ASP formula? If this is true, do distributors need to take another 4% profit from their customers?
4. Why hasn’t One Oncology launched its product? We are told that distributors will not sell to them and this interferes with the free market system. So, who is responsible for stopping this from working?
5. Have the manufacturers, distributors and GPOs misled their customers by making them think they are purchasing drugs below ASP, when in fact the customer is buying below ASP + 6% (huge difference)?
6. Isn’t the GPO supposed to help practices save money?
7. Aren’t we all supposed to purchase drugs at ASP?

Share your thoughts and ideas so we can collectively find the solution. On our Neltner Billing website, we have posted a short “worksheet” in the News area that will enable you to compare the Medicare allowable to what you are actually paying. You can fill it out, fax it back to us anonymously and we will build a spreadsheet with the results we receive. I think this is the type of real data we need to start lobbying.

Our next post will include a sample letter and instructions on writing your senators and congress representatives about this issue. We will do the same. If enough oncologists/ hematologists write in, we can create momentum. I think this is the first step in developing awareness.

Myths and Realities in Oncology Drug Purchasing

The price of oncology drugs is sky rocketing and reimbursement for them has continued to fall. This may be hurting your practice more than you know. What are you paying for your drugs as compared to the Average Sales Price (ASP)? Do you know the Medicare allowable for these drugs? If you cannot answer these questions, what you don't know may be hurting you.

What person would enter into a business where:
· 85% of his/her product has a margin less than 2%?
· The cost of the product is paid in not less than 90 days?
· The product purchase price requires a huge cost of labor to support the product and has a bad debt of not less than 5%?

Probably no one. Now, let’s take a quiz.

Reality or Myth:
· Oncologists cannot purchase drugs at ASP or lower.
· Oncologists have been misled by industry representatives that oncologists are purchasing drugs at or below ASP.
· Many oncologists are now faced with hundreds of thousands of dollars in debt using the “buy now and pay later” leverage.

If you answered “myth” once and reality twice, you are in the same boat as many of your colleagues. The unfair practices occurring in oncology drug purchasing are putting small private practice oncology groups out of business as we speak. Within our client base, we are finding that several small oncology/ hematology practices and solo practitioners are ending up in the red relative to the purchase of their oncology drugs.

At the helm of a Midwest billing and consulting firm that works with many oncology practices, I intend to continue to investigate what is happening here.

Smaller practices and solo practitioners don't have the purchasing power of larger practices. Therefore, they pay higher drug prices. That does not seem fair. The Medicare allowable for these drugs is ASP plus 6%. Medicare's payment is 80% of their allowable. While this may seem to come out in your favor, many times it does not and you end up paying for your patients' drugs.

There is a difference between purchasing drugs at ASP and at ASP + 4%, 5% or higher. Many oncologists think they are purchasing drugs below ASP, when in fact, they are purchasing drugs at ASP + 6% or 7%. Yes, there is a difference. Calculate your complete numbers and see what you are really paying. Don’t rely on certain drugs with their rebates that come later.

The free enterprise system suggests you, the oncologists, must figure out the process to purchase your drugs at ASP. Is that your job? The perfect world would be when every oncology practice can buy at ASP – because no one would be offering a drug cost below ASP. We’d all be on a level playing field.

So now that we have identified the problem, what is the solution? Share your thoughts by clicking the comment button below.