ACCCExchange: A Members-Only Listserve

Q. How long are procedures scheduled on the Linac? We are scheduling 20 for IMRT, and I would like to make them 15 minutes. Is there a standard?

A. We have two accelerators. The Trilogy is set for 20-minute time slots and does the IMRT/IGRT, SRS, and SRB treatments. The 21EX does the simpler treatments, including our breast, w/brain, and mets patients, and is set for 15 minutes. We decided that the longer time slots help the RTTs stay on track and relieve a little pressure on them. With the newer more complicated setups and treatments, you can’t always think volume but need to think more about patient safety and service. And it’s hard to catch up once you are behind doing IMRT/IGRT treatments. You can always upgrade to Rapic Arc or the like if you need to really put patients through.

A. First question is why do you want to schedule them for every 15 minutes? You need to make the schedule fit the time required to treat the patient. Depending on tumor site, 15 minutes may be completely unrealistic.

A. Fifteen minutes would be sufficient regardless of delivery method (Sliding window vs. Step and Shoot IMRT) and most tumor sites. RapidArc IMRT should further improve throughput, saving an extra couple of minutes.

A. We have one linear treatment unit and schedule our patients in 10 minute increments. We believe this gives us more flexibility in scheduling. Most IMRT treatments require two appointments with a few IMRT treatments in 10-minute appointment slots. Other non-IMRT patients who receive more time-consuming treatments are given two (20 minute) or even three (30 minute) appointment slots. Our radiation therapists make the scheduling decisions based on the amount of time needed for each individual patient.

Q. I oversee a hospital-based radiation therapy/med/onc center and was wondering how your areas handle dietary referrals. We serve a very large underinsured population and our nutritional services department does not bill for nutrition consults. Is any one billing for this service? Are nutrition services just provided as a complement to your overall cancer program?

A. We have two clinical dietitians attend our weekly chart rounds and when they suggest a consult, a radiation oncology RN places the consult request, and we go from there. It is not a billable event, but we consider it an essential element of care and is in support of our whole person holistic model of care. NCCN guidelines support this service also.

A. We do not bill for any of our RD services. Medicare does not pay for this service currently with a cancer diagnosis. Some (very few) private payers will pay a small amount. We choose not to bill those insurance companies as the money is so minimal it would not be worth the time and effort needed to bill.

A. We provide nutritional counseling free of charge with money obtained from grants from a local breast cancer agency and the hospital's advisory foundation board.

Q. How are those of you in hospital infusion centers handling medical reconciliation? If you have a patient who is coming in for consecutive treatments, how often are you reviewing the medication list and performing a med rec? Are you asking the date & time of the last dose and recording that as part of your med rec each time?

A. Our institution has been working on this for several years, successfully implementing various steps along the way in the outpatient setting as well. All outpatients receive and review a list of their meds upon arrival. For chemotherapy or infusion patients, the changes upon arrival are made by the clinic nurses. The medication additions (post chemo meds) are added by the infusion nurses as they work the chemo orders.

We have a medication reconciliation group that is looking to write some nursing guidelines to address some of the questions you ask and more---such as---do we record regularly scheduled IV and sub-Q medications that could be important in a diagnosis (for instance bisphonates and vitamin b?)

We feel as though we need some standards to better instruct nursing about the process. For multi-day patients, we review the sheet and update, but subsequent days, we simply ask if there have been any changes. We have a specific place to document this in nursing notes. Guidelines state that med profiling is needed with a physician visit, therefore, on BP or simple nurse visits, profiling is not done because there is no physician to reconcile.

A. We complete medication reconciliation with each visit on every patient. The nurse compiles the list of all medications with dose on a form along the first column. There are columns across the sheet, and with each visit the column is dated and a checkmark is placed in that column if the medication is still being taken. If the medication has been discontinued, we line through the remaining columns. We add as needed with a line through columns to the date the of visit the drug was first reconciled. This is quick and easy. We copy it month to month since we use a recurring FIN system so that this information does not have to be done over with each visit. This works especially well with our long term outpatients. We are in the process of moving to an electronic medical record in our outpatient unit (inpatient already has), but as with our inpatient our medication reconciliation will stay on paper for now.

Q. When you have a patient with a port that is receiving a multiple day regimen, do you leave the port accessed or do you reaccess every day?

A. According to Oncology Nursing Society (ONS) venous access device guidelines, you need to change the needle on a weekly basis. We leave it up to the patients about whether they would like to leave the needle in for the 4-5 days, or if they want to be reaccessed each time. Some really dislike the pokes, so they choose to leave the needle in. It may also depend on their living situation. If they are not real compliant, have risky behaviors (IV drug abuse), or are not careful with hygiene, you may want to deaccess it every day. If they are real active and might be at risk for dislodging the needle, they might not want to have the needle in (exercise, heavy work, gardening/mucking out horse stalls, etc.). You can always change your decision based on your ongoing monitoring of the VAD.

A. You can leave the port accessed up to 7 days. We leave our ports needles in. This lessens the opportunity for infection and decreases pt discomofort.

A. I would like to add, if we leave the port accessed for multiple days, we use a biopatch to decrease the risk of infection.

A. We leave it up to the patient. I would say that 70 percent request to leave it in, and we dress it accordingly.

Q. Regarding Tumor Boards, after decisions are made about treatment, where does that go? Does it get sent to the PCP, surgeon and/or oncologist for follow up, or does it go into a file in the Tumor Registry? Are your Tumor Boards more educational, or for active treatment planning with the expectation that the Tumor Board recommendations are implemented?

A. We place the recommendations in a file in Tumor Registry. The physicians can obtain a copy at any time. After discussion with our legal counsel it was felt this was most beneficial due to concerns regarding discoverability. Our Tumor Boards are prospective with 3 to 4 one-hour educational programs on different days throughout the year.

A. Our weekly and bi-weekly Tumor Boards are educational forums. One category 1 CME is available for each. We do not record or retain ‘minutes’ or ‘recommendations’ from any Tumor Board. (Our counsel is concerned about discoverability also.) We do have ‘follow-up’ presentations periodically that will update the patient’s status, so patient outcomes are shared.

A. We did an extensive analysis with our legal department on what tumor conference documentation should comprise. Our current practice is that the 'notes' taken on each patient are kept centrally (with the Tumor Board administrator), all relevant care providers are in attendance (either in person or remotely using conference call and Live Meeting) and participate in the discussion, and attendance is documented and CME's provided. Legal recommended we stay with current practice based on: 1) Concerns around the legal liability to the hospital and participating physicians making recommendations with no patient present and limited information. 2) No control on outside physicians following the agreed upon recommendations. 3)Disclosure statements are not 'foolproof' and offer little legal protection. Basically we came away with the idea the tumor conferences are 'sophisticated hallway consultations'.

Q. I am creating a treatment planner that our patients can use to keep track of appointments and resource information. This will be a self contained piece with tabs for each subject and business card holders. Any suggestions to assist my patients would be welcome.

A. We have a large and busy cancer resource center and decided to use a great planner from Cancer 101 (www.cancer 101.org). Their planner has everything one would need. You can see it and order it online. Saved us a lot of work.

A. We adopted the use of the American Cancer Society’s "Personal Health Manager," which appears almost identical to the "Cancer101 planner" and a complimentary copy is provided to every new patient, saving the $10 per planner fee that Cancer101 charges.

A. We are developing a binder to be used by patients for their entire treatment course. This will provide patients with easy access to pertinent information, and allow current meds, chemo, scans, etc., to be recorded here. In short, a current medical history as well as education information.

A. ACS seems pretty inconsistent by market. My folks are okay with the planner they have but really don't like the registration process. Even if leadership is okay with it, some infusion center folks are not, so it gets kiboshed. We are working with a third-party planner we like and doing some customization.

Q. How do your infusion center nurses utilize and dispose of chemotherapy approved gowns when delivering chemo?

A. We checked with Marti Polovech, author of the chapter for the Oncologn Nursing Society (ONS) "Guidelines" (Edition 2, 3). We were told the nurse could wear one gown all day and move from patient to patient. The purpose of the gown is to protect the nurses’ clothing from possible contamination. Once the gown has been removed, it must be disposed of. This works well for centers that are doing primarily chemotherapy. Once the gown is removed, the nurse dons a new gown if there is a gap of time between chemo patients. This has increased our cost but puts us in compliance with the Practice Recommendations.

A. Basically, each nurse uses one gown because we are constantly having to move between patients and hanging multiple drugs. If nurses have a lull between duties or leave the pod, then they may hang the gown inside out on a hook outside the pod, but still on the unit. We also checked with ONS and were informed that nurses may use the same gown all day and must leave it on the unit if they go for break or lunch or leave the unit for any other reason.

A. We have the Phaseal system in place, and the RNs use chemo gowns for all chemotherapy. They remove the gowns between treatments when there is a gap of time, fold the gowns to the inside, roll them up, and leave them by the patient station.

Q. Currently, our center typically does not allow family members in to the control area to observe radiation treatments. I am considering making a change to that philosophy. Can anyone comment on what your practice is around this issue?

A. To us the bigger issue is privacy of the other patients in the center. We allow the family member to come into the treatment room on the first day, so they can see what we do. After that, they are asked to remain in the family room. With patients in a variety of states of undress, patient information in the control area (schedule, charts, camera for patient viewing, etc.) and healthcare information being discussed throughout the department, we have taken the position that patient privacy trumps allowing others unnecessarily into the department. We have extended this to other “visitors” to the department also, including marketing (tours only after hours), staff family members coming for a quick visit (must be met outside the department in the lobby, not allowed into the department). The exception to all this is if we have a pediatric patient their family member is along for the ride because the benefit to the patient outweighs the risk of privacy invasion.

A. Regardless of the radiation center that I have worked with in the past 20 years, the policy was not to allow family members at the control area. The concern was not radiation exposure but to ensure the therapists do not become distracted. They need to concentrate of the treatment to ensure the appropriate dose is delivered to the correct patient. This is a safety issue for the patient.

A. We on occassion have allowed a family member to be in the control room. In our experience if you are clear in the boundaries you set with the person (where to sit, not to ask questions of the therapist, not to touch anything), they are very respectful and appreciative of the opportunity. You should plan beforehand where the visitor will sit, and minimize any screens with PHI of other patients. You also need to get permission from the patient.

A. We don’t routinely allow family in the control room; however, the question is being posed more often, and we have accommodated some patients. As a group, we’ll need a better, well-scripted explanation for whichever side our facilities take with this issue than we’re seeing here, and here’s the precedent: The AHA now advocates for allowing family members to be present during a Code Blue, or cardiac resuscitation. We have adopted that here, and it is very helpful to families as it allows them to see the enormous team effort to save their loved one. Often, they ask us to stop our efforts, and this has eliminated much emotional turmoil for them and clarifies their decision. Our teams are adept at concentrating during medical emergencies, demonstrating sound critical thinking when drawing up critical meds, performing CPR, etc.

HIPPA is not an issue if a patient requests that the family member be there, most often to provide audio support to the patient. Transparency is here, whether it’s the OR for a C-section, a Code Blue, ER visit, LDRP room, dialysis or stem cell pheresis procedures. We have made this exception for pediatric/adolescent patients and for those with a psychological indication (therapist or family member present). We schedule these as last treatments of the day, charts are already put away, and the other patients have been treated for the day. We limit the control room support to one person/day and educate them about saving questions for the therapist who’s “driving” that day until after the procedure is completed, providing safety rationale. We recognize that the cancer experience is about the patient and their needs. It does take a little more planning, but we’ve had cases with truly inspiring results.

Q. Is anyone billing for above services? I am almost positive that this can be done but wanted to know what guidelines others follow. The Medical Records Director at my facility did not code and E&M for social work because he felt there was not enough information to bill. What criteria do you use for either of these disciplines?

A. In my experience this is not a charge that is reimbursed at this time. There are both MNT codes and Evaluation and Management codes for billing. However, Medicare only reimburses for diabetes and kidney disease and, therefore, most insurance companies follow the same reimbursement for medical nutrition therapy. Also, even if you did bill, it is my understanding that depending on your contracts with insurance companies you may see very little reimbursement depending on your contract and fee for service. Until reimbursement improves for medical nutrition therapy, charging for services will continue to be a problem.

Q. When are your cancer registrars producing staging sheets (for those of you that still work with paper). Is this done at case finding, abstracting, etc.?

A. In years past our pathology department attached paper staging forms to all positive pathology reports…all positive reports: diagnostic and definitive specimens. This created a glut of staging forms that were often left incomplete, even though the forms were tracked in the chart deficiency system.

In response to an ACoS survey, we changed this process to increase physician completion of staging on the paper staging form. The registrars took up the role of:

• Identifying which cases require staging by reviewing positive path reports daily
• Preparing the appropriate staging form
• Sending the form to medical records deficiency room for inclusion on the medical record
• Tracking the forms sent to med rec in a registry created database
• Monitoring documentation compliance at the time of abstraction (4-6 months later)

This system improved physician completion of the paper staging form from below 50% to over 98%. The above system has created a new level of confidence for the physicians asked to complete staging forms. They are aware that the registrar (the staging and ACoS standards experts) have pre-reviewed the case and that staging is appropriate. Taking this process to electronic staging forms will be our next initiative. The registrars also do real time (daily) monitoring of the path reports for CAP protocol compliance, notifying the pathologist for correction/clarification as necessary.

A. As a cancer registrar, I’ve found the process of staging at case-finding is much more efficient, improves accuracy and completeness, and enhances the collaboration of the physicians and the cancer registrars. However, the ultimate impact is improvement of cancer patient care.

I used some of the following rationale to change one registry’s policy of asking physicians to document staging when it was identified as incomplete at abstracting:

• Staging is an essential part of patient management decisions. Documentation of AJCC stage not only impacts continuity of care and communication among healthcare providers; it is critical in determining outcomes and quality of care, so the staging forms should be provided to physicians while the patient is undergoing diagnostic and treatment planning (when the case is identified).
• CoC Standard 4.3 mandates that AJCC stage and appropriate treatment according to national guidelines be monitored by the Cancer Committee, so it is imperative that the staging be documented in the record prior to treatment to measure compliance.
• Appropriate/correct staging should not be documented retrospectively 6 months after diagnosis and treatment have been initiated (at the time of abstracting).
• It is a burden on physicians, medical records personnel and registrars to have staging forms completed retrospectively.

A. Education on staging is an ongoing project. It always has been and there is no reason to think it will change.

First: the audience in an tumor conference or special meeting is often the "choir" who already is engaged and semi-knowledgeable. The problems are in those who rarely grace your conferences. Second: although to me, the idea of working stage is simple, you would think that I was presenting a complicated mathematical project. Change is difficult and getting the concept to the managing physician, that he/she is no longer providing the stage which the registrar submits to the NCDB is challenging. Third: the stage itself is a moving target, and rightfully should be: as the data and clinical impressions change so does the working stage. Fourth: it is virtually impossible to adequately explain all the changes in the new AJCC staging manual in a single setting, just lung alone is very complex.

In reality, every physician should be staging his/her patient at every juncture and using that stage to direct therapy – whether or not it is a formal listing of TNM. If, indeed, they are not doing so, they just should not be involved in cancer care of any patient. (For example, to say that all breast cancer needs a mastectomy and no other treatment is ignoring current best practices and wrong!) The ideal, to me, is a short discussion by a knowledgeable source at every possible chance. This is accomplished at our institution by the presenting physician indicating the stage and how it was derived. The real chore, however, as mentioned above, is to get he message to those who are not participators but still care for cancer in your institution. That often requires much sweat equity by the medical director, etc. in contacting the individual physician – and the tip- off for this contact is usually an incomplete medical record for that physician!

Q. Who does the Cancer Registry report to in most facilities? Does anyone have a valid tool or information for staffing a Cancer Registry?

A. Regardless of their duties, an average of 400 a year is roughly 9 a week-working 45 weeks annually. If they do one per hour, that leaves 31 hours a week for other responsibilities.

A. Registry staffing/productivity is always a contested subject. The rule of thumb, if you were to hire an independent outside abstractor or a registry service, is 1.25 - 1.5 abstracts per hour. Of course, this is ALL THEY WOULD BE DOING! How the registry is structured makes all the difference. Does 1 staff abstract only? Do follow-up only? Do case finding only? Do quality checks or support CoC standards activities only? If your registry staff is not limited to one function, than abstracting 1.5 cases per hour is reasonable. If the registry staff specializes in abstracting to the exclusion of the others, then you can start talking about the number of abstracts per day. Remember, as of 1/1/2010, all bets are off! The release of Collaborative Staging V2; AJCC Staging Ed7; and the FORDS updates will change the game. CS data alone will increase 341 percent (per NAACCR). TNM Staging is completely revamped including newly formatted staging forms. The CoC FORDS manual is changing to address the added data fields for the other two…the learning curve will be significant. I recommend you do not stake too much on 1.5 abstracts per hour. Those of you who use IMPAC software keenly felt the learning curve with the release of METRIQ. Productivity normalized in 3-4 months. The changes coming in 2010 will be as or more significant.

A. We need to also consider accuracy and follow-up rate when assessing registry performance. The higher the accuracy and follow-up rate you expect the more time per case you can expect. Increasing both of these metrics is not a linear equation, i.e. when pushing the upper 90th percentile it will require more effort (time) to go from to 96 to 97 percent than going from 86-87 percent. So if your expectations are low, you can staff less, if they are high, you need more depth. The best approach in all this is to take a bench mark (seems the consensus is 1.25-1.5 hrs/case, our average is 1.75hrs) then do a time study on your own performance and then measure the time spent on the many other valuable components the registry provides to your cancer program. (Registry studies, requests for information, CoC Special Studies, RQRS, Cancer Committee, conferences, etc.) If your registry is doing "stuff" that belongs somewhere else, reassign the tasks so your registry can focus on what they do. We have 1,350 new cases per year, 30,000 in the registry, have a follow-up rate of 95.7 percent, and a 100 percent accuracy rate. We have 4.0 FTE registrars (just added the 4th a few months ago to participate in RQRS) and 0.6 admin assistant.

A. The real question is what is the goal of your cancer center. Then how does the registrar fit into that mission? And a lot of this depends on size of the institution and scope of the center. There are many cancer programs in this country, as a matter of fact most of the centers, that are small but excellent and in effect run by a registrar - a real gem if you have one!

Q. I am looking for information on verbal orders being given by a RadOnc to Radiation Therapist (simulations especially). My understanding was that only licensed personnel such as RN or PA could take a verbal order.

A. Verbal orders are really on the hot seat right now with the Joint Commission. In fact, in our organization, we track the number of verbal orders, and we do not accept verbal orders at all when the physician is on-site. So, the verbal orders that we would accept would be in the situation when the physician is off-site and calls in a verbal order for a medicine to an RN or PA as you described. I would be very uncomfortable taking any verbal order for a simulation because CMS tells us that simulation must be completed under the DIRECT supervision of the radiation oncologist. This means the radiation oncologist must be on-site. I think you would have a hard time explaining to someone why this must be a verbal order when the physician is present. We utilize the MOSAIQ system, and we have built a rather robust table for simulation in the “Quick Rx” section that it is easy for the radiation oncologist to order vac locks, masks, prone position, contrast, etc.

Q. Who does the Cancer Registry report to in most facilities? Does anyone have a valid tool or information for staffing a Cancer Registry?

A. Regardless of their duties, an average of 400 a year is roughly 9 a week-working 45 weeks annually. If they do one per hour, that leaves 31 hours a week for other responsibilities.

A. Registry staffing/productivity is always a contested subject. The rule of thumb, if you were to hire an independent outside abstractor or a registry service, is 1.25 - 1.5 abstracts per hour. Of course, this is ALL THEY WOULD BE DOING! How the registry is structured makes all the difference. Does 1 staff abstract only? Do follow-up only? Do case finding only? Do quality checks or support CoC standards activities only? If your registry staff is not limited to one function, than abstracting 1.5 cases per hour is reasonable. If the registry staff specializes in abstracting to the exclusion of the others, then you can start talking about the number of abstracts per day. Remember, as of 1/1/2010, all bets are off! The release of Collaborative Staging V2; AJCC Staging Ed7; and the FORDS updates will change the game. CS data alone will increase 341 percent (per NAACCR). TNM Staging is completely revamped including newly formatted staging forms. The CoC FORDS manual is changing to address the added data fields for the other two…the learning curve will be significant. I recommend you do not stake too much on 1.5 abstracts per hour. Those of you who use IMPAC software keenly felt the learning curve with the release of METRIQ. Productivity normalized in 3-4 months. The changes coming in 2010 will be as or more significant.

A. We need to also consider accuracy and follow-up rate when assessing registry performance. The higher the accuracy and follow-up rate you expect the more time per case you can expect. Increasing both of these metrics is not a linear equation, i.e. when pushing the upper 90th percentile it will require more effort (time) to go from to 96 to 97 percent than going from 86-87 percent. So if your expectations are low, you can staff less, if they are high, you need more depth. The best approach in all this is to take a bench mark (seems the consensus is 1.25-1.5 hrs/case, our average is 1.75hrs) then do a time study on your own performance and then measure the time spent on the many other valuable components the registry provides to your cancer program. (Registry studies, requests for information, CoC Special Studies, RQRS, Cancer Committee, conferences, etc.) If your registry is doing "stuff" that belongs somewhere else, reassign the tasks so your registry can focus on what they do. We have 1,350 new cases per year, 30,000 in the registry, have a follow-up rate of 95.7 percent, and a 100 percent accuracy rate. We have 4.0 FTE registrars (just added the 4th a few months ago to participate in RQRS) and 0.6 admin assistant.

A. The real question is what is the goal of your cancer center. Then how does the registrar fit into that mission? And a lot of this depends on size of the institution and scope of the center. There are many cancer programs in this country, as a matter of fact most of the centers, that are small but excellent and in effect run by a registrar - a real gem if you have one!

Q. I am looking for a way to benchmark physician productivity with RVU. What would a reference annual RVU count be for a medical oncologist who sees a 50/50 mix of oncology vs. hematology for 250 new patients per year? I have the same question for a radiation oncologist.

A. Our highest producing physician does about 7,500 total RVUs per year. We also have a couple that do as low as 4,000 per year. Their mix is more like 75/25 hematology/oncology so theirs is probably higher. We use total RVUs, not worked RVUs. I have seen the 250 new patients per rad onc before, but ours only do about 190 per year. They believe that is because they travel to four sites and cannot be as productive with all the traveling.

Q. Do programs with certified genetic counselors credential them and bill in their name, do you bill under a supervising physician, or do you just write off the counseling as a free service?

A. Our genetics counselor is licensed. The problem seems to be one of credentialing. Do you credential the counselor with each private insurer and what codes do you use?

A. Medical genetics counseling is reported with code: 96040. Medical genetics and genetic counseling services, each 30 minutes face-to-face with patient/family. According to the AMA: “These services are provided by trained genetic counselors and may include obtaining a structured family genetic history, pedigree construction, analysis for genetic risk assessment, and counseling of the patient and family. These activities may be provided during one or more sessions and may include review of medical data and family information, face-to-face interviews, and counseling services.” Any medical genetics counseling performed by the physician would be reported with patient visit codes (generally 99212-99215). Cindy C. Parman, CPC, CPC-H, RCC, Coding Strategies, Inc.

A. We have an annual fund raiser (Wine Tasting) lead by a great group of community women (breast cancer survivors) that raises about half of the cost of this service.

A. We have had genetic counselors for many years and have had the patient see an MD for a few minutes as part of the session so we could bill under the provider. This year genetic counselors have by state statute become licensed in our state, so now we bill directly for their services.

Q. I am looking for two things: 1) an institution policy on brownbagging and 2) a letter to patients explaining our position on this issue to be provided on receipt of orders and subsequent preauthorization/financial counseling.

A. There is a white paper written for AOHA that is under Publications on www.dghconsulting.net that describes how a number of practices were dealing with brown bagging when the last major wave hit in 2001. The first and easiest defense arguments are centered on liability and MD responsibility. Since the MD is ultimately responsible for the drugs given to a patient under his care, particularly in chemotherapy treatments, he or she has the right to say "I don't know the source, I don't trust the source, and unless you sign a waiver of liability completely taking the responsibility for forcing this drug onto me and my patient, I am not comfortable accepting this program." Payers won't even consider such a waiver, and so most programs disappear after this conversation. There are other issues, involving waste, additional costs of administration, and drug substitution, but this is all part of a bigger issue of payer negotiations and relations. Every single day, payers are receiving calls and marketing visits from companies seeking to move into the management of oncology drugs and oncology care, and a common theme is that they can save payers money by narrowing the drug choices and controlling the treatments - usually without the involvement/agreement of the physician. It's a key part of charting your course for the next few years, understanding all these various challenges (brown bagging programs are just the tip of the iceberg) and how you want to deal with them.

Q. I am looking for some guidance on the Tumor Registry. Where can I find productivity benchmarks and job descriptions?

A. I would recommend that you go to the National Cancer Registrar Association (NCRA) website. www.ncra-usa.org. You should be able to find some resources there.

Cancer Registry Management Principles & Practice (2nd Edition, Softcover) ISBN 0-7575-0192-3; $89.95 Member and $114.95 Nonmember. You may want to call the publisher at 800) 338-8290 or visit www.kendallhunt.com. Now in its second edition, this remains an excellent resource providing valuable information to hospitals and outpatient treatment centers on how to set up and maintain a Cancer Registry. Published in 2004, the book can be used as a basis for all disease registries, but Cancer Registry issues are addressed specifically. Thirty chapters address all areas of Cancer Registration, meeting the demands for registrars employed in hospital-based, free-standing facilities and central registries. Both clinical and administrative aspects of the acquisition and dissemination of cancer information are addressed. The book offers: basic training for new registrars, study material for certification, NCRA-Accredited Formal Education Program textbook and overall, a resource in the health care system. The chapters, written by a team of 50 experts, are concisely written and most contain charts, tables, or illustrations. They also include introductions, summaries, study questions and answers, and references.

Q. Is there now an expected standard of care for anthracycline extravasations?

A. I was given a copy of the ONS Guidelines (3rd ed, p. 108). Table 11: Vesicant Extravasation Management Guidelines—Totect (without recognition of the generic drug) is the only listed "Treatment"—the doses are as noted in the HemOncToday article of May 25, 2009.

Q. Please share OCN pay differential policy and rate if applicable.

A. Our organization does pay a $.75/hour differential for OCN. If the nurse has more than one certification, though, we only pay the differential for the first certification. We also pay up front for the exam cost and only ask that it be reimbursed to the organization if they do not pass the exam. The exam cost, therefore, can only be paid one time.

A. OCN certification has always been an expectation in our clinic. Before we were hospital affiliated, we paid for the exam and then $.50/hour once they had successfully passed. Now that we have the hospital affiliation, the nurses who have OCN certification get $1.00/hour, but have to pay for the test themselves.

A. We do not offer a pay differential. Upon successful completion of the OCN exam, we reimburse the staff for the cost of the test.

A. We pay the expenses for the exam, and we give a $2.00/hr raise for passing the exam and maintaining the credential – We do not increase at time of renewal. We do the same for AOCNP.

A. We pay for travel and cost of exam, recertification every four years, and $1/hour stipend.

A. OCN certification is just one of the things that can get additional pay for nurses at our hospital. We pay 29¢ per hour for up to three certifications or competencies - a person might be ACLS certified, OCN certified, and a nurse preceptor, for example and would get 29¢ x 3 for a total of 87¢ per hour added to their pay. Each unit defines what they consider important competences/certifications that will get additional pay. Obviously, OCN certification is part of the list for the IP and OP oncology areas.

Q. Wondering how other organizations utilize oncology social workers at their facilities. Do you have a social worker that is specific to each individual unit regardless of the patient's diagnosis (cancer or non-cancer) or does your oncology social worker go more "housewide" for cancer patients and work with just cancer patients from various units (i.e., surgical, outpatient, and inpatient units)?

A. Our social workers are assigned by units but we have one on our inpatient oncology unit.

A. We have an oncology dietitian that sees oncology patients by appointment—we don’t bill for this. She also sees patients for diabetes and weight management (non-oncology) and we do bill for these. All the patients she sees are at the Cancer Center but none seems to mind coming here. Social worker is at the cancer center but inpatient RNs can trigger a consult for the social worker to come over to the hospital to see a patient. We don't bill for this or any social work.

A. We have both a full time dietitian and social worker and include their time spent with the patient when we charge the clinic visit for that day ( we are a hospital based facility) . We only do that for initial consults - any time the patient is seen after that is unbilled from the dietitian/social worker.

A.We have one social worker for both inpatient and outpatient. We consider her a vital part of our cancer team. Along with her, our team is made up of two oncology nurses, chaplain, and financial counselor. We are a rural hospital.

A. We have a certified oncology social worker who sees both med onc and rad onc outpatients only. We accession about 900 patients in the cancer registry annually. Recently, we added per diem social worker hours because when the full time social worker was away, we needed dedicated and skilled coverage as she is an indispensable part of the team.

Q. Recently, two of our nurses attended a ONS Review Class. At the meeting, one of the speakers discussed having nurses, pharmacists, and other ancillary staff who work in the infusion unit and/or administer chemotherapy under go blood work once a year to measure their exposure to chemotherapy despite taking all the necessary precautions. How are other cancer centers are handling this situation?

A. Good question! Our charge nurse was interested in this several years ago, and did a fair amount of research to see if there were any protocols already in place. She could not find anything substantial at that time. However, as a result of that we have an informal policy that the RNs in the infusion suite voluntarily keep a list of all drugs they handle, mix and/or give on a daily basis. Their monthly lists are filed. Beginning last year we had them see an occupational physician for a base-line annual review with blood work. Most of them now consider it a waste of time, as participation has dropped dramatically. Part of the reason is there seems to be no known consensus on what significance raised LFT's would mean in relation to their chemotherapy work, as the variables are so immense. If any one knows of any articles on this subject that have any significant conclusions regarding actions to take if blood work begins to be off; or have policies in place that describe actions to take in the same event, with published rational, I am sure there are many of us out here who would be interested in reviewing it as well. Maybe ONS can encourage some research on this issue and get it published to provide some evidence based rationale.

A. All of our staff who mix and administer chemo undergo a yearly oncology medical surveillance exam which includes a health history, CBC, CMP, UA, and physical exam. Any new hires have this done and then it is done annually, and after an acute exposure incident and upon termination.

A. Is there any scientific basis for this sort of thing? How can you decide what to do if you don't even know what you are looking for? As our friend the Cheshire Cat once said: "When you don't know where you are going, any road will get you there."

A.We do not perform any medical surveillance of our staff. The problem with recommendations (CDC/NIOSH) is that there is no guidance or standards to follow after you uncover a potential issue. There is also a cost to all of this. How would one ever prove cause and effect? Does the practice/worker go down the litigious path. There are more environmental and other toxins we are exposed to every day not to mention familial/genetic risk factors. From my point of view, it is our responsibility to provide the best protection we can for our workers. If correct technique, PPE, BSC's, and closed-system devices are used, the chances of any toxic exposure are minimal if any. If someone has any scientific proof that workers are at risk when following the above procedures, I would love to see it.

A. In my previous employment in a physician's office, I requested health screening for all our employees because I wanted the chemo nurses screened in accordance with ONS guidelines. The more I thought about it, I thought it should be a benefit available to all the employees, and the physicians agreed. Testing was required of the chemo nurses, but only offered to others if they wanted to do it. Almost everyone participated. We drew CBC, CMP, and did urinalysis, we also did hepatitis B titers for those who had received the injections and wanted to know their status. We did have some abnormal findings in non-infusion employees. Those employees were referred to their personal physicians for follow up. It was all done very confidentially. They stayed healthy on the job, and learned some responsibility about taking care of their health. Seems like a pretty low cost to have some peace of mind about the health of the people you work with.

Q. We are seeing an increasing number of iron patients in our outpatient (hospital-based) cancer center. Does anyone know of a reimbursement change with Venofer? I have heard that it is no longer being reimbursed for anything except patients with anemia due to CKD. We have been using it off-label for our other iron patients, and as of a few months ago, we were getting reimbursed. If that has changed, what is our alternate drug?

A. We use Ferrlicet and are reimbursed with no issues. Venofer is non-formulary here, and we have had to special order it only once for a patient intolerant of Ferrlicet. We do not give a test dose and we infuse 125 mg in 100 ml N/S over one hour and have never had a problem (times 4 doses or 8 doses). It is much better tolerated than Infed. Previously, we used to infuse Ferrlicet 250 mg in 100 ml over 1 hour, however, in our gastric bypass, young, female patients of slight build (but no other types of patients), they ended up in the ER several hours after the infusion on either day 1 or day 2 with hypertension and swollen lower extremities. Our PharmD did a lot of research and we lowered our dose to the 125 mg and have not had a problem since.

A. I agree in that this is a carrier-specific issue. A little education on your part to them should help (this is not unlike the recent Leucovorin shortage, where we contacted our payers ahead of time to inform and educate them on why we would be using Levoleucovorin in the short term). We are also fortunate that our Medicare carrier (NGS) already recognizes and pays for both Iron Sucrose and Iron Dextran for all Iron indications. Below is the LCD for NGS. Not sure if it will help, but will at least give you a reference to work with.

Q. We are a hospital-based, outpatient cancer center. Within our center we have radiation oncology, private oncology practices, and chemo/treatment outpatient. For those of you who have two areas (rad onc and med onc), how many of you have separate check-in and check-out desks/areas for your patients? How many have one central check in and check out? We currently have two separate desks, and I'm in the process of moving to one central check in and out areas.

A. We have two separate check-in areas because Rad/Onc is located on floor 1 and Chemo on floor 2. Unfortunately, centralized scheduling is not seamless due to the fact that ARIA is used for Rad/Onc and a McKesson product for Chemo. This also leads to problems merging accounts for billing purposes. Having one enterprise system capable of handling both portions will save future headaches.

Q. We are seeing more patients without insurance in medical oncology. We are considering some type of discount up front for patients that have no ins. Does anyone have a "self pay" policy that they can share?

A. We provide a 20 percent discount if the patient pays on the date of service. We also have our own financial hardship policy. Patients can qualify for a 40-60 percent discount if they meet certain criteria. For uncompensated care patients, we have an arrangement with our hospital in which they pay us ASP + 6 for drugs and a fee for each patient encounter. Our next contact with them will incorporate additional reimbursement in the form of a contract to provide those services.

A. Here is our policy.

Self-Pay Prompt Pay Discounts: At times, patients with no insurance coverage will request discounts on their accounts. Also, staff may offer a prompt pay discount directly to patients with no insurance coverage. Such discounts may be provided in the following situations:

• No other discounts have been provided (Managed Care, Administrative, etc), unless the self pay portion of the balance is due to non-covered charges.
• Full payment of the remaining balance will be made within 10 working days
• No third party payor payment has been applied to account
• Self-Pay discount levels from final bill date.
  
  1. 0-30 days - 30%
  2. 31-60 days - 20%
  3. 61-90 days - 10%
• Patients who have obtained a bank loan through the Hospital will be eligible for the self-pay prompt pay discount. The discount will be revoked if the bank loan goes into default.
• Under special circumstances to be determined on an individual account basis, accounts greater than 90 days may be granted a discount with Patient Accounts Management Approval.