The Centers for Medicare and Medicaid Services (CMS) continue to collect data related to oncology services to determine appropriate payment rates in private practices and in hospital outpatient departments. The proposed -10.1 percent cut in physician services was reversed by Congress, giving physicians a temporary 0.5 percent increase in the conversion factor to $38.087 through June 30. The payment rate will revert back to the original -10.1 as of July 1, 2008 if further action is not taken.

New Infusion Codes. Effective January 2008, three new codes have been added for therapeutic and prophylaxis infusion. These codes are as follows:

• 90769 – Subcutaneous infusion for therapy or prophylaxis initial, up to one hour, including pump set-up and establishment of subcutaneous infusion site. (16 minutes or more)
• 90770–Each additional hour
• 90771–Subcutaneous infusions additional pump set up with establishment of new subcutaneous infusion site. (once per encounter)

These codes are reimbursed in both the practice and hospital settings.

Revised Codes: 90760–IV infusion hydration, initial hour now requires at least 31 minutes. Documentation of start and stop times becomes even more important in determining whether it is correct to use this code. If the infusion for hydration is less than 31 minutes, you are required to use the injection code.

Modifiers. Three new modifiers are now required when reporting claims for erythropoiesis stimulating agents (ESA’s) J0881, darbepoetin alfa, 1 mcg, and J0885, epoetin alfa: 1000 units. 1) EA-ESA, anemia, chemo-induced; 2) EB-ESA, anemia, radio-induced; and 3) EC-ESA, anemia, non-chemo/radio induced. In addition to the modifier, all claims require reporting of either the most recent hematocrit or hemoglobin levels.

Two additional modifier changes relate to clinical trials: Q0 – Replaces QA and QR for investigational clinical services provides during a research study; Q1 – Replaces the QV modifier for routine items or services provided in a Medicare Qualifying clinical trial on facility claims.

For 2008 in the practice setting, reimbursement for pharmaceuticals remains at the Average Sales Price (ASP) +6 percent.

Click here to view a table (from the upcoming March/April 2008 Oncology Issues) that demonstrates drug reimbursement for the first quarter of 2008 in the private practice setting, the current hospital outpatient department at ASP +5 percent, and the proposed ASP +3 percent for hospitals in 2009.

Hospital outpatient department reimbursement was reduced to ASP +5 percent for 2008. CMS has proposed to use 2008 as a transition year for hospital outpatient departments and initiate ASP +3 percent in 2009. For 2008, the hospital outpatient department packaging threshold for drugs not paid separately was raised to $60.

Medicare continues to reimburse pre-administration services for IVIG using code G0332. In addition, anti-emetics are reimbursed separately and exempt from the hospital outpatient packaging rule.

Section 911 of the Medicare Modernization Act (MMA) of 2003 requires the Centers for Medicare & Medicaid Services (CMS) to integrate the administration of Medicare Parts A and B fee-for-service benefits into Medicare Administrative Contractor (MAC) jurisdictions. The contracting reform is aimed at integrating the work performed by Medicare Part A fiscal intermediaries and Part B carriers, so that each regional MAC will adjudicate all fee-for-service claims that come from Part A and Part B. The agency plans to award 15 A/B MACs by 2009.

The transition from Medicare Part A fiscal intermediaries and Part B carriers to MACs began more than two years ago. In July 2006, CMS awarded the Jurisdiction 3 (J3) A/B MAC contract to Noridian Administrative Services. The J3 MAC is now fully implemented and operational, and in its first months of operation the transition appears to be going smoothly.

Click here to view a national map of the A/B MACs by state.

The status of MAC contracts under Cycle One of the roll-out is as follows:

• August 2007, CMS awarded the J4 A/B MAC contract to Trailblazer Health Enterprises. Trailblazer is scheduled to assume full responsibility by spring 2008.
• September 2007, CMS awarded the J5 A/B MAC contract to Wisconsin Physicians Services Health Insurance Corporation. The company is scheduled to assume full responsibility by September 2008.
• October, 2007, CMS awarded the J12 A/B MAC contract to Highmark Medicare Services, Inc. On November 5, 2007, Palmetto GBA filed a protest against the award with the Government Accountability Office (GAO). Currently, the contact is under a stay of performance until CMS completes corrective action on certain aspects of the award decision.
• October, 2007, CMS awarded the J1 A/B MAC contract to Palmetto GBA. On November 13, 2007, National Heritage Insurance Company filed a protest against the award. The deadline for the GAO decision on the protest was February 21, 2008. The filing of the protest triggered an automatic stay on performance of the contract while the GAO’s decision was pending.

To summarize, at this time five MAC contracts have been awarded: J1, J3, J4, J5, and J12, and two awards have been protested: J1 and J12. The Cycle Two MAC roll out starting in 2008 will include seven MAC A/B jurisdictions: J6, J8, J9, J10, J14, and J15.

CACs' Role Remains. MACs will continue to use the Carrier Advisory Committees (CACs) unless or until there is a change to the Program Integrity Manual (PIM). To date, the three MAC contractors that have implemented services are not planning to change the CAC process, and these three have kept in place a CAC from each state. What has changed is representation; to date, each MAC has opted to have one medical director, rather than one medical director for each state within the MAC’s jurisdiction. Note: The implementation of regional MACs will result in the consolidation of local coverage determinations (LCDs). Having input into that final LCD is an important issue as this transition process continues and states begin to use regional decisions. Ongoing communication individually and between the CACs and MACs will be vital in the ongoing transition process and for consistency in the future.

Questions? Contact Marci Cali, Executive Director, Oncology State Society Network at 301.984.9496, ext. 238 or email: mcali.ossn@accc-cancer.org.

• Avastin. The Food and Drug Administration (FDA) gave accelerated approval to use Avastin (bevacizumab) in combination with paclitaxel chemotherapy in patients with metastatic HER2-negative breast cancer who haven't had any chemo yet. Accelerated approval can be changed to full approval after Genentech submits data from two additional Avastin breast cancer trials. According to an announcement from Genentech, the approval is based on a Phase III study (E2100) that showed that Avastin in combination with paclitaxel chemotherapy resulted in a 52 percent reduction in the risk of disease progression or death compared to those treated with paclitaxel alone and a doubling in progression-free survival (PFS) (based on a hazard ratio of 0.48; p<0.0001). Avastin is already approved in the U.S. for treating lung and colon cancer. Through a partnership with Genentech, Swiss drug maker Roche markets the drug in Europe, where it had previously been approved as a breast-cancer treatment.
• Ixempra. CMS has assigned a specific C-code, C9240, to Ixempra (ixabepilone) effective date of service January 1, 2008. Billing for Ixempra should be done by total dose, in 1-mg billing units.
• Leukine. Bayer Healthcare Pharmaceuticals and the FDA have informed healthcare professionals of the market withdrawal of the current liquid formulation of Leukine, a growth factor that helps fight infection and disease in appropriate patients by enhancing immune cell function. The product was withdrawn because of an upward trend in spontaneous reports of adverse reactions, including syncope, which are temporally correlated with a change in the formulation of liquid Leukine to include edetate disodium (EDTA). The upward trend in adverse reaction reporting rates has not been observed with the use of lyophilized Leukine. Healthcare professionals should immediately stop using liquid Leukine and return unused vials to the manufacturer.
• Thyrogen. Genzyme Corp. announced that the FDA has approved a supplemental indication for Thyrogen® (thyrotropin alfa for injection) to be used in combination with radioiodine to ablate the remaining thyroid tissue in patients who have had their cancerous thyroids removed. The FDA approved Thyrogen for remnant ablation based on results from a clinical study which suggest that treatment with Thyrogen is similar to withdrawal from thyroid hormone in achieving ablation, and that it could significantly reduce the side effects of thyroid hormone withdrawal by allowing patients to remain on hormone replacement therapy.

Apache, Coconino, La Paz, Navajo, and Yuma Counties have a stable trend of  cancer death rates below the national norm. How does your county fare? Click here.

For more data on cancer in Arizona, visit the Arizona Cancer Registry.

For specific information about the The Arizona Comprehensive Cancer Control Plan, click here.

As a member of the local and state-wide oncology community, the specifics of your state’s plan for dealing with comprehensive cancer control are of particular importance. Defined by the Centers for Disease Control (CDC) as “a collaborative process through which a community and its partners pool resources to reduce the burden of cancer,” the specifics of a state’s comprehensive cancer control program are spelled out in state plans. All 50 states have such plans that describe the strategic actions a state is taking to address the prevention and treatment of cancer.

For further information about state comprehensive cancer control measures, click here to read an Oncology Issues article by Leslie S. Given and Karin Hohman.

The Association of Community Cancer Centers (ACCC) will present its 34th Annual National Meeting at the Baltimore Marriott Waterfront Hotel in Baltimore, Md., on April 2-5, 2008. ACCC's Annual Meeting is the perfect opportunity for your entire cancer care team (physicians, nurses, administrators, and billers/coders) to strengthen their skills and network with their colleagues. Learn about Medicare rule changes, physician/hospital alignment, contract negotiation, compendia changes, quality improvement...and much more. ACCC's Annual National Meeting offers practice tracks with hands-on and timely information to help your practice and the entire multidisciplinary cancer team.

Read the agenda.

Read more and register.

The National Institutes of Health (NIH) asked the Institute of Medicine (IOM) to study the delivery of psychosocial services to cancer patients and their families and identify ways to improve it. The IOM defined psychosocial health services ias: "psychological and social services and interventions that enable patients, their families, and health care providers to optimize biomedical health care and to manage the psychological/behavioral and social aspects of illness and its consequences so as to promote better health."

In its October 2007 report, the IOM examines the inclusion of psychosocial services as appropriate cancer care. The report is entitled: Report Brief, October 2007, "Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs."

The IOM report concludes that all cancer care should ensure the provision of appropriate psychosocial health services by: 1) facilitating effective communication between patients and care providers; 2) identifying each patient’s psychosocial health needs; and 3) designing and implementing a plan that: links the patient with needed psychosocial services, coordinates biomedical and psychosocial care, engages and supports patients in managing their illness and health, and systematically follows up on reevaluating and adjusting plans.