MSCO Newsline

WPS article on on reducing error rates for chemotherapy-related services

WPS Medicare has noted a recent increase in errors assessed for chemotherapy-related services.  These services have the potential to have a large impact on Comprehensive Error Rate Testing (CERT) error rates for WPS Medicare and on a national level.  To assist its providers and combat potential future errors, WPS has asked us to let our state society members know about an educational article written specifically for those who perform and bill chemotherapy-related services.

WPS eNews

Wisconsin Physician Services (WPS) Medicare Jurisdictions 5 and 6 has issued a positive local coverage determination for CellSearch® Circulating Tumor Cell test. This policy will become effective 2/15/12. This coverage policy is for the CellSearch® (Veridex) Circulating Tumor Cell (CTC) assay utilizing CPT codes 0279T and 0280T. The policy clearly states that all other methods for circulating tumor cell detection, including PCR (RTPCR) assays, are non-covered as they are considered investigational.

Circulating tumor cells represent the point in the metastatic process of solid tumors when cells from a primary tumor invade, detach, disseminate, colonize and proliferate in a distant site. Detection of elevated CTCs during therapy is an accurate indication of subsequent rapid disease progression and mortality in breast, colorectal and prostate cancer. Therefore, CTC testing will be limited to metastatic breast, colorectal and prostate cancer. CTC testing for all other malignant diagnoses will be denied as not reasonable and necessary. The WPS policy can be found in its entirety at www.wpsmedicare.com, Circulating Tumor Cells Assays – L-32218.

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In Section V of its eNews for Monday, October 17, 2011, Wisconsin Physicians Services (WPS) provided instructions to providers on the documentation to be submitted to get high dollar drug claims paid in a timely fashion. The instructions read:

What documentation do I have to submit to get my high dollar drug claims paid timely?
To expedite your payment and to avoid CERT errors submit at least:

1. The original medication order that is signed by the ordering physician. A complete order will include the drug name, the ordered dose, and the ordered frequency.
   
   
2. The flow sheet, which includes the patient's name, dated the same as the date of service billed, shows the name of the medication given, the amount of the medication given, and any wasted amount of the medication.

The information also is available on the WPS website in the news scroll.

Please note that the "Medicare Tip of the Week," also contained in the October 17th issue, is a link to specific policy requirements for certain chemotherapy drugs and their adjuncts. To view this policy, go to: www.wpsmedicare.com/part_b/policy/active/local/l28576_honc010.shtml.

HR 905 and S 733: Remove the Prompt Pay Discount

MSCO President Joseph W. Leach urges all MSCO members to contact their senators and representatives regarding the two bills to remove the prompt pay discount from the ASP calculation.

As of Thursday, May 12, 2011 there are 31 co-sponsors for HR 905 across 20 states and 2 co-sponsors of S 733. These bills are gaining momentum in the House and Senate and now we need co-sponsors from Minnesota to sign on in both chambers.

The Minnesota Society of Clinical Oncology (MSCO) supports HR 905 and S 733, companion bills in the House and Senate that would remove the prompt pay discount from the calculation of Average Sales Price (ASP). These bills are bi-partisan and were introduced by Representatives Gene Green (D-TX) & Ed Whitfield (R-KY) in the House and Senators Stabenow (D-MI) & Roberts (R-KS) in the Senate.  The bills would remove the prompt pay discount from the ASP calculation, thus giving physicians a more accurate reimbursement for drugs, closer to the ASP+6% they should be getting based on the 2003 Medicare Modernization Act (MMA).  

MN providers are facing increased difficulties in caring for their patients and inclusion of the prompt pay discount in reimbursement calculations makes care of Medicare patients almost impossible.  Medicaid does not include the prompt pay discount in its calculation of AMP, and neither should Medicare.  Let your representatives know that you support the removal of the prompt pay discount from Medicare’s ASP calculation.

Call or write your members of Congress today! The Legislative Action Center on ACCC’s website features letter templates for your use.

Minnesota members in the House of Representatives:

Minnesota Senators:

Learn more about RAC Region B

Approved Audit Issues

CGI, the Medicare Recovery Audit Contractor (RAC) for Region B, identified on its website CMS approved audit issues.

The following claims will be edited automatically and monies recouped in these areas if they were billed incorrectly:

• Excessive units - Blood transfusions
• Excessive units - Bronchoscopy
• Excessive units - IV hydration

Posted 9/17/09

New Exclusion from Self-Administered Drug Benefit Change

Medica implemented a coverage change for self-administered drugs received in a physician's office effective July 1, 2008.

Due to concern about the impact of this change on the administration of three self-administered drugs that are colony stimulating factors (CSFs)— Neupogen, Neulasta and Leukine—Medica has decided to exempt CSFs from its coverage change beginning June 1, 2009. As a result, Medica members will not be required to purchase these medications at a pharmacy.

This coverage change should accommodate immediate availability needs for these medications after members receive chemotherapy.

While Medica believes there are strategies for managing these challenges, Medica has agreed to allow for coverage of these drugs under either the member's medical or pharmacy benefit, effective June 1, 2009.

Note: When members receive a CSF from a physician, the member's medical benefit will apply.

WPS Updates Chemotherapy Drugs and their Adjuncts LCD (HONC-010)

WPS has updated its Medicare policy to include new language referencing compendia as sources for medical necessity and coverage. This policy is effective May 16, 2009.

The following pages and sections are of note:

• Page 2, section A under “Indications and Limitations of Coverage and/or Medical Necessity"
• Page 13, section G
• Page 14, "Utilization Guidelines"
• Page 19, “Current Compendia.”

• MSCO NewsLine: Summer 2011
• MSCO Newsline, Summer 2009
  President's Message, Healthcare Reform, Drugs in the News
• MSCO NewsLine, Spring 2009
• MSCO News Bulletin, Spring 2008
• MSCO News Bulletin, Spring 2007
• MSCO News Bulletin, Winter 2007
• MSCO News Bulletin, Summer 2006