Medicare Compliance & Reimbursement

New codes or new legislation cold rescue practices.

It's going to take a minor miracle to save oncologists and other specialties from the drug payments axe.

"If all the cuts that are scheduled to go through do go through, it'll make it extremely difficult," says Ris Marie Cleland with Oplinc Oncology in Lawton, OK. "There will be a disruption in care for patients" and a reduction in patient access. Not only are drug payments being slashed to rock-bottom levels, but a 32-percent add-on payment for drug administration is dropping to just 3 percent in 2005 and nothing in 2006.

The Centers for Medicare & Medicaid Services did increase the relative value units for drug administration codes themselves, and those increases are permanent, notes Cleland.

CMS insists that oncologists will see only an 8-percent decrease in their drug revenues in 2005, and rheumatologists will see only a 6-percent drop. But urologists will lose 36 percent of their Medicare drug revenues, and Ob/Gyn physicians will lose 18 percent of drug payments.

"I can't figure out how they get to 8-percent actually," gripes Cleland. But she notes that the impact will differ greatly for different providers depending on their patient population and the types of drugs they use. If you happen to provide drugs that are targeted for deeper cuts, then you're in for a rougher time.

"Our numbers are looking like it's going to be closer to a 20-percent cut," says Elaine Towle, practice administrator with New Hampshire Oncology-Hematology in Hooksett, NH. Her practice is using "a couple of different modeling methods," including a survey tool distributed by the American Society for Clinical Oncology. Senate Bill, New Codes Could Help Providers A pending bill in the Senate would rescue physicians from steep cuts. Sen. Deborah Stabenow (D-MI), introduced the Ensuring Quality and Access to Cancer Care Act, which would extend this year's 32-percent add-on payment into 2005. Cleland says she's hopeful that this bill could save oncologists from having to rethink their practices.

Meanwhile, CMS is talking to the American Medical Association and the Physicians Regulatory Issues Team about ways to add to drug administration payments, and the groups have raised some important issues. For example, if extra payments rely on current codes for chemotherapy and non-chemotherapy administration, can these take into account the expense and difficulty involved in administering highly toxic non-chemotherapy drugs? Or are new or revised CPT codes required?

Also, the physician advisers asked, does current coding for chemotherapy administration include all the support services that oncology practices provide? Or do cancer management codes need to be revised?

The CPT Editorial Panel established a workgroup that will report back at its August 2004 meeting. Meanwhile, ophthalmologists, urologists and other specialists raised questions about their drug reimbursements. CMS [...]