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Medicare Compliance & Reimbursement

ONCOLOGY:

Get Ready For Increased Chemotherapy Coverage

Published on Sat Oct 23, 2004

CMS may expand definition of chemotherapy in 2005.

The CPT Editorial Panel made some far-reaching decisions about chemotherapy drug administration codes in its August 2004 meeting, according to a summary shared with the Physician Regulatory Issues Team at the Centers for Medicare & Medicaid Services.

The codes discussed in the Panel's meeting don't appear in the preliminary list of 2005 CPT codes obtained by MLR, but CMS may issue them as G-codes.

The panel considered four main resolutions suggested by the Drug Administration Workgroup:

1) New and revised drug infusion/administration codes. The new codes will set up a hierarchy of codes. The least complex infusion codes will be for hydration and the more complex administration codes will be for therapeutic drugs. The revision also will expand CPT's definition of chemotherapy beyond anti-neoplastic drug therapy, to include complex drugs that physicians administer for non-cancer diagnoses, such as cyclophosphamide for auto-immune conditions. The more complex category also will include mono-clonal antibodies. The panel accepted this recommendation.

2) New codes for management of severe adverse reactions to chemotherapy drugs. These reactions can be life-threatening, but the panel rejected this recommendation, on the grounds that high-level evaluation and management codes already cover this service.

3) A new code for clinical treatment planning for chemotherapy drug administrations. Again, the panel rejected this proposal on the grounds that it would overlap with existing E/M codes. Also, the panel felt that the issue of treatment planning applied to other physician specialties and disease processes.

4) New codes for physician supervision of a pharmacist's or nurse's preparation of chemotherapy pharmaceutical supplies. The panel rejected this proposal as well, on the grounds that it would break this service out of the administration codes, which currently include practice expenses for it. Because this service is always necessary for administration, CMS should pay for it via the administration codes, the panel decided.

The panel and the RVS Update Committee will speed up the next steps in their process of developing codes, including allowing specialty societies to survey their members on the physician work and practice expenses involved in the new and revised codes. The RUC will consider the data until early October, then present the new codes and final RVU recommendations to CMS.

This process should allow enough time for CMS to accept, reject or tinker with the recommendations. CMS then should issue G-codes in time for 2005's fee schedule, the panel hopes.

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