Oncology & Hematology Coding Alert

Patients under private payers should see coverage for clinical trial standard-of-care costs.

Many coders are taking the "wait and see" approach regarding how the Supreme Court's recent decision on the Affordable Care Act (ACA) will affect their day-to-day job functions.

In that decision, the Supreme Court ruled the requirement that individuals must have health care coverage or face a penalty was an allowable tax (rather than a penalty). But the Court decided the federal government couldn't require states to expand existing Medicaid programs by planning to disqualify noncompliant states from Medicaid funding.

Here are a few ACA areas to watch for hematology and oncology.

Preventive services: If patients "have a new health insurance plan or insurance policy beginning on or after September 23, 2010," certain preventive services must be covered when delivered by a network provider. For these services, the patient is not responsible for a copayment, co-insurance, or meeting the deductible. Early detection could mean an increase in oncology and hematology patients. According to the preventive services fact sheet at www.healthcare.gov/news/factsheets/2010/07/preventive-services-list.html, some of the covered services that may affect your oncology/hematology practice include:

• Colorectal cancer screening for adults over 50
• BRCA counseling about genetic testing for women at higher risk
• Mammography screenings every 1 to 2 years for women over 40
• Breast cancer chemoprevention counseling for women at higher risk
• Cervical cancer screening for sexually active women
• Hemoglobinopathies or sickle cell screening for newborns
• Iron supplements for children ages 6 to 12 months at risk for anemia.

Clinical trials: "This is the first federal law mandating group health plans (including new self-funded arrangements) and state-licensed health insurance issuers to cover the standard of care costs associated with participation in clinical trials," according to ASCO's ACA and clinical trials FAQs: http://ascoaction.asco.org/Portals/0/Documents/FAQ_Clinical%20Trials%20Coverage%20Statute.pdf. Medicare already covers standard of care costs, so Medicare coverage shouldn't be affected.

Pre-existing conditions: U.S. citizens and legal residents may qualify for the Pre-Existing Condition Insurance Plan if they have been uninsured for at least six months and have been denied health insurance because of a pre-existing condition. By 2014, additional reforms are planned to keep insurance companies from refusing to sell coverage or renew policies because of pre-existing conditions.

"Under [the Affordable Care Act], insurance companies cannot deny coverage for people with preexisting conditions, and premiums cannot be based on gender or health status," said Beverly Moy, MD, MPH, of Massachusetts General Hospital at the 2012 ASCO Annual Meeting (www.ascopost.com/issues/july-15-2012/the-affordable-care-act-stands-now-what.aspx).

ACOs: The ACA creates voluntary Accountable Care Organizations (ACOs). An ACO is a group of providers, hospitals, and others who coordinate to improve a Medicare patient's care. The coordination aspect of the ACOs has left some coders speculating how ordering habits and rules will be affected.

MPPR: Generally speaking, the ACA and the Medicare physician fee schedule (MPFS) are different entities. For instance, "The Sustainable Growth Rate (SGR) formula is not addressed in the ACA and is not affected by the ruling," says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J.

But you may be acquainted with the ACA-related Multiple Procedure Payment Reduction (MPPR) if your center provides imaging. The MPPR reduces payment for second and subsequent services for certain imaging procedures performed at the same session.