![]() |
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Letter From the Presidentby Tim McMahon The presents have long since been unwrapped, the incessant line-up of Holiday television favorites are over (for another year) and the BCS has left us with co-national champions in college football (something that wasn’t supposed to happen). Thank you notes have been sent (well most of them anyway), the ball has dropped ushering in the New Year and the Holiday “lag time” (you know, those two weeks where nothing seems to get done) is now behind us. It is back to reality time. Reality smacked me square between the eyes in two different situations the other day that foretells how 2004 will play out for most cancer program administrators. Both reflect the ever-changing dynamics of cancer care. The technological advances, emotional component, the financial and reimbursement challenges and the impact our decisions have (or will have) on how services will be delivered in the future. The first situation involved a conversation I had with a Medical Oncologist shortly before the Holidays. He has been practicing in our community for more than 15 years in a solo practice (an enigma in this day and age) and is highly regarded by patients for his compassion. He knocked on my office door, poking his head in to say that during a recent review of his practice that the new Medicare payments for outpatient chemotherapy will result in him probably closing his practice. After a brief conversation, he said he would make his final decision sometime during 2004. This comes on the heels of losing two other Medical Oncologists during 2003. Some people are already waiting 4-5 weeks for a new patient appointment in some offices. While that may be an acceptable wait time for some of your settings, this is a new phenomenon here, and most patients and referring physicians are having a difficult time adjusting to it. The other situation involved me helping someone out of his car. I was walking into the Powell Cancer Center after a meeting at the hospital. A woman was struggling to help a man into a wheelchair. I stopped and helped, then stayed with this gentleman while his daughter went to park the car. During the ensuing conversation, I leaned that this gentleman, in his mid 40s, had been diagnosed with colorectal cancer 14 months ago. During that time he has had surgery twice, one course of radiation therapy and he was set to begin a third chemotherapy regimen that day. In his voice I heard hope and optimism, in his eyes I saw fear and despair. He talked with me about the drain his illness has had on the family’s financial situation and how the fatigue has left him feeling a shell of his former self. His wife and he both had been using the counseling provided by our cancer program and he did say that it was helping, but he didn’t know how much longer he wanted to continue, in his words, “feeling crappy”. At that point his wife returned from parking the car and I walked with them to the elevator, wishing them both my best as the doors closed. When I returned to my office, I sat at my desk feeling drained. Looking at the calendar it struck me; it’s almost time for the ACE Annual Conference. I look forward to this meeting as a time to share information with colleagues and gain new insight into what others are doing to meet the challenges we all face. This year’s conference is shaping up to be the best ever. Kay Petras and the program committee have planned a fantastic group of speakers and topics. I also enjoy reconnecting with colleagues from across the country to share and support each other especially during challenging times like these. I look forward to seeing everyone in Orlando. Commission
on Cancer Program Standards – 2004
|
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
Table 1 – Average Wholesale Price (AWP), Average Sales Price (ASP),
and Average Acquisition Cost (AAC) |
||
| Drug Type |
Hospital Outpatient |
Physician Office / Freestanding Clinic |
| Sole source drugs (brand
name w/o generic equivalent) |
88% - 95% of AWP, 2004 <83% of AWP in 2005 |
85% of AWP* in 2004 Avg sales price + 6% in 2005 |
| Mult source drugs, innovator (brand name with generic equivalent) |
68% of AWP, 2004 & 2005 |
85% of AWP* in 2004 Avg sales price + 6% in 2005 |
| Mult source drugs, noninnovator (generic) |
46% of AWP, 2004 & 2005 |
same as above |
| Pass thru drugs |
85% of AWP (same as phys fee sched) |
same as above |
| Packaged drugs |
Drugs costing over $50 per encounter will be unbundled; if under $50, drugs are bundled |
same as above |
| New drugs |
95% of AWP (drugs without a C code) |
95% of AWP (“C” codes not allowed for physician use) |
| In 2006, all covered drugs will be subjected to new reimbursement methodologies: |
Average acquisition cost, or if AAC is not available, physician fee schedule fee will be used. |
Physicians choose whether to purchase drugs and be paid ASP, or to obtain drugs through Mandatory Vendor Imposition in which the competitive bidding contractor bills directly to Medicare & pt. |
| Brachytherapy seeds - no longer bundled |
Paid according to hosp cost-to-charge ratio in 2004-2006 |
|
*Exceptions to the 85% AWP rule include 29 common (and most frequently billed) OIG/GAO survey drugs, which are to be paid to physicians or free-standing clinics at generally lower rates (80%-81% of AWP, with a few higher exceptions).
Sources: ACCC
Additional Information for all above:
Major changes proposed for hospital coding were not adopted in the final rule, but one code was deleted (Q0085).
Physician work values are increased for all administration codes, and a 32% transitional adjustment will be added for 2004. A 3% transitional increase is scheduled for 2005.
Minimal [nursing] visit 99211 can no longer be billed with chemotherapy administration on the same patient, same day. This represents a major change for many physician office practices.
|
Table 2 – Drug Administration Coding for 2004 |
||
| |
Hospital Outpatient |
Physician Office / Freestanding Clinic |
| Non chemo IM/SC |
90782 per separate inj |
90782 per separate injection |
| Non chemo IV Push |
90784 per separate inj |
90784 per day, but DIMA strongly urges modification to mult. pushes |
| Non chemo IV Infus |
Q0081 one per visit |
90780 1st hr; 90781 ea addtl hr |
| Chemo IM/SC |
Q0083 one per visit |
96400 one per day |
| Chemo IV Push |
Q0083 one per visit |
96408 one for each drug |
| Chemo IV Infuse |
Q0084 one per visit |
96410 1st hr; 96412 ea addtl hr |
| Other provisions |
Deleted Code - Q0085 (ok to bill both Q0083 + Q0084 when needed) |
Work RVU to be increased 0.17 (approx $6.35) for each of above codes billed by oncologists in addition to transitional bonus. |
Table
3 – Drug Administration National Average Fees for 2004 |
|||||||||
|
Hospital Outpatient |
Phys Office / Freestg Clinic |
|||||||
HCPCS |
2003 |
2004 |
CPT |
2003 |
2004 |
2004+ |
|||
Non
chemo IM/SC |
90782 |
20.72 |
21.73 |
5% |
90782 |
4.41 |
18.67 |
24.64 |
458% |
Non chemo IV Push |
90784 |
59.12 |
43.65 |
-26% |
90784 |
18.39 |
37.71 |
49.78 |
171% |
Non
chemo IV Infus |
Q0081 |
113.7 |
104.29 |
-8% |
90780 |
42.67 |
89.24 |
117.79 |
176% |
…ea
add hr |
n/a |
90781 |
21.70 |
25.02 |
33.02 |
52% |
|||
Chemo
IM/SC |
Q0083 |
40.43 |
43.63 |
8% |
96400 |
37.52 |
48.54 |
64.07 |
71% |
Chemo
IV Push |
Q0083 |
40.43 |
43.63 |
8% |
96408 |
37.52 |
117.24 |
154.76 |
312% |
Chemo
IV Infuse |
Q0084 |
187.98 |
165.65 |
-12% |
96410 |
59.22 |
164.66 |
217.35 |
267% |
… ea add hr |
n/a |
96412 |
44.14 |
34.72 |
45.84 |
4% |
|||
| Table 4 – New Coverage for Hospital Drugs
Previously Not Paid in 2003 (List is not all-inclusive) |
|||||
| J1626 |
Granisetron HCl
injection |
17.18 |
J9093 |
Cyclophosphamide
lyophilized |
2.36 |
| J2353 |
Octreotide injection,
depot |
73.62 |
J9098 |
Cytarabine liposome
|
344.08 |
| J2354 |
Octreotide inj,
non-depot |
3.94 |
J9100 |
Cytarabine hcl
100 MG inj |
1.55 |
| J2505 |
Pegfilgrastim,
per 6 mg single dose vial Chg code from Q4053 |
2,596.00 |
J9130 |
Dacarbazine 100
mg inj |
5.31 |
| J2790 |
|
92.93 |
J9178 |
Inj, epirubicin
hcl, 2 mg |
25.60 |
| J2820 |
Sargramostim injection
|
26.92 |
J9181 |
Etoposide 10 MG
inj |
0.83 |
| J3315 |
Triptorelin pamoate,
per 375 mg |
59.58 |
J9213 |
Interferon alfa-2a
inj |
32.31 |
| J3486 |
Ziprasidone mesylate,
per 10 mg |
3.11 |
J9214 |
Interferon alfa-2b
inj |
13.78 |
| J7310 |
Ganciclovir long
act implant |
86.54 |
J9215 |
Interferon alfa-n3
inj |
8.17 |
| J7317 |
Sodium hyaluronate
injection |
67.16 |
J9270 |
Plicamycin (mithramycin)
inj |
86.89 |
| J7525 |
Tacrolimus injection
|
110.04 |
J9320 |
Streptozocin injection
|
131.05 |
| J8510 |
Oral busulfan
|
1.93 |
J9340 |
Thiotepa injection
|
45.31 |
| J9000 |
Doxorubic hcl
10 MG vl chemo |
4.69 |
J9395 |
Injection, Fulvestrant,
per 25 mg |
13.09 |
| J9020 |
Asparaginase injection
|
58.00 |
Q0137 |
Darbepoetin alfa,
non esrd |
3.88 |
| J9031 |
Bcg live intravesical
vac |
77.54 |
Q0166 |
Granisetron HCl
1 mg oral |
171.78 |
| J9070 |
Cyclophosphamide
100 MG inj |
2.77 |
Q0180 |
Dolasetron mesylate
oral |
152.38 |
| Drugs Previously Paid in 2003, but Not Covered
in 2004 |
|||||
| J9050 |
Carmus
bischl nitro inj |
.00 |
J9266 |
Pegaspargase/singl
dose vial |
.00 |
| J9165 |
Diethylstilbestrol
injection |
.00 |
|
|
|
Note: Hospital Medicare drug fees are not subject to wage index or geographic adjustments. The same amount is paid to all hospitals, nationwide.
| Table 5 –
Other Frequently Billed Drug Price Changes |
|||||||
| |
|
Hosp |
Hosp |
% |
Phys |
Phys |
% |
| Drug |
HCPCS |
2003 |
2004 |
Diff |
2003 |
2004 |
Diff |
| Immunoglobulin |
J1563 |
43.46 |
37.95 |
-13% |
85.50 |
52.00 |
-39% |
| Ondansetron
|
J2405 |
- |
- |
|
6.09 |
5.58 |
-8% |
| Pamidronate |
J2430 |
170.29 |
128.74 |
-24% |
275.50 |
237.88 |
-14% |
| Carboplatin |
J9045 |
77.82 |
137.79 |
77% |
148.75 |
126.83 |
-15% |
| Docetaxel |
J9170 |
203.14 |
331.53 |
63% |
357.91 |
301.40 |
-16% |
| Gemcitabine |
J9201 |
67.71 |
112.09 |
66% |
121.01 |
101.90 |
-16% |
| Irinotecan |
J9206 |
91.46 |
135.00 |
48% |
145.74 |
122.73 |
-16% |
| Paclitaxel |
J9265 |
120.77 |
79.04 |
-35% |
164.08 |
139.90 |
-15% |
| Rituximab |
J9310 |
286.52 |
464.20 |
62% |
501.13 |
427.28 |
-15% |
| Topotecan |
J9350 |
402.24 |
739.80 |
84% |
798.65 |
706.17 |
-12% |
| Epoetin
Alpha |
Q0136 |
9.10 |
11.76 |
29% |
12.69 |
11.62 |
-8% |
| Aranesp
1mcg |
Q0137 |
2.37 |
3.88 |
64% |
- |
4.24 |
|
| |
2004 |
2004 |
|||
| |
|
|
|
OP Hosp |
Phys |
| HCPCS |
Drug |
Dose |
|
Pmt |
Pmt |
| J0880 |
Non-ESRD
Aranesp/Darbepoetin Alfa |
5
mcg |
|
not avail |
$21.20 |
| Q0137 |
Non-ESRD
Aranesp/Darbepoetin Alfa |
1
mcg |
|
$3.88 |
$4.24 |
| |
Non-ESRD Aranesp hosp code C1774 deleted
(with grace period) |
||||
| Q0136 |
Non-ESRD
Epoetin Alfa |
1000
U |
|
$11.76 |
$11.62 |
| |
|
|
|
|
|
| Q4054 |
ESRD
Aranesp/Darbepoetin Alfa |
1
mcg |
* |
not avail |
$4.24 |
| Q4055 |
ESRD
Epoetin Alfa |
1000
U |
* |
not avail |
$11.62 |
| |
ESRD
EPO codes Q9920-Q9940 deleted in 2004 |
* hct
required |
|||
Sources updated
Oncology Alliance estimates Part B losses to physician or free-standing clinics at $165 million in 2004, and $1 billion in 2005. Cancer Consultants, an internet information site, has provided via a cancerrx.info newsflash, additional insight. Their estimates are $1 billion per year for 10 years in decreased revenues. The recurring theme in Medicare’s reform act (HR-1) is the impetus towards privatization. The plans for future distribution of drugs through a specialty pharmacy are designed to create market forces to drive down prices, which is good. However, many oncologists who were surveyed appear to be not inclined to use specialty pharmacies. In any event, the next two years will be transformational in the business of oncology.
Under the average sales price methodology, 50% of sales will be higher and 50% will be lower than the ASP payment rate. Those who are not prudent buyers will lose money and may opt to discontinue practice, thus causing the average sales price to ratchet down. Under this scenario, many physicians will shift care back to hospitals. Those who continue office treatments will need to be both aggressive and creative to control costs and increase revenues. Conversely, the same may be said of hospital chemotherapy programs as well.
As most have already heard, the overall fee reductions by Medicare for radiation therapy are significant for 2004 hospital outpatients. The following is a side-by-side comparison of hospital and physician national average fees for 2004 for the most frequently billed codes.
| Table 7 –
Radiation Therapy Fee Comparisons |
||||||||||
| Radiation |
2003 |
2004 |
% |
2003 |
2004 |
% |
2003 |
2004 |
% |
|
| CPT |
Brief Descriptn |
APC |
APC |
+ / - |
Phys TC |
Phys TC |
+ / - |
Phys PC |
PhysPC |
+ / - |
| 77263 |
Cpx
Phys Plan |
- |
- |
- |
- |
- |
|
163.33 |
165.03 |
1% |
| 77290 |
Cpx
Simulation |
190.51 |
200.60 |
5% |
249.04 |
256.88 |
3% |
79.09 |
79.16 |
0% |
| 77295 |
3-D
Simulation |
712.51 |
748.39 |
5% |
1068.25 |
1,101.83 |
3% |
231.38 |
232.61 |
0% |
| 77300 |
Basic
Dosimetry |
84.39 |
91.35 |
8% |
51.13 |
53.02 |
3% |
31.64 |
32.11 |
1.5% |
| 77301 |
IMRT
Plan |
875.00 |
850.00 |
-2% |
1068.25 |
1,101.83 |
3% |
415.31 |
401.38 |
-3% |
| 77334 |
|
148.06 |
157.33 |
6% |
123.97 |
128.07 |
3% |
62.90 |
63.10 |
0% |
| 77336 |
Weekly
QA |
84.39 |
91.35 |
8% |
114.04 |
117.61 |
3% |
- |
- |
|
| 77427 |
Phys
Wkly Mgt |
- |
- |
|
- |
- |
|
168.11 |
169.14 |
0% |
| 77413 |
Cpx
Daily Tx. |
164.73 |
116.43 |
-29% |
89.39 |
92.22 |
3% |
- |
- |
|
| 77418 |
IMRT
Tx./ day |
400.00 |
294.11 |
-26% |
665.08 |
678.79 |
2% |
- |
- |
|
| 77778 |
Interstit
Implant |
2853.58 |
558.24 |
-80% |
196.07 |
202.37 |
3% |
567.60 |
570.52 |
0.5% |
| 77784 |
HDR
Brachy |
1097.10 |
753.34 |
-31% |
776.18 |
800.51 |
3% |
283.98 |
285.63 |
0.6% |
The hospital reduction of 29% for high volume, complex daily treatment delivery will have the greatest negative impact overall, and financial planners need to begin preparing for the consequences. HDR reimbursement is down 31%, and other hospital rates for brachytherapy codes 77763-77777 are reduced 80%.
Codes G0256 and G0261 have been deleted, and prostate seed implant codes are reverting to 7777x implant + 55859 cath/needle placement + C code for seeds. Reinstated codes: C1718 per I-125 seed at $37.34 (need to bill each seed), and C1720 for Palladium 103 at $44.67.
In Table 8, hospital outpatient technical payments are limited to three reimbursement rates, regardless of the CPT status of new, established or consultative visit.
| Table 8 – Hospital Outpatient Medicare
Reimbursement |
||||
| CPT |
Description |
2003 |
2004 |
%
|
| |
|
APC |
APC |
Diffrnc |
| 99201, 99211, 99241 |
Visit Lev 1 |
43.96 |
50.62 |
15% |
| 99202, 99212, 99242 |
Visit Lev 2 |
43.96 |
50.62 |
15% |
| 99203, 99213, 99243 |
Visit Lev 3 |
50.53 |
53.56 |
6% |
| 99204, 99214, 99244 |
Visit Lev 4 |
76.30 |
82.07 |
8% |
| 99205, 99215, 99245 |
Visit Lev 5 |
76.30 |
82.07 |
8% |
Professional reimbursements reflect five code levels each for new patients, established patients, and outpatient consolations.
| Table 9 –
Physician Medicare Reimbursement |
|||||||
| |
Office |
Office |
Office % |
|
Outpatient |
Outpatient |
OP % |
| |
Current |
Revised |
Difference |
|
Current |
Revised |
Difference |
| E&M |
2003 |
2004 Fee |
(NonFacility) |
|
2003 Fee |
2004 Fee |
(Facility) |
| 99201 |
34.95 |
36.22
|
3.6% |
|
23.17 |
23.52
|
1.5% |
| 99202 |
62.54 |
64.59
|
3.3% |
|
45.98 |
47.05
|
2.3% |
| 99203 |
92.7 |
95.96
|
3.5% |
|
70.26 |
71.69
|
2.0% |
| 99204 |
132.06 |
135.53
|
2.6% |
|
103.74 |
105.66
|
1.9% |
| 99205 |
168.48 |
172.13
|
2.2% |
|
137.58 |
140.39
|
2.0% |
| 99211 |
20.6 |
21.28
|
3.3% |
|
8.83 |
8.96
|
1.5% |
| 99212 |
36.42 |
37.71
|
3.5% |
|
23.17 |
23.52
|
1.5% |
| 99213 |
51.13 |
52.65
|
3.0% |
|
34.58 |
35.47
|
2.6% |
| 99214 |
79.82 |
82.14
|
2.9% |
|
56.65 |
57.87
|
2.2% |
| 99215 |
116.98 |
119.11
|
1.8% |
|
91.23 |
93.34
|
2.3% |
| 99241 |
47.45 |
50.03
|
5.4% |
|
33.11 |
33.98
|
2.6% |
| 99242 |
88.29 |
91.48
|
3.6% |
|
68.05 |
69.45
|
2.1% |
| 99243 |
116.61 |
120.60
|
3.4% |
|
90.49 |
92.22 |
1.9% |
| 99244 |
165.9 |
170.63
|
2.9% |
|
134.27 |
136.65
|
1.8% |
| 99245 |
215.2 |
220.29
|
2.4% |
|
177.67 |
181.09
|
1.9% |
Inpatient DRG 492 is to be assigned with ICD procedure code 00.15 for patients hospitalized for High Dose Interleukin 2 therapy for end stage renal cell or melanoma chemotherapy.
For those who are interested, go to http://grants.gov/ for a new comprehensive web site by HHS, listing information to find and apply for all federal grant programs.
Ace
Update Info
ACE Update is produced by the Association of Cancer Executives.
ACE assumes no liability for any errors that may be contained in the source
material. Opinions expressed in articles appearing in ACE Update are those
of the authors and not necessarily those of the Association of Cancer
Executives or the editor of ACE Update.
Barbara Mathison
E-mail: barbara.mathison@phci.org
Genevieve (Gen) Hedland
Managing Director
475 S. Frontage Road, Suite 101
Burr Ridge, IL 60527-6282
Phone: (630) 323-1170
Fax: (630) 323-6989
E-mail: ghedland@cancerexecutives.org
Web site: www.cancerexecutives.org
Janet Kalbhen
Electronic
Publisher
Calvin Harrison
Executive Director - Cancer Services
Providence Health System
Brian McCagh
Executive Director
Washington Cancer Institute
Susan Granucci
Healthcare Reimbursement Specialist
Barbara Mathison
Executive Director
ProHealth Care, Inc.
Joseph Piccolo
Associate Administrator
Fox Chase Cancer Center
John Rieke, MD
Medical Director
Virginia Mason Cancer Center
Subscriptions—Subscriptions for ACE Update are $25 per year for non-members. To request your subscription, forward your name, address and check to the ACE office. Subscriptions are automatically renewed and invoiced unless cancellation is received in writing 30 days prior to the renewal date.
Submission Guidelines—Articles submitted for consideration should be doublespaced and no longer than five pages. If possible, also submit your article on diskette in Microsoft Word for Windows format. Author(s’) identification (title and affiliation) should be included.
Please submit articles, ads, subscription requests, special announcements, meeting notices or request for additional information to Genevieve Hedland at the ACE office.