Policy Perspectives, November 2017

 

By Stephanie Farnia, ASBMT Director of Health Policy and Strategic Relations

New Resources:

(I have learned from previous columns not to bury key content!)

As you have read in previous columns, the approval of CAR-T products in 2017 has created several substantial streams of work on the reimbursement and coding side of the world.   For the last several months, a small team has been working to assess which codes currently available in the various reimbursement systems would be useable for billing CAR-T services and, in a complementary fashion, to establish which new codes would need to be created. 

To complicate matters, we need to think across several systems of codes due to the various aspects of the health care system they touch. 

  • ICD-10: Inpatient diagnosis and procedure billing
  • CPT: Outpatient billing, professional fee billing, hospital charge masters, payer authorizations
  • HCPCS Level II: Specialized health care services, new technologies, private payers
  • Revenue Codes: Hospital financial accounting

The result of the coding assessment effort is that we now know that there are multiple new codes needed across multiple coding systems.   Each of these coding systems is governed by a different organization and has timelines and processes specific to that system.  The common denominator is the expectation of a time lag between applying for the code and being able to utilize it, assuming the request is successful – the shortest delay between application and use is just over 3 months, with certain HCPCS codes, and the longest wait time is for CPT codes, where the process takes approximately 3 years in its entirety.   In a future column, I will outline which specific new codes are being sought and the timelines for each.

While it is helpful to know that there will be new codes in the future, the issue of what codes to use today remains.   To support that need, the ASBMT has worked to create a new CAR-T coding guidance document available on the ASBMT website.  It is important to understand that this document is called a guidance document for good reason – unless CMS or another regulatory body indicates otherwise, all coding of patient encounters should always be completed based on the clinical notes provided by physician or clinician providing the service, as they have the best knowledge of the events.  Additionally, we acknowledge these documents may not be in alignment with reimbursement guides issues by manufacturers.  The assessment we performed included in-depth discussions with physicians, administrators and revenue cycle leaders, coding system experts and national payers.  We feel strongly that the coding guidance provided in the document is the most appropriate given the current alternatives.  These documents will be updated when new codes become available and/or when other authoritative guidance is issued from CMS or the American Medical Association.

The coding guidance document is set up for three sections: the actual billing of the product, another that describes codes for use in the inpatient setting and a final one referencing the outpatient setting and physician professional fee billing.  For a more in-depth discussion of the coding grid, Medicare payment issues and insight into the next phase of coding work, please register for and join us on the webinar ASBMT will be holding on Thursday, November 2.

All of this work would not be possible without the assistance of an incredible core group of individuals willing to embrace the minutiae of the coding world: Jugna Shah, Valerie Rinkle and Amy Rinkle of Nimitt Consulting; Dr. James Gajewski, ASBMT Practice Policy Consultant; and the members of the ASBMT Cell Therapy Coding and Reimbursement Task Force – Aaron Chrisman (Chair), Rocky Billups, Colleen Dansereau, Clint Divine, Gary Goldstein, Helene Stephan, Angela Kopetsky, Susan Leppke and Dr. Carolyn Mulroney. 

 

Questions? Contact StephanieFarnia@asbmt.org or follow @HCT_Policy on Twitter.