December 2020 - AUA Public Policy Council Update for MAS
From the Chair
I am pleased to share updates from the AUA Public Policy Council that may benefit your Section members. Our updates include information on our 2021 federal and state legislative priorities (see committee highlights), physician payment reform, and congressional support for an AUA-led legislation on a student loan forgiveness program.
Fall Public Policy Council Meetings: AUA 2021 Federal and State Legislative Priorities Approved
Last month, the AUA Public Policy Council and its committees convened virtually to set the AUA’s 2021 state and federal legislative priorities, create additional telehealth advocacy strategies, and discuss engagement strategies with appropriators, agencies and congressional offices. Below are highlights from the November meetings:
- The Coding and Reimbursement Committee (CRC) primarily focused on six different presentations from either industry or medical societies that requested AUA coding advice. The CRC will make final determinations and notify those representatives with the AUA recommendations. The CRC also received updates from other AUA workgroups including the AUA Current Procedural Terminology (CPT) Editorial Panel, the AMA Specialty Society Relative Value Scale Update Committee (RUC) team and the National Insurance Advisory workgroup (NIAW).
- The Legislative Affairs Committee (LAC) approved its 2021 priorities, which included amending four existing priorities and adding one new priority.
Amendments included the following:
- Combining the prostate specific antigen (PSA) screening and U.S. Preventive Services Task Force reform priorities to streamline the work being done within the Veterans Health Administration and other systems;
- Updating the workforce priority to address issues on shortages and diversity;
- Broadening the research funding priority to include language on health care disparities; and
- Expanding the veteran’s infertility priority to include the work the AUA has done on the Veteran’s Prostate Cancer Treatment and Research Act.
New priority:
- Based on this year’s legislative priority survey results, a new priority was created to address issues around the use of and access to telemedicine.
The new slate was subsequently sent to the AUA Board of Directors where it was unanimously approved.
- The Practice Management Committee (PMC) heard results of the COVID-19 member survey and made recommendations for additional questions aiming to get insights into preference of telehealth versus in-office visits.
- The Research Advocacy Committee (RAC) reviewed accomplishments from 2020, which included securing Patient-Centered Outcomes Research Institute (PCORI) funding for 10 years, continuation of the Congressionally Directed Medical Research Programs (CDMRP) and an increase in National Institutes of Health (NIH) funding for fiscal year (FY) 21. A discussion on the 2021 direction resulted in a focus on relationship development between RAC and patient advocacy groups who prioritize research funding for urologic disease and will engage with congressional appropriators on NIH and CDMRP funding for FY 22, as well as ways in which to educate stakeholders on the needs of the urologic research community.
- The State Advocacy Committee (SAC) primarily focused on setting the AUA’s 2021 state advocacy initiatives. There were lengthy discussions on physician contracts/restrictive covenants, the Interstate Medical Licensure Compact and utilization management protocols such as step therapy and prior authorization. The amended list, which was recently approved by the AUA Board of Directors, reads as follows:
- Support traditional medical liability reform efforts
- Promote efforts to support adequate insurance networks
- Support state efforts to reduce the burden of utilization management tools such as prior authorization and step therapy
- Support access to prostate cancer screening
- Support legislation and regulation to maintain the physician led care team
- Preserve appropriate use of the in-office ancillary services exemption (IOASE) to the federal Stark law and support legislation allowing appropriate participation in alternative payment models
- Support legislative and regulatory efforts to expand meaningful patient access to telemedicine services
- Support legislative and regulatory efforts to minimize disruption of patient access to care from United States Pharmacopeia Chapter 800 Handling of Hazardous Drugs Guidance
- Monitor and promote the expansion of the Interstate Medical Licensure Compact in all 50 states
Additionally, the SAC voted to focus on Men’s Health Awareness Month in 2021 by working with different legislators and governors to submit proclamations marking this important health awareness month designation – particularly focusing on health care disparities when it comes to men’s health.
- The Patient Advocacy Liaison (PAL) participated in RAC, CRC, LAC, and SAC meetings. The role was made permanent by the board following a year-long pilot that was seen as largely successful. The PAL has been able to provide the patient perspective in almost every aspect of public policy and has been very helpful for committee members to connect their committee work to the patient.
- During the Public Policy Council, the eight AUA Sections reported highlights from their Sections. Hot issues included ongoing advocacy for intersex, how small and large practices are affected by COVID-19, optimizing video visits and incorporating advanced practice providers into telemedicine. Want to know more? Your Section representatives to the council will receive a draft council minutes later this month.
Physician Payment Reform: AUA Signs Letter Opposing Medicare Payment Cuts
On December 3, the AUA signed an Alliance of Specialty Medicine-led letter that was sent to House and Senate leaders urging them to prevent Medicare payment cuts set to take effect for many specialties on January 1, 2021. Based on changes to the codes for office and outpatient evaluation and management (E&M) services CMS will implement next year, some specialties in the Alliance face cuts as high as nine percent due to a statutory budget neutrality rule that requires any increases in Medicare payments to be offset by corresponding decreases. The letter is attached for your review.
As a reminder, since the onset of the pandemic, the AUA has consistently advocated Congress suspend budget neutrality requirements for the Medicare Physician Fee Schedule to ensure changes in underlying payment policies do not counteract the other steps Congress and the Administration have taken to protect our health care system and patient access to care.
Alliance of Specialty Medicine Virtual Fly-In: AUA Physicians Participate in Virtual Meetings with Members of the House and Senate
On November 19, AUA members participated in a virtual fly-in hosted by the Alliance of Specialty Medicine. The event saw more than 100 physicians from 14 different medical organizations participate in meetings with House and Senate leaders on health policy. The daylong event saw 11 members of Congress cover the following legislative issues:
- Medicare Physician Fee Schedule Cuts;
- COVID-19 Provider Relief;
- Medical Liability Reform;
- Physician Student Loan Forgiveness;
- Surprise Medical Billing;
- Step Therapy; and
- Prior Authorization.
In particular, out of the many issues covered during the event, the one on physician student loan forgiveness specifically dealt with AUA-led legislation (H.R. 5924) to create a student loan forgiveness program for specialty physicians who practice in a rural area. The goal is to continue to build congressional support for the bill by garnering additional cosponsors heading into the new 117th Congress, which will convene in early January.
The AUA had 11 urologists participate in the event, with representation from the Legislative Affairs Committee, Coding & Reimbursement Committee and the Policy & Advocacy Resident Workgroup, including the following physicians:
- Juan Andino
- Vikas Bhatt
- Mark Fallick
- Mayer Grob
- Jason Jameson
- Kevin Koo
- Jay Motola
- Tom Rechtschaffen
- Ruchika Talwar
- David Taub
- Mei Tuong
For more information on this event or any other AUA legislative activity, please contact the AUA’s Legislative & Political Affairs Department at LegislativeAffairs@AUAnet.org.
Below are insurance updates from national insurance carriers. If you have questions about insurer issues, contact Keith Hawman at khawman@auanet.org
Aetna
Aetna reviewed its Proton and Neutron Beam Radiotherapy (Commercial) Policy with the following changes:
- Revised approval criteria for proton beam radiotherapy (PBRT) when used as curative treatment. Added coverage for the following:
- Added that proton beam radiotherapy and IMRT are considered clinically equivalent for localized cancer of an intact prostate.
Aetna reviewed its Benign Prostatic Hyperplasia Policy adding the following not covered HCPCS code:
- C9769 – Cystourethroscopy, with insertion of temporary prostatic implant/stent with fixation/anchor and incisional struts
Aetna reviewed its Jevtana Policy revising medically necessary criterion regarding treatment of metastatic castration-resistant prostate cancer, replaced combination therapy with steroids to combination therapy with Xtandi or Zytiga.
Aetna reviewed its Prostate Biopsy with the following changes:
- Added policy statement indicating that transrectal ultrasound (TRUS)-guided prostate biopsy is considered medically necessary for diagnosis, follow-up, and active surveillance of prostate cancer when criteria are met (see policy for details).
- Added policy statement indicating that transperineal or transrectal magnetic resonance imaging (MRI)-guided prostate biopsy (including the in-bore [direct] approach, and fusion imaging of multi-parametric MRI with TRUS [MRI-TRUS; e.g., the UroNav fusion biopsy system]) medically necessary for diagnosis, follow-up, and active surveillance of prostate cancer when criteria are met (see policy for details).
- Clarified existing criteria for transperineal stereotactic template-guided saturation prostate biopsy.
- Added the following CPT codes:
- 45342 – Sigmoidoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s)
- 72195-72197 – Magnetic resonance (e.g., proton) imaging, pelvis
- Changed title from “Prostate saturation biopsy” to “Prostate biopsy”.
Aetna reviewed its Prostate Cancer Vaccine Policy with the following changes:
- Added experimental/investigational criterion regarding administration of more than 3 complete doses of sipuleucel-T.
- Renamed doing information section as dosing recommendations section and updated dosing recommendations for Provenge.
Anthem
Anthem reviewed its Whole Genome Sequencing, Whole Exome Sequencing, Gene Panels, and Molecular Profiling (Commercial, Medicaid) Policy adding:
- Policy statement indicating that testing for prostate cancer using gene panels may be considered medically necessary when the panel evaluates homologous recombination repair (HRR) gene alterations; and the individual is a candidate for treatment using Lynparza (olaparib).
- A note specifying that the test should be performed using tumor tissue (not cell-free circulating tumor DNA, also known as liquid biopsy).
BCBS Federal Employee Plan
BCBS Federal Employee Plan reviewed its Lynparza Policy with the following changes:
- Revised medically necessary policy statement for Lynparza to add metastatic castration-resistant prostate cancer, remove specification of BRCA mutation, and remove specification of HER2-negative for breast cancer.
- Added diagnosis of metastatic castration-resistant prostate cancer with criteria stating homologous recombination repair gene mutation; disease progressed following prior treatment with enzalutamide or abiraterone; and member has had a bilateral orchiectomy or member will be receiving a GnRH analog concurrently.
CGS Administrators
CGS Administrators reviewed its Molecular Diagnostic Tests (MolDX) (J15) (A56973) Local Coverage Article (LCA) updating the following CPT code descriptor
- 0154U – Oncology (urothelial cancer), RNA, analysis by real-time RT-PCR of the FGFR3 (fibroblast growth factor receptor 3) gene analysis (i.e., p.R248C [c.742C>T], p.S249C [c.746C>G], p.G370C [c.1108G>T], p.Y373C [c.1118A>G], FGFR3-TACC3v1, and FGFR3-TACC3v3) utilizing formalin-fixed paraffin-embedded urothelial cancer tumor tissue, reported as FGFR gene alteration status
CGS Administrators released the following Local Coverage Determinations (LCD) and Local Coverage Articles (LCA) effective November 9.
- Decipher Biopsy Prostate Cancer Classifier Assay for Men with Favorable Intermediate Risk Disease (MolDX) (J15) (L38303) LCD
- Fluid Jet System in the Treatment of Benign Prostatic Hyperplasia (J15) (A57926) LCA
- Fluid Jet System in the Treatment of Benign Prostatic Hyperplasia (J15) (L38378) LCD
CGS Administrators has retired the following Local Coverage Determinations (LCD) and Local Coverage Articles (LCA) effective November 7.
- Decipher Biopsy Prostate Cancer Classifier Assay for Men with Favorable Intermediate Risk Disease (MolDX) (L38077) LCD. The contractor states that this LCD is being retired because the information in this policy has been incorporated within the new Prostate Cancer Genomic Classifier Assay for Men with Localized Disease (MoIDX) (L38303).
- Decipher Biopsy Prostate Cancer Classifier Assay for Men with Intermediate Risk Disease (MolDX) (J15) (A57796) LCA. The contractor states that this article is being retired as this information as incorporated into new billing and coding article A58371 related to policy L38303.
- Decipher Biopsy Prostate Cancer Classifier Assay for Men with Very Low and Low Risk Disease (MolDX) (J15) (A56984) LCA. The contractor states that this article is being retired because this information was incorporated into the new billing and coding article A58371 related policy L38303.
- Decipher Biopsy Prostate Cancer Classifier Assay for Men with Very Low and Low Risk Disease (MolDX) (J15) (L37834) LCD. The contractor states that this LCD is being retired because the information in this policy has been incorporated within the new Prostate Cancer Genomic Classifier Assay for Men with Localized Disease (MoIDX) (L38303).
- Decipher Prostate Cancer Classifier Assay (MolDX) (J15) (A56992) LCA. The contractor states that this article is being retired because this information was incorporated into the new billing and coding article A58371 related to policy L38303.
- Decipher Prostate Cancer Classifier Assay (MolDX) (J15) (L36656) LCD. The contractor states that this LCD is being retired because the information in this policy has been incorporated within the new Prostate Cancer Genomic Classifier Assay for Men with Localized Disease (MoIDX) (L38303).
Cigna
Cigna reviewed its Sacral Nerve and Tibial Nerve Stimulation for Urinary Voiding Dysfunction, Fecal Incontinence and Constipation Policy adding the following codes:
- 64585 – Revision or removal of peripheral neurostimulator electrode array
- 64595 – Revision or removal of peripheral or gastric neurostimulator pulse generator or receiver
- C1883 – Adapter/extension, pacing lead or neurostimulator lead (implantable)
- L8681 – Patient programmer (external) for use with implantable programmable neurostimulator pulse generator, replacement only
National Government Services
National Government Services released its Fluid Jet System Treatment for LUTS/BPH (J06, JK) (A56797) effective November 1.
Noridian
Noridian reviewed its Fluid Jet System in the Treatment of Benign Prostatic Hyperplasia (JE) (L38705) LCD, effective December 27. The associated response to comments article can be found here.
Noridian reviewed its Fluid Jet System in the Treatment of Benign Prostatic Hyperplasia (JE) (L38707) LCD, effective December 27. The associated response to comments article can be found here.
Noridian reviewed its Outpatient Therapy Biofeedback Training (A53352) (A52755) LCA, effective January 1, 2021, adding the following codes to CPT/HCPCS Code Group 1:
- 90912 – Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry, when performed; initial 15 minutes of one-on-one physician or other qualified health care professional contact with the patient
- 90913 – Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry, when performed; each additional 15 minutes of one-on-one physician or other qualified health care professional contact with the patient (List separately in addition to code for primary procedure)
Noridian published its Response to Comments: Transurethral Waterjet Ablation of the Prostate (JF) (A58523) LCA, and published its comment/response article for DL38707 Transurethral Waterjet Ablation of the Prostate, effective December27.
Noridian published its Transurethral Waterjet Ablation of the Prostate (JE) (A58227) LCA effective December 27. The article addresses billing and coding guidelines that complement the LCD for “Transurethral Waterjet Ablation of the Prostate” (L38705).
Noridian published its Transurethral Waterjet Ablation of the Prostate (JF) (A58229) LCA effective December 27. The article addresses billing and coding guidelines that complement the LCD for “Transurethral Waterjet Ablation of the Prostate” (L38707).
Novitas
Novitas released its Response to Comments: Transurethral Waterjet Ablation of the Prostate (JH, JL) (A58377) LCA, Pharmaceutical Policy, and comment/response article published for DL38712 Transurethral Waterjet Ablation of the Prostate, effective November 12.
Noridian released its Transuretheral Waterjet Ablation of the Prostate (JH, JL) (L38712) LCD, effective December 27. The associated response to comments article can be found here.
Noridian released its Transurethral Waterjet Ablation of the Prostate (JH, JL) (A58243) LCA, effective December 27. Article addresses billing and coding guidelines that complement the LCD for Transurethral Waterjet Ablation of the Prostate (L38712).
Noridian released its Urodynamic Services Non-invasive (JH, JL) (A58541) LCA, effective November 12. The article addresses billing and coding for urodynamic services noninvasive.
Palmetto
Palmetto retired the following LCA and LCDs, Effective November 7.
- Decipher Biopsy Prostate Cancer Classifier Assay for Men with Intermediate Risk Disease (MolDX) (JJ, JM) (A57761) LCA. The contractor states that this article is being retired because the information in this article has been incorporated within the new article for Prostate Cancer Genomic Classifier Assay for Men with Localized Disease (MoIDX) (A58343).
- Decipher Biopsy Prostate Cancer Classifier Assay for Men with Very Low and Low Risk Disease (MolDX) (JJ, JM) (A56921) LCA. The contractor states that this article is being retired because the information in this article has been incorporated within the new article for Prostate Cancer Genomic Classifier Assay for Men with Localized Disease (A58343) (MoIDX).
- Decipher Biopsy Prostate Cancer Classifier Assay for Men with Very Low and Low Risk Disease (MolDX) (JJ, JM) (L37785) LCD. The contractor states that this LCD is being retired because the information in this policy has been incorporated within the new LCD for Prostate Cancer Genomic Classifier Assay for Men with Localized Disease (MoIDX) (L38292).
- Decipher Biopsy Prostate Cancer Classifier Assay for Unfavorable Intermediate Risk Disease (MolDX) (JJ, JM) (L38029) LCD. The contractor states that this LCD is being retired because the information in this policy has been incorporated within the new LCD for “Prostate Cancer Genomic Classifier Assay for Men with Localized Disease” (L38292) (MoIDX).
- Decipher Prostate Cancer Classifier Assay (MolDX) (JJ, JM) (A56958) LCA. The contractor states that this article is being retired because the information in this article has been incorporated within the new article for Prostate Cancer Genomic Classifier Assay for Men with Localized Disease (MoIDX) (A58343).
- Decipher Prostate Cancer Classifier Assay (MolDX) (JJ, JM) (L35868) LCD. The contractor states that this LCD is being retired because the information in this policy has been incorporated within the new LCD for Prostate Cancer Genomic Classifier Assay for Men with Localized Disease (L38292) (MoIDX).
Palmetto released its Fluid Jet System in the Treatment of Benign Prostatic Hypertrophy (BPH) (MolDX) (JJ, JM) (L38549) LCD, effective December 27. The associated response to comments article can be found here.
Palmetto released its Response to Comments: Transurethral Waterjet Ablation of the Prostate (JJ, JM) (A58451) LCA, effective November 12, and a comment/response article published for DL38549 – Fluid Jet System in the Treatment of Benign Prostatic Hypertrophy.
Palmetto released its Transurethral Waterjet Ablation of the Prostate (JJ, JM) (A58008) LCA, effective December 27. The article addresses billing, coding, or other guidelines that complement the LCD for Transurethral Waterjet Ablation of the Prostate (L38549).
United Healthcare
United Healthcare reviewed its Prostate Services and Procedures Medicare Coverage Summary with the following changes:
- Added the following coverage guidelines for fluid jet system for treatment of benign prostatic hyperplasia (BPH):
- Medicare does not have National Coverage Determination (NCD) for fluid jet system for treatment of BPH.
- Local Coverage Determinations (LCDs)/Local Coverage Articles (LCAs) exist and compliance with these policies is required where applicable. For specific LCDs/LCAs, see the LCD/LCA Availability Grid (Attachment B).
- For coverage guidelines for states/territories with no LCDs/LCAs, see the United Healthcare Commercial Medical Policy for Omnibus Codes.
- Added the following CPT code:
- 0421T
WPS Government Health Administrators
WPS Government Health Administrators retired the following LCA and LCDs, effective November 7.
- Decipher Biopsy Prostate Cancer Classifier Assay for Men with Very Low and Low Risk Disease (MolDX) (J05, J08) (L37911) LCD. This LCD is being retired because the information has been incorporated within the new LCD for Prostate Cancer Genomic Classifier Assay for Men with Localized Disease (L38433) (MoIDX).
- Decipher Biopsy Prostate Cancer Classifier Assay for Men with Intermediate Risk Disease (MolDX) (J05, J08) (A57798) LCA. The article is being retired because the information has been incorporated within the new Billing and Coding: MolDX: Prostate Cancer Genomic Classifier Assay for Men with Localized Disease Article A57106.
- Decipher Biopsy Prostate Cancer Classifier Assay for Men (MolDX) (J05, J08) (L38166) LCD. The contractor states that the LCD is being retired because the information has been incorporated within the new LCD L38433 MolDX: Prostate Cancer Genomic Classifier Assay for Men with Localized Disease.
- Decipher Biopsy Prostate Cancer Classifier Assay for Men with Very Low and Low Risk Disease (J05, J08) (A57564) LCA. This article is being retired because the information has been incorporated within the new Billing and Coding: MolDX: Prostate Cancer Genomic Classifier Assay for Men with Localized Disease Article (A57106).
- Decipher Prostate Cancer Classifier Assay (MolDX) (J05, J08) (L36791) LCD. The contractor states that this LCD is being retired because the information in this policy has been incorporated within the new LCD for Prostate Cancer Genomic Classifier Assay for Men with Localized Disease (MoIDX) (L38433).
- Decipher Prostate Cancer Classifier Assay (MolDX) (J05, J08) (A57565) LCA. This article is being retired because the information has been incorporated within the new Billing and Coding: MolDX: Prostate Cancer Genomic Classifier Assay for Men with Localized Disease Article A57106.
WPS Government Health Administrators released its Fluid Jet System Treatment for LUTS/BPH (J5, J8) (L38682) LCD, effective December 27. The associated response to comments article can be found here.
WPS Government Health Administrators released its Response to Comments: Transurethral Waterjet Ablation of the Prostate (J05, J08) (A58539) LCA, effective December 27, and Comment/response article published for DL38682 – Transurethral Waterjet Ablation of the Prostate.
WPS Government Health Administrators released its Transurethral Waterjet Ablation of the Prostate (J05, J08) (A58209) LCA, effective December 27. The article addresses billing and coding guidelines that complement the LCD for Transurethral Waterjet Ablation of the Prostate (L38682).
WPS Government Health Administrators reviewed its Prostate Cancer Genomic Classifier Assay for Men with Localized Disease (MoIDX) (J5, J8) (A57106) with the following changes:
- Revised billing information stating that to report a prostate genomic classifier service, claim information must be submitted; changed ‘decipher prostate cancer genomic classifier assay’ to ‘prostate genomic classifier service’.
- Revised billing information stating that to report a prostate genomic classifier service, applicable CPT code must be selected; changed ‘select CPT code 81542’ to ‘select applicable CPT code’.
- Added the following CPT code:
- 81541 – Oncology (prostate), mRNA gene expression profiling by real-time RT-PCR of 46 genes (31 content and 15 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as a disease-specific mortality risk score
WPS Government Health Administrators retired its Oncotype DX AR-V7 Nucleus Detect for Men with Metastatic Castrate Resistant Prostate Cancer (MCRPC) (MoIDX) (J05, J08) (A57582). Contractor states that the information in this article is duplicative, as it is present in LCA A57102 “Billing and Coding: MolDX: Androgen Receptor Variant (AR-V7 Protein Test”.
Local and Regional Updates
The following are updates in your Section. The AUA routinely monitors state legislative, regulatory, and insurance policy trends. For this month, there were several balance billing, telemedicine, and medical licensure measures prefiled, meaning they will be considered during the upcoming 2021 legislative cycle. Please contact AUA State Advocacy Manager Catherine Hendricks at chendricks@AUAnet.org for more information on any of these issues.
New Jersey
- 5029 – Provider Contracts
Introduced November 19 by Assemblymember Shavonda Sumter (D), A. 5029 seeks to create the New Jersey Public Option Health Care Program to provide a comprehensive health insurance coverage option for every resident who enrolls. The health insurance coverage offered by the program will compete in the market with private health insurers. The bill was introduced and referred to the Assembly Financial Institutions and Insurance Committee. Read the bill.
S.B. 3145 – Medical Licensure
On November 5, Sen. Linda Greenstein (D) introduced S.B. 3145 requiring applications for a professional license to include a separate line allowing an individual to list a professional name, a line for a legal name and the ability for the individual to choose which name is to appear on the license. This bill is similar to A.B. 2308 introduced by Assemblymember Valerie Vainieri Huttle (D) earlier this year. S.B. 3145 was referred to the Senate Commerce Committee for further consideration.
Pennsylvania
Cap Blue Cross
Cap Blue Cross reviewed its Genetic and Protein Biomarkers for the Diagnosis and Risk Assessment of Prostate Cancer Policy with the following changes:
- Revised policy language to replace “single nucleotide polymorphisms (SNPs) testing” with “single nucleotide variant testing”.
- Removed the following CPT code:
- 81552 – Oncology (uveal melanoma), mRNA, gene expression profiling by real-time RT-PCR of 15 genes (12 content and 3 housekeeping), utilizing fine needle aspirate or formalinfixed paraffin-embedded tissue, algorithm reported as risk of metastasis
Highmark Inc.
Highmark reviewed its Lab Management Code List adding the following code:
- 0016M – Oncology (bladder), mRNA, microarray gene expression profiling of 209 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as molecular subtype (luminal, luminal infiltrated, basal, basal claudin-low, neuroendocrine-like)
Independence Blue Cross
Independence Blue Cross reviewed its eviCore Lab Management Program (Commercial) Policy, indicating that the following CPT code has been added to Attachment A (codes requiring pre-service and prepayment reviews) and its Genetic Testing (Commercial) Policy indicating the following CPT code has been added to Attachment C (experimental/investigational):
- 0016M – Oncology (bladder), mRNA, microarray gene expression profiling of 209 genes, utilizing formalinfixed paraffin-embedded tissue, algorithm reported as molecular subtype (luminal, luminal infiltrated, basal, basal claudin-low, neuroendocrine-like)
Independence Blue Cross reviewed its Experimental/Investigational Services CPT/HCPCS Codes (Medicare Advantage) Supporting Coverage Document with the following changes:
- Added the following HCPCS code:
- C9769 – Cystourethroscopy, with insertion of temporary prostatic implant/stent with fixation/anchor and incisional struts
- Removed the following CPT codes:
- 0596T – Temporary female intraurethral valve-pump (i.e., voiding prosthesis); initial insertion, including urethral measurement
- 0597T – Temporary female intraurethral valve-pump replacement
Independence Blue Cross reviewed its Molecular Diagnosis Attachment C (Medicare Advantage) Supporting Coverage Document adding the following CPT code:
- 0016M – Oncology (bladder), mRNA, microarray gene expression profiling of 209 genes, utilizing formalin-fixed paraffin-embedded tissue, algorithm reported as molecular subtype (luminal, luminal infiltrated, basal, basal claudin-low, neuroendocrine-like)
COVID-19
Pennsylvania Secretary of Health, Rachel Levine, M.D., issued an Executive Order outlining the metrics under which acute care hospitals will be required to reduce elective surgeries in order to ensure room for COVID-19 patients. The Order took effect November 30. Read the Order.
Virginia
S.B. 1107 – Medical Malpractice *Pre-filed for 2021
Pre-filed by Senator William Stanley (R), S.B. 1107 removes the limit on the total amount of recoverable damages for acts of malpractice on or after July 1, 2021. The Virginia Legislature convenes January 13, 2021. Read the bill.
ICYMI: Updates from the AUA Policy & Advocacy Brief blog
AUA Publishes Urology Impacts for the Calendar Year (CY) 2021 Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center Payment System Final Rule
On December 2, the Centers for Medicare and Medicaid Service (CMS) released the final CY2021 Medicare Hospital Outpatient Prospective Payment System (OPPS) and the Ambulatory Surgical Center (ASC) Payment System Final Rule. Policy items in the rule that impact urology include:
- CMS finalized a proposal to eliminate the inpatient only (IPO) list over a three-year period, starting with 266 musculoskeletal-related services and 32 additional HCPCS codes for CY2021, permitting these procedures to be performed in hospital outpatient settings as appropriate and to be priced under OPPS.
- CMS added 267 surgical procedures to the ambulatory surgery center covered procedures list for CY2021, including several urology procedures.
- CMS declined to designate CPT code 50590 (Lithotripsy, extracorporeal shockwave) device-intensive status. CMS also declined to establish alternative device-intensive criteria so that the costs of a lithotripter would allow CPT 50590 to receive a device-intensive designation.
For more information, click here.
AUA Insurance Roundtable: Telehealth and Burden Reduction Highlight Agenda
In early November, the American Urological Association (AUA) convened its third annual Insurance Roundtable (Roundtable). The Roundtable brought together more than 13 specialty societies and representatives from Medicare and private insurers for an open discussion and engagement on issues facing today’s healthcare providers.
Dr. Mary G. Greene, Centers for Medicare and Medicaid Services (CMS) Director of the Office of Burden Reduction & Health Informatics provided the keynote presentation on Burden Reduction. Dr. Aaron Spitz, Chair of the AUA Urology Telehealth Task Force provided the afternoon presentation on telehealth. Dr. Jonathan Rubenstein, AUA Chair of the Coding and Reimbursement Committee served as the moderator. Key takeaways included prior authorization remain a high priority for the Office of Burden Reduction; CMS is assessing programmatic changes to reduce physician and office staff burden; and CMS will be holding additional listening sessions with key stakeholders to further assess the situation.
Due to COVID-19, unlike the previous two years, the 2020 Roundtable was held virtually. This year’s roundtable was a rousing success, having more than doubled in participation from 21 in 2018 to almost 50 participants in 2020. Engagement among participants was high with almost 60 questions on issues ranging from step therapy to prior authorization.
Looking for more specifics from the day, search for the hashtag #auaroundtable on social media.
Surprise Medical Billing: Compromise Reached on Surprise Billing Fix
On December 11, key members of Congress released details of their negotiated agreement to protect patients from surprise insurance gaps and end surprise medical billing, which would use an independent dispute resolution (IDR) process without benchmark pay rates to resolve disputes over out-of-network bills between providers and payers. The arbiter would be directed to consider the median in-network payment rate for the service in question, information related to the providers’ experiences, the complexity of the service and the market share of the parties and their previous contracting history. The IDR would be binding, and there would be no monetary threshold for seeking arbitration. Patients would be held harmless from surprise medical bills and only be responsible for the in-network payment rate, unless they are notified about receiving out-of-network services 72 hours prior to receiving care.
All four health care committees of jurisdiction —led by House Ways and Means Chair Richard Neal (D-MA-01), House Energy and Commerce Chair Frank Pallone (D-NJ-06), House Education and Labor Chair Bobby Scott (D-VA-03), and Senate Health, Education, Labor and Pensions Chair Lamar Alexander (R-TN) — have agreed to the proposal. House Speaker Nancy Pelosi (D-CA-12) has said she will push for the measure’s passage before the end of the year, but it remains unclear whether Senate Majority Leader Mitch McConnell (R-KY) will support the inclusion of the measure in a year-end legislative package.
As a reminder, the AUA has been working closely with other physician groups in coalitions such as the Surprise Medical Billing Coalition and the Alliance of Specialty Medicine to seek a more balanced approach that incentivizes both physicians and insurers to contract and avoid government rate-setting. The longstanding goal has been to provide a fair, independent dispute resolution process that allows arbiters to consider, among other things, market rates.
With my warmest wishes for your good health during this holiday season,
Kathy