May 2019 - 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 the positive impact of your AUA Summit “ask” on prostate cancer screening as well as our attendance at the National Institute of Diabetes and Digestive and Kidney Diseases’ Subcommittee meeting for Kidney, Urologic, and Hematologic Diseases to advocate for urologic research and funding opportunities.
Access to Prostate Cancer Screening: AUA Summit “Ask” Included in House Spending Bill
On May 7, the House Appropriations Committee released its accompanying report to the Fiscal Year 2020 Departments of Labor, Health & Human Services, and Education Appropriations Act. In the report is language directed at the National Cancer Institute (NCI) that was advocated for by the urologic community at the AUA Summit this past March. The language encourages further investment in research for prostate cancer screening for high-risk populations, like African American men and those of a family history. This request stems from the 2018 upgrade in recommendations for prostate cancer screening by the U.S. Preventive Services Task Force, but, at the time, was unable to give specific insight for African American men – citing a lack of available research evidence of the benefits to this population.
While the report does not require the NCI to apply its appropriated funds in any specific way, it is a strong encouragement and provides an outline on what Congress believes are the important issues to focus on. The full prostate cancer language can be found on page 83 of the report, which is available here:
As the annual appropriations process continues through Congress, we will keep you updated on this and other issues that affect urology.
Current Procedural Terminology (CPT) Editorial Panel Meeting – May 2019
AUA CPT Advisor Dr. Ronald P. Kaufman, Jr., and Alternate Advisor and Coding & Reimbursement Committee Chair Dr. Jonathan Rubenstein represented the AUA at the American Medical Association CPT Editorial Panel meeting last week. Drs. Kaufman and Rubenstein specifically addressed issues submitted by industry that impact urology that industry submitted. The AMA CPT Public Agenda for this meeting included Category I Transrectal High Intensity Focused US Prostate Ablation (HIFU), Multianalyte Assays with Algorithmic Analyses (MAAA) Prostate Cancer Metastasis Risk Score, Category III Transurethral US-Guided Ablation of Prostate and Cat III Posterior Tibial Nerve Neurostimulation. If these codes are approved, they will be available in January 2021. Any Category I CPT code approved will be RUC surveyed for valuation. The MAAA laboratory test – if approved for coverage – will be paid under the Medicare Laboratory Fee Schedule and Category III codes will be priced by Medicare contractors. The full CPT agenda is posted here.
Research Advocacy: AUA Attends National Institute of Diabetes and Digestive and Kidney Diseases’ (NIDDK) Subcouncil Meeting of the Division of Kidney, Urologic, and Hematologic Diseases
On May 8, the AUA attended the National Institute of Diabetes and Digestive and Kidney Diseases’ (NIDDK) Subcouncil Meeting of the Division of Kidney, Urologic, and Hematologic Diseases. The meeting hosted stakeholders within the NIDDK community and featured subject matter presentations from disease-specific areas. Dr. Paul Lange represented the AUA and addressed specific needs in urologic research through a presentation that focused on the importance of surgeon-scientists and the benefits of surgeon-scientist collaboration with basic scientists. Dr. Lange encouraged additional collaboration with the AUA’s Office of Research team to help recruit and make successful MDs and PhDs in urologic research. Read more here about AUA’s research advocacy efforts.
The following insurance updates are from national insurance carriers.
Aetna
Aetna has updated its Benign Prostatic Hypertrophy (BPH) medical policy with the following changes:
- Added the following covered CPT code:
- 53854 – Transurethral destruction of prostate tissue; by radiofrequency generated water vapor thermotherapy
- Expanded the following covered ICD-10 code range:
- 010 – N35.92 – Urethral stricture [previously listed N35.010 – N35.9]
- Removed the following covered CPT code:
- 53852 – Transurethral destruction of the prostate tissue; by radiofrequency thermotherapy [TUNA]
Cigna
Effective May 18, Cigna has advised it will deny claims for pass through laboratory services. These services are submitted for reimbursement with modifier 90 in place of service (POS) 11. The processing laboratories should bill Cigna directly and they will reimburse the labs according to the beneficiary’s plan. Pass through billing is occurs with providers will draw the blood in the office setting, however, send the blood out to be processed.
Cigna has announced it will no longer separately reimburse for infusion and injection administration services billed by a facility. Cigna considers infusion and injection administration services incidental to the primary service and are no longer separately reimbursable.
United Healthcare
United Healthcare has revised its Proton Beam Radiation Therapy medical policy with the following changes to criteria and coding:
- Revised coverage status for prostate cancer from “unproven and not medically necessary” to “medically necessary” for treatment with proton beam therapy (PBT) and intensity-modulated radiation therapy (IMRT) based on the terms of the member’s benefit plan;
- Added the following ICD-10 diagnosis code:
- 0 – Malignant neoplasm of prostate
- Updated description of the following CPT code:
- 77387 – Guidance for localization of target volume for delivery of radiation treatment includes intrafraction tracking, when performed.
Moved notation regarding the applicability of the policy to members 19 years of age and older from the benefit considerations section to the coverage rationale section.
Read the complete policy.
United Healthcare has revised its Posterior Tibial Nerve Stimulation (PTNS) medical policy with the following changes:
- Removed policy statement indicating that continued treatment is not considered medically necessary if the member fails to improve after six PTNS treatments.
- PTNS should not be performed as first line therapy for patients with overactive bladder (OAB). It may be considered medically necessary and covered to treat patients with OAB and associated symptoms of urinary urgency, urinary frequency, and urge incontinence when the patient has tried at least two different anti-cholinergic drugs, or a combination of an anti-cholinergic and a tricyclic drug for a period of four to six weeks without improvement, or the documentation shows the patient is unable to tolerate these type drugs.
- Treatment regimens consist of 30-minute weekly sessions for 12 treatments. Treatment beyond the initial 12 sessions may be allowed at a frequency of one every one to two months when medical necessity is supported by documentation.
UHC Community Plan
United Healthcare Community Plan has revised its Proton Beam Radiation Therapy medical policy with the following changes to criteria and coding:
- Revised coverage status for prostate cancer from “unproven and not medically necessary” to “medically necessary” for treatment with proton beam therapy (PBT) and intensity-modulated radiation therapy (IMRT) based on the terms of the member’s benefit plan.
- Added the following ICD-10 diagnosis code:
- 0 – Malignant neoplasm of prostate
- Updated description of the following CPT code:
- 77387 – Guidance for localization of target volume for delivery of radiation treatment, includes intrafraction tracking, when performed
Humana
Humana has revised its Benign Prostatic Hyperplasia (BPH) Treatments medical policy with the following changes to criteria, coding, and supporting information.
- Reversed coverage status for prostatic urethral lift (i.e., NeoTract UroLift), previously called implantable transprostatic tissue retractor system, from not eligible to eligible for the treatment of benign prostatic hyperplasia when non-surgical management has failed.
- Removed coverage limitation statement indicating that robotic-assisted surgery and/or the use of robotic guidance systems are not separately reimbursable, as they are considered integral to the primary procedure.
- Removed non-coverage status for the following CPT codes:
- 52441 – Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; single implant
- 52442 – Cystourethroscopy, with insertion of permanent adjustable transprostatic implant; each additional permanent adjustable transprostatic implant (List separately in addition to code for primary procedure)
- Removed non-coverage status for the following HCPCS codes when used to report implantable transprostatic tissue retractor system:
- C9739 – Cystourethroscopy, with insertion of transprostatic implant; 1 to 3 implants
- C9740 – Cystourethroscopy, with insertion of transprostatic implant; 4 or more implants
- Updated the description section to replace implantable transprostatic tissue retractor system with prostatic urethral lift; added UroLume as an example of a permanent urethral stent.
- Updated the list of medical terms to add bladder, catheter, cauterize, chronic, and cryoprobe among others.
- Removed the term endoscope.
Read the complete policy here by clicking on the link for Benign Prostatic Hyperplasia (BPH) Treatments Revised.
Humana has added a new policy for Reclast to its database. Humuna has created an individual policy for Reclast for Medicare plans which was previously addressed in an overarching policy for commercial and Medicare plans. Reclast may be considered medically necessary when criteria are met.
Humana has revised medically necessary criteria regarding previous treatment, contraindication, or intolerance for all indications to add applicability to intravenously administered bisphosphonate.
Local and Regional Updates
The following are updates in your Section. Please contact AUA Executive Vice President Kathleen Zwarick at kzwarick@AUAnet.org for more information on any of these issues.
Maryland
HB 162 – Medical Malpractice
Governor Larry Hogan (R) signed HB 162 into law on April 18. The bill limits the requirement that insurers that issue or deliver medical professional liability insurance policies in the state offer, in addition to the basic policy, additional policies with certain deductibles to insurers that issue or deliver a policy with an annual premium of a certain amount or more. It takes effect on October 1, 2019.
The final bill is available here: 4/18/2019 Final Version
SB 773 – Medical Malpractice
Senator Will Smith (D) introduced SB 773 exempting certain documents relating to a health care professional’s income from discovery and admission on the question of whether the health care provider qualifies as an expert in a certain health care malpractice proceedings.
The bill alters the percentage of an expert’s professional activities that may have been devoted to activities that directly involve testimony in personal injury claims in order for the expert to qualify to testify in relation to a proceeding. It specifies that the health care provider who attests in a certificate of a qualified expert or who testifies in relation to a proceeding before an arbitration panel or a court concerning compliance with or departure from standards of care may not have devoted 50 percent of the expert’s professional activities to activities that directly involve testimony in personal injury claims during the calendar year when the alleged event or omission giving rise to the cause of action occurred.
Finally, SB 773 states that a health care provider will be deemed to have met a requirement during the pendency of a claim and that a claim or an action may be reviled only once.
SB 773 was signed into law by Governor Hogan (R) on May 13.
The bill is available here: 5/13/2019 Final Version
SB 940 – Certificate Of Need
Senator Katherine Klausmeier (D) introduced SB 940 providing that a certificate of need is required before the type or scope of any health care service is changed if the health care service results in a change in operating room capacity in a health care facility. This measure alters the circumstances under which a certificate of need is required before certain capital expenses are made by or on behalf of a certain health care facility. It repeals a provision authorizing a hospital to acquire a freestanding ambulatory surgical facility or a certain office or group practice.
SB 940 was signed into law by Governor Hogan (R) on May 13.
The bill is available here: 5/13/2019 Final Version
Pennsylvania
SB 25/HB 100 – Scope of Practice
Senator Camera Bartolotta and Representative Jesse Topper introduced SB 25/HB 100, respectively, granting independent practice to certified registered nurse practitioners after completion of a collaborative agreement with a physician for a minimum of 3 years and 3,600 hours.
SB 25 was voted out of the Senate Consumer Protection and Professional Licensure Committee, as amended, on March 27. HB 100 was referred to the House Professional Licensure Committee on April 15, 2019 where it awaits further consideration.
The bill is available at: 3/27/2019 Version
HB 1063 – Medical Malpractice
Representative Donna Oberlander (R) introduced HB 1063 allowing courts to exercise general personal jurisdiction over a health care provider in a medical professional liability claim in the county of which the cause of action arose.
HB 1063 has been referred to the House Judiciary Committee for further consideration.
The bill is available here: 5/13/2019 Version
ICYMI: Updates from the AUA Policy & Advocacy Brief blog
Reducing Regulatory Burdens: Prior Authorization Update
On May 9, the AUA received an updated draft of the prior authorization bill sponsored by Reps. Mike Kelly (R-PA-16), Roger Marshall, MD (R-KS-1), Susan DelBene (D-WA-1) and Ami Bera, MD (D-CA-7). The AUA actively is engaged in quickly moving negotiations on the legislation with the Regulatory Relief Coalition, and this pending legislation was one of three congressional “asks” during the 2019 AUA Summit. The bill calls for automating prior authorization requests, increasing transparency in prior authorization processes, and prohibiting Medicare Advantage plans from imposing additional prior authorization requirements on surgeries and other invasive procedures. For more information, read here.
American Telemedicine Association Annual Conference: Highlights from AUA Telehealth Task Force
The AUA Telehealth Task Force Co-chair Dr. Eugene Rhee, Dr. Errol Singh (member of the AUA Telehealth Task Force), Dr. Neil Baum (AUA member), and Director of Payment Policy Stephanie Stinchcomb-Stork recently attended the American Telemedicine Association Annual Conference. The meeting, the third AUA representatives attended, had access to more than 100 sessions themed around emerging best practices, tools, and techniques for building telehealth. There are more than 150 exhibitors with the latest in telehealth technologies. The Task Force returned with actionable insights, lasting connections, and an enhanced appreciation of telehealth.
‘Patient Advocacy Connections’ at AUA 2019
The Patient Advocacy Program at AUA 2019 successfully connected more than 20 patient advocacy organizations with annual meeting attendees. The Patient Advocacy Connections Booth, located in the Science & Technology Hall, offered participants an opportunity to showcase their organization materials and interact with meeting attendees about advocacy initiatives and improving patient access to care. In addition to time in the Science & Technology Hall, participants attended three roundtable meetings entitled “Legislative Issues Impacting Patient Access to Care, Effectively Mobilizing Advocates on Capitol Hill, and Activating Your Story in a Noisy World.” Learn more about patient activities here.
Practice Management: Register Today for The AUA’s Regional Coding Seminar, Join the Practice Management Network
The AUA is returning to The Westin Las Vegas for our annual Las Vegas Coding Seminar, to be held July 19-20. Registration for this event is officially open. The seminar will feature experts in the field of urology, who will provide updates on coding changes, discussions of common coding questions and payment denials gathered from the AUA Coding Hotline. Our event is widely-praised by its attendees, with one suggesting that they “highly-recommend that physicians, managers, coders & billers of any level should attend.” The seminar will offer practical exercises to hone the skills of anyone in the practice who is involved with CPT, HCPCS, or ICD coding. Our seminar also will feature coding workshops to educate attendees on coding basics and discuss surgical coding challenges, as well as our auditing workshop, which will show our attendees how to face the challenges of E&M documentation head on.
Visit our website to view the seminar schedule for each day and register for the AUA Coding Seminar.
Does your practice needs access to valuable coding resources and updates on current urology management trends and issues? If so, you need to join the AUA’s Practice Management Network. The Practice Managers Network (PMN) is a vibrant hub of education and interaction. Our network allows its members to engage in a variety of ways, from discussing important matters in our online community, to receiving essential coding guidance from our AUA Coding Hotline. Let PMN give your practice the tools it needs to succeed. Join the Practice Managers’ Network and optimize your practice today.