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Read the RheumWATCH archives on topics such as rheumatology advocacy, policy updates, insurance advocacy, and practice management.
Last week the ACR Board of Directors, Government Affairs Committee, RheumPAC Committee, Affiliate Society Council leaders, and several other committee chairs embarked on Capitol Hill to meet with legislators and discuss concerns with the proposed Part B demo and other issues important to Advancing Rheumatology! In addition to Hill meetings, the group met with CMS Deputy Chief of Staff and Director of Delivery Reform Tim Gronniger, and heard from Congressman John Shimkus (R-IL) and Congressman G.K. Butterfield (D-NC), both senior members of the House Energy & Commerce Health Subcommittee.
As a complement to the fall Advocates for Arthritis program, this annual additional Hill fly-in brings together seasoned advocates and leaders from across the country to address rheumatology’s most pressing concerns. Hill meetings focused on the Part B demo, patient access to treatments, and funding for medical research.
Even if you weren’t able to participate with us on the Hill, you can make an impact by sending messages to your legislators via the ACR’s Legislative Action Center.
On April 29, CMS released MLN Matters Article MM9603 and change request Transmittal R3508CP regarding use of the JW modifier for drug wastage, which states that effective July 1, claims for discarded drug or biological amounts not administered to any patient shall be submitted using the JW modifier. Also, CMS states clearly that providers must document relevant information regarding discarded drugs in the patient’s medical record, including the actual dose administered, the exact amount wasted, and the total amount the vial is labeled to contain.
Previously, the policy allowed Medicare Administrative Contractors (MACs) the discretion to determine whether to require the JW modifier for discarded drugs or biologicals and how it should be documented. CMS indicates that the change is being made to more effectively identify and monitor billing and payment for discarded drugs and biologicals for single-use vials or single-use packages. Therefore, they have revised their claims processing policy to now require the uniform use of the JW modifier for all claims with discarded Part B drugs and biologicals.
Keep in mind, instructions regarding drug wastage have been in the manual since before 2003. These instructions have encouraged physicians of Part B drugs to schedule patients in such a way that they can use drugs or biologicals in the most efficient and clinically appropriate manner. This practice is to avoid drug wastage, but if a Part B drug provider had to discard the remainder of a single-use vial or other single-use package after administering a dose to a patient, CMS allowed payment for the amount of drug or biological discarded along with the amount administered, up to the amount of the drug or biological as indicated on the vial or package label. Note that these instructions only apply to single-dose vials, not to multi-dose vials nor drugs or biologicals under the Competitive Acquisition Program (CAP).
While the new requirements are concise, the operational issues to ensure compliance may not be so straightforward. It is critical when following this new requirement that the amount of each drug purchased from the manufacturer needs to be in the smallest package size available or closest to the dosage amount. Availability of package sizes and the dosage definitions for the HCPCS codes to correctly bill the drugs are two factors that make this new requirement challenging to implement.
Below are key billing guidelines for outpatient drugs covered under Part B contained in a single-dose or -use vial, including discarded drugs, that are reimbursable:
The ACR practice management staff recently spoke with CMS official Dr. William Rogers, who strongly recommended that patients should be administered the dose as indicated in their chart. Practices should bill for the required dose and if there is wastage, then CMS’s policy should be applied and coded properly with the JW modifier. For additional information on billing and documentation, contact Antanya Chung at email@example.com or 404-633-3777 ext. 818.
With multiple challenging policy issues facing the rheumatology subspecialty and rheumatology practices, there has never been a more important time to participate in RheumPAC. The ACR needs your support through donations to RheumPAC and involvement in advocacy activities to accomplish our many objectives for the remainder of 2016.
A donation to RheumPAC of any amount means investing in the future of rheumatology and helping to address these challenges. The RheumPAC page features an online contribution center that can accept contributions via credit card. Make your contribution today by simply visiting the site and using your ACR login credentials. For more information about how RheumPAC donations impact rheumatology, check out the 2015 Annual Report.
We just returned from Washington, D.C. and our springtime Capitol Hill fly-in with many ACR volunteer leaders. We met with lawmakers – 92 Congressional offices, to be exact – and focused on some of the major challenges facing rheumatology and patients today, including the flawed Part B drug payment demo. Many of you have already done so, but if you haven’t yet, it’s critically important that you take a moment to follow up on recent Hill work by taking action yourself. And it’s easy to do!
1. Proposed Medicare Cuts that Would Restrict Patient Access to Biologics.
A new federal proposal to further cut payments for Medicare Part B drugs would be devastating for rheumatology practices and patients who rely on biologic therapies and make existing access problems even worse. You can act now by asking your lawmakers to sign on to a Congressional letter urging the Centers for Medicare & Medicaid Services to stop the proposed payment test.
2. Innovative Medical Research for Rheumatic Disease.
Rheumatic diseases are the leading cause of disability in the U.S., affecting more than 50 million people. Arthritis also affects a disproportionate number of U.S. military members, yet there is no dedicated arthritis research program at the Department of Defense to aid prevention and treatment efforts. (Read more about arthritis in the military.) Thanks to discoveries made possible by the National Institutes of Health (NIH), including life-saving biologic drugs, patients living with rheumatic diseases have experienced extraordinary improvements in care. Unfortunately, the NIH receives nearly 25% less federal funding than it did in 2003, stalling important rheumatic disease research, innovative treatments, and possible cures. Ask your lawmakers to reinvest in U.S. medical research through the NIH and the Department of Defense.
3. Legislation to Help Patients Access Life-Saving Specialty Therapies.
Many insured patients have difficulty affording their biologic therapies because insurers have placed them on “specialty tiers” that require patients to pay expensive co-pays. The Patients’ Access to Treatment Act (PATA), introduced by Rep. David McKinley, would limit patients’ cost-sharing requirements for specialty tier drugs and make them easier to afford. Ask your lawmakers to co-sponsor PATA.
Thank you for the tireless work you do as advocates Advancing Rheumatology!
Will Harvey, MD, MSc
Chair, Government Affairs Committee