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.
As the annual appropriations process continues through Congress, we will keep you updated on this and other issues that affect urology.
Annual Urology Advocacy Summit: 2020
Earlier this month, we extended an invite to you to participate in the 2020 Annual Urology Advocacy Summit. As a reminder, we asked if you would send us your liaison appointment to the AUA Summit on or before August 1. Once we have your liaison’s name, we will schedule an introductory phone call to discuss content submissions, ideas on potential speakers, and the highly popular young urologist, fellow, and resident “match” program.
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.
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 about AUA’s research advocacy efforts.
Insurance Updates from National Insurance Carriers
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]
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 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.
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 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.
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.
Read the complete policy.
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.
New England Section
LD 1672 – Medical Malpractice
Representative Donna Bailey (D) introduced LD 1672 stipulating that records, including itemized bills, kept by health care practitioners, health care entities, health care providers, pharmacists and pharmacies may be admissible in court as evidence of the
- fair and reasonable charge for such services or the necessity of services or treatments;
- diagnosis provided by the medical entity;
- prognosis provided by the medical entity;
- opinion provided by the medical entity regarding the proximate cause of the condition diagnosed; and
- opinion provided by the medical entity regarding any disability or incapacity proximately resulting from the condition diagnosed.
LD 1672 has been referred to the Committee on Judiciary for further consideration.
The bill is avialable here: 5/2/2019 Version
HB 1172 – Provider Contracts
Representative David Linsky (D) introduced HB 1172 stating that reimbursement from managed care organizations that contract with the executive office for hospital and physician services provided to beneficiaries will be subject to negotiation between providers of medical services and managed care organizations and will not be limited or determined through contracts between the executive office and managed care.
HB 1172 states that acute hospital and non-acute hospital reimbursement from managed care organizations that contract with the executive office will for health services provided to beneficiaries under this chapter be subject to negotiation between those hospitals and managed care organizations and shall not be limited or determined through contracts between the executive office and managed care organizations, including accountable care organizations and dual-eligible health plans.
Finally, this measure states that the executive office will not, in its contracts with acute hospitals and non-acute hospitals or through any other rule or regulation, require hospitals to accept fee-for-service rates established by the office of Medicaid for non-emergency services provided to beneficiaries enrolled in managed care organizations including for accountable care organizations and dual eligible health plans. The office may require hospitals that are not in a managed care organization’s provider network to accept fee-for-service rates established by the office for emergency services only.
A public hearing on this, and other bills, was held by the Joint Committee on Health Care Financing on May 7. A date has not yet been set on when the joint committee will vote on the bill, but we will update you as HB 1172 progresses.
The bill is available here: 1/22/2019 Version
HB 1140 – Provider Contracts
Representative Claire Cronin (D) introduced HB 1140 limiting the conditions that health care organizations can include in contracts with health care providers. Specifically, the bill stipulates that a health care organization or delivery system cannot establish as a condition of a contract with a health care provider that said provider be required to create a separate legal entity and/or separate tax identification number. A health care entity also cannot penalize health care providers who elect not to create a separate legal entity and/or separate tax identification number.
A hearing was held by the Joint Committee on Health Care Financing on May 7. A date has not yet been set on when the joint committee will vote on the bill, but we will update you as HB 1140 progresses.
The bill is available here: 1/22/2019 Version
SB 662 – Medical Malpractice
Senator Michael Brady (D) introduced SB 662 limiting, in contacts with acute hospitals, the financial penalty related to potentially preventable readmissions. Under this measure, in its contracts with acute hospitals, the executive office and any third party under contract with the executive office to provide medical benefits for medical assistance recipients, must limit any financial penalty related to potentially preventable readmissions to no more than 4.4 percent of a hospital's total annual inpatient payments covered under the contract.
A hearing was held by the Joint Committee on Health Care Financing on May 7. A date has not yet been set on when the joint committee will vote on the bill, but we will update you as SB 662 progresses.
The bill is available here: 1/22/2019 Version
BMC Health net has reviewed its Posterior Tibial Nerve Stimulation (PTNS) with the following changes to coverage, limitations, coding, and supporting information:
- Updated policy summary section to replace statement of non-coverage for PTNS for all indications with language stating that PTNS for treatment of non-neurogenic overactive bladder syndrome in adults may be considered medically necessary when criteria are met.
- Criteria added to medical policy statement section include, but are not limited to, the following:
- member is age 18 or older on the date of service,
- member is diagnosed with non-neurogenic overactive bladder (OAB) syndrome as documented by the treating provider,
- member has not received a course of treatment with PTNS sessions in the past for the treatment of OAB symptoms.
- Updated limitations section with circumstances requiring review by the plan medical director, list of contraindications for PTNS, and indications considered experimental/investigational for PTNS.
- Added the following experimental/investigational CPT codes:
- 97014 - Application of a modality to 1 or more areas; electrical stimulation (unattended)
- 97032 - Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes
- Added the following experimental/investigational HCPCS code:
- G0283 - Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care
- Added list of ICD-10 codes, which include, but are not limited to, the following:
- 81 - Overactive bladder
- 9 - Bladder disorder, unspecified
- 3 - Stress incontinence (female)(male)
- 41-N39.43 - Other specified urinary incontinence
- 45-N39.46 - Other specified urinary incontinence
SB 97 - Certificate of Need
Senator Jeb Bradley (R) introduced SB 97 requiring an applicant seeking to construct certain health care facilities for licensure to submit a report showing how the proposed project will affect certain health care services.
SB 97 passed the Senate in March, it was then referred to Health, Human Services, and Elderly Affairs Committee where it was approved on May 7. It is now eligible for consideration by the full House.
The bill is available here: 3/28/2019 Version
HB 5582 – Provider Contracts
Representative David Bennett (D) introduced HB 5582 requiring a health insurer to submit information about each health care risk contract within 30 days of a request to the Insurance Commissioner, as directed by the Commissioner.
The measure requires the Insurance Commissioner to establish a process for certifying provider organizations that intend to enter into health care risk contracts for Medicaid enrollees. The measure also requires the Commissioner to establish a process for reviewing and evaluating the financial solvency of risk-bearing provider organizations by considering all the health care risk contracts that a provider organization has entered into at the time of a financial solvency review.
Finally, HB 5582 prohibits a risk-bearing provider organization from entering into or renewing a health care risk contract without approval from the Commissioner if the organization does not meet the standards of financial solvency.
HB 5582 has been referred to the House Finance Committee where a hearing was held on May 15.
The bill is available here: 2/27/2019 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. Read the full post for more information.
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.
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.