Healthcare Common Procedure Coding System

You can't manage what you can't see.

So the Part B drugs that hit the medical benefit billed through HCPCS codes, those aren't NDC numbers the way the pharmacy claims are billed.

So that's not a small technical detail.

That's an actual reason the spend is so hard to find.

Now, the proposal recommends 10 lab tests currently paid on the clinical laboratory fee schedule, the CLFS, to shift over to the MPFS or the OPPS.

One code example that they provide in the proposed rule is for HCPCS code 0376U for oncology, prostate cancer, image analysis of at least 128 histologic features and clinical factors, prognostic algorithm determining the risk of distant metastases, and prostate cancer specific mortality includes predictive algorithm to androgen deprivation therapy response if appropriate.

Now the other eight HCPCS codes are also specific to oncology as well as one additional HCPCS code for an unexplained constitutional or heritable disorder or syndrome.

And now it's time for my best practice tips in trustee tip.

So here we go.

There's a request for information about an al- essentially an Alzheimer's disease benefit is what they're signaling, a way to, to create service, uh, or care that can be delivered and billed for specific to, to those with dementia.

And there's an RFI on whether CMS should think about moving away from the CPT and HCPCS standard of coding, and a lot of detailed questions that they pose around why is it problematic to use the CPT system? What alternatives might we use? What would we base that on? There's, you know, there must be 50 questions just embedded in that RFI.

But I think really important takeaway for PT and OT here is they're looking at ways to reimburse for care that is cognitive in nature, not necessarily task or intervention or, you know, surgical based, but is based on the care that does not have good reimbursement and that they want to be able to change the way they've always done things.

And not too surprising given what else we've seen, you know, the innovation center under the same administration thinking about and proposing to do.

We've really had to operationalize an auto billing so that the economics work because hospitals are really struggling with the budgetary challenges that all the hospitals have come across throughout the country, making sure that the billing, the utilization, and the economics work on their end, and that takes a lot of communication with payers because they're trying to deal with this in a new and novel way as well because some AI models do not have any reimbursement at all.

With EchoGo, we actually worked with CMS to go through HCPCS to Category Three.

Awesome.

And so we have reimbursement specifically for EchoGo, and that sounds great, but then you have to work with everybody to make sure that the payers are aware and the education's there, the training and best practices are kind of put in place.

We...

The only thing for CPT and HCPCS is there's some that [clears throat] are not ... eligible for risk adjustment.

So, you know, if you're going to dialysis center, you know, th- that's a not eligible for risk adjustment, so they need to be sure that we're getting in them in to see their, their PCP.

I pulled a report and lo and behold, somebody was getting dialysis all year and never went to go see their doctor.