Brief Blog: The Nit-Picky World of CMS Policy Gems

While we hurtle forward in Washington with health insurance reforms, CMS continues to put out little policy corrections on a daily basis.   These are called "Transmittals" - they have a special webpage and there are several hundred per year (here).

• PLA Codes.  In R3783CP, CMS updates some details of hospital outpatient claims processing and includes use of the brand-new AMA CPT "PLA" section of codes, which AMA will produce quarterly.  Here.  (There's a policy mistake in it; here.)
• HIV Screening.  Based on a USPSTF recommendation, Medicare covers HIV screening tests under one set of conditions between ages 18-65 and another set below 18 or over 65.  
• Medicare has 4M beneficiaries below age 65.   
• There are also a set of special rules and specific codes for pregnant Medicare beneficiaries.  
• Here. 
• Oncology Care Model - Includes Cancer Patients Who Need Hospital Care ("Somebody tell the computer.")  With much fanfare, CMS created a monthly special payment for cancer care called the "Oncology Care Model" or OCM.  It was discovered that payments were blocked if a claim for the monthly support was submitted on a day when the patient was in hospital.  CMS fixes this.  Here.
• Mysteries of Drug Q Codes.  CMS normally produces new drug codes on a January 1 basis, based on a year long review process for applications submitted the prior January.   However, it sometimes pulls drugs into rapid code production, called "Q" codes, which are issued quarterly and help the claims processing work until the next January cycle.  When and how CMS decides to upgrade a drug to a rapid temporary Q code is an enigma to me.  
• The drug ustekinumab (Stelara, for psoriasis, iv) gets a Q code right now.  Few other drugs do, they have to wait til January.  Here.
• There is also the mysterious creation of two codes for hydroxyprogesterone caproate, available as Makena, under an orphan drug license that may expire in early 2018. One of the codes is specific to "Makena."  For articles, here and here.  Issues on orphan pricing of Makena and accusations of price gouging date at least to 2011 (here).
• CGM.  In a big breakthrough for diabetes patients, CMS finally approved coverage of continuous glucose monitors earlier in 2017.   This requires codes.  Here come the codes (here).  They are a rarely use class of codes,  "K" codes, which are "temporary DME codes."   
• PILD.  Since 2014, CMS has not covered lumbar spinal stenosis surgery if done by the percutaneous image guided technique (PILD).  After two CED trials, CMS reviewed the topic and decided to wait for more CED trials.  Sounds like the goalposts are not clear.  NCD here, transmittal here.
• Note that open and endoscopic lumbar surgeries are covered without further controls; it is only image-guided lumbar surgery that is restricted.  
• This is a variant from most CMS surgical coverage, which is agnostic to method.  For example, there was never any NCD on the topic of robotic prostate surgery as a technique nor on any other robotically-mediated surgeries.