Blood Processing Approved for the Office Setting
Robert Weinstein, M.D., Chair, ASH Committee on Practice
In 2002, a consortium of professional societies, led by ASH, obtained six new CPT codes for therapeutic apheresis. Separate codes were established for leukapheresis, plateletpheresis, red cell exchange, plasma exchange, immunoadsorption apheresis (Prosorba® and Excorim®), and non-immune adsorption or filtration apheresis (principally used for LDL-apheresis). At the time, CMS approved therapeutic apheresis in both hospital and non-hospital settings but would only pay for the procedures in the hospital setting. Physicians' fees could be paid in either setting, but the costs of providing the procedures (the practice expense) were prohibitive without reimbursement in the non-hospital setting. ASH mounted a successful defense of physician reimbursement before the Relative Value Update Committee (RUC) {see column below} in 2002, but the absence of practice expense reimbursement in the non-hospital setting remained as unfinished business.
By 2004, the changing landscape in therapeutics brought renewed emphasis on the issue of non-hospital reimbursement for therapeutic apheresis. In many regions of the country, hospital-based therapeutic plasma exchange was becoming unavailable. In rheumatology practices, the early enthusiasm for Enbrel® injections and Remicade® infusions for the treatment of severe rheumatoid arthritis was waning in favor of a renewed interest in apheresis-based Prosorba® column treatments, but, again, hospitals in certain regions would not provide them. Perhaps most significantly, the one-third of patients maintained on LDL apheresis procedures in the non-hospital setting were increasingly being denied treatment because of lack of reimbursement.
The American College of Rheumatology (ACRh) had requested that outpatient Prosorba® treatments (under CPT code 36515) be on the agenda at the March 2004 meeting of the Practice Expense Advisory Committee (PEAC). There was concern on the part of ASH that the Society was recognized by the AMA as a leadership voice for apheresis while the ACRh did not possess the expertise to mount a credible defense of a proposal in the apheresis field. Thus the Committee on Practice of ASH partnered with ACRh and with the American Society for Apheresis to propose outpatient practice expense reimbursement for three of the six therapeutic apheresis codes (plasma exchange, immunoadsorption and LDL-apheresis).
The culmination of two days of conferences at the PEAC meeting of March 2004 was approval, almost intact, of the proposal. The approval process now moves to CMS. The further good news is that the CMS representatives to the PEAC fully understood the purpose of, and the justification for, the proposal and were very supportive. We trust it will emerge intact in time for full implementation in January 2005. Thus therapeutic plasma exchange, Prosorba® treatments, and LDL-apheresis procedures may soon be performed in the non-hospital setting as chemotherapy treatments are now. This will add an element of versatility to outpatient practice in our field, and a major element of convenience to many of our patients.
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A PEAC at Reimbursement for Office-Based Blood Transfusion
Robert Weinstein, M.D., Chair, ASH Committee on Practice
It is probably not widely known that a committee of the American Medical Association (AMA), the Relative Value Update Committee (RUC), determines the worth of all services performed by physicians. A special subcommittee of the RUC, the Practice Expense Advisory Committee (PEAC {pronounced peek}), is particularly important to those of us in practice. Whereas the RUC deals directly with reimbursement for the physician's own services (the professional component), the PEAC deals with all other expenses (nursing, supplies and equipment, pharmaceuticals, etc.) we incur when providing services to patients. Each service or procedure (as represented by its CPT code) is reviewed every five years, and the PEAC decides whether or not the practice expense allowances for them are appropriate. Procedures that are performed infrequently, so-called orphan procedures, are typically dropped from the reimbursement radar screen unless an interested professional society arrives to make the case for its preservation. In addition, the PEAC entertains proposals for new codes to be performed in the office setting.
CPT code 36430, which codes for red blood cell transfusion in the office setting, is performed approximately 10,000 times per year in the United States, thus qualifying for true orphan procedure status. It is most performed in oncology clinics and treatment centers as a convenience to patients receiving myelosuppressive chemotherapy. The ASH Committee on Practice attended the March 2004 meeting of the PEAC in order to ensure the continued valuation of 36430. Our presentation resulted in practice expense approval assuming a typical patient would be transfused through an implanted infusion port using a Huber needle. This is significant with respect to the allowed supply budget. Thus transfusion in the oncology office setting will be secure for the next five years.
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