The Case of Penny Wise but Access and Quality of Care Foolish

Excerpt

Recently, the Healthcare Common Procedure Coding System (HCPCS) coding committee for supplies [headed up by Center for Medicare and Medicaid Services (CMS), with private payer representatives] denied a request for a unique HCPCS level II code for use of a novel bone marrow biopsy system in the physician office setting (POS). This code would in effect allow access/use of a powered bone marrow biopsy system (brand name OnControl^®) in this setting, where a significant number of bone marrow biopsy procedures are performed. Hematologists and oncologists perform the vast majority of these types of procedures [1]. In randomized controlled trials this new system has demonstrated significant reductions in patient pain as well as significantly improving upon the sample yield to more accurately assess a patient’s pathology [2]. It also demonstrated the potential ability for a patient to be able to better tolerate the pain of the biopsy based on the visual analog scale (VAS) pain reduction seen with the powered system [3]. Interestingly, 3 years prior to this, CMS granted a unique code for the use of OnControl^® in the hospital outpatient setting (HOPS), permitting the full amount of this technology to be paid for. Why would CMS pay additionally in one care setting but deny access in another less expensive care setting (i.e., POS)? Before this question is answered, we need a history of how this determination was made. …