Medicare Coverage of HIFU Treatment
Medicare Coverage of HIFU : Update
Written by Dr. Stephen Scionti
Director Scionti Prostate Center
Medical Director Vituro Health
There has been progress on Medicare coverage of HIFU since my last post in July 2017.
Does Medicare cover HIFU?
I get this question all the time, so I will attempt to explain what changes I am beginning to see regarding Medicare coverage of HIFU for prostate cancer. There have been a few isolated episodes of facility fee reimbursement ( The C-Code) around the United States, however, this has been sporadic, unpredictable and cannot be guaranteed.
The Scionti Prostate Center in conjunction with Vituro Health will begin offering HIFU at Lakewood Ranch Medical Center in Bradenton, Florida. HIFU Procedures performed at Lakewood Ranch Medical Center are eligible for C -Code reimbursement and It is my belief that Medicare will reimburse the facility fee. Please note that this blog post represents my opinion and my observations after careful study of the Medicare rules governing C-codes and discussion with healthcare reimbursement specialists. Please call Dr. Scionti to request the most updated Medicare reimbursement status.
CMS announced the establishment of a new C-code for the ablation of prostate tissue using high intensity focused ultrasound or HIFU in July 2017.
C-codes are unique temporary pricing codes established by CMS (Center for Medicare and Medicaid Services) that apply only to the hospital outpatient facility and the ambulatory surgery center (ASC) settings. The C-code does not apply to the office based outpatient surgery center or to physician services. Please note that there are NO codes for payment of the HIFU doctor’s fees or of the Anesthesia doctor’s fees as of the time of this writing. ( March 21, 2018)
HIFU has been assigned HCPCS C-Code C9747, Ablation of prostate, transrectal, high intensity focused ultrasound (HIFU), including imaging guidance C9747 became effective July 1, 2017.
- At this time, it does not apply to commercial insurers.
- It does not apply to procedures performed in a physician’s office or to a physician’s services..
How does this affect your costs for HIFU procedure?
When a man undergoes HIFU, much like other medical procedures, there are a variety of necessary services in order to carry out the treatment. When you choose HIFU with The Scionti Prostate Center and Vituro Health, this includes:
- The facility (hospital, outpatient facility etc.) where the procedure takes place. This is Possibly reimbursed by Medicare
- The physician who performs the HIFU procedure.
- The anesthesiologist who administers anesthesia
- Concierge Patient Support Services
There is a specific cost associated for each of these services.
What services does the Medicare C-code cover?
- This code applies only to the facility. This means that it may only reimburse the hospital or surgery center for services provided.
- Although, there is now a code and a payment has been determined, there has been sporadic coverage (reimbursement) as of April 1,2018. What does this mean for you?
CMS assigned a code (C9747) and a payment (APC 5376, Level 6 Urology and Related Services, national average payment of $7,452.66) to that code.
However, having a code does NOT guarantee that Medicare will actually pay a facility for a HIFU procedure. Coverage is determined by the individual CMS Medicare Administrative Contractors (MACs). Please note that Medicare did NOT issue a national coverage determination (NCD) and that Local MACs individually decide on whether or not they will pay the facility fee..
The U.S. is divided into twelve (12) regions for the purposes of administering Medicare claims, including coverage decisions. These MACs are private health care insurers that have been awarded a geographic jurisdiction to process Medicare Part A and Part B medical claims for Medicare Fee-For-Service (FFS) beneficiaries.
In the absence of a national Medicare policy, each MAC decides individually, according to their own criteria, whether to cover a procedure and, if so, under what circumstances. It is possible that different MACs will issue different local coverage determinations (LCD) or that CMS will issue a national coverage determination (NCD) in the future. Please note that Medicare reimbursement of the facility code is NOT determined by The Scionti Prostate Center, Vituro Health, or any other HIFU services provider. Reimbursement decisions are made by the MAC (Medicare Area Contractor) .
Map of MAC coverage regions on the US
There has been no national coverage determination( NCD) at this time that will guarantee payment. Typically, NCD's are only issued after the publication of scientific studies in peer reviewed medical journals. Although HIFU has been well studied in Europe and Asia and there are numerous published studies outside of the US that document it’s effectiveness, my opinion is that definitive, binding coverage determinations will be issued ONLY after the publication of results from US HIFU centers. A medical journal will usually require a few years of follow up in order to deem a study worthy of publication. Since the first HIFU procedures were done in the USA in December 2015, it is still too soon for studies to be submitted to medical journals and for them t be published. I think we are about 2 years away from automatic guaranteed coverage.
So, what does this really mean?
Medicare patients should be optimistic that Medicare will reimburse the facility fee portion of their HIFU procedure at this point in time. There have been episodes of the facility fee being paid, but this has been unpredictable. Virtually all facilities will request payment upfront and ask the Medicare patient to sign an "Advanced Beneficiary Notice" or ABN that informs them that Medicare may not pay. If Medicare does reimburse the facility charges, the patient should receive a refund from the facility. Over the next 6 - 12 months, I expect to see more episodes of the facility fees being reimbursed by the local MACs. Vituro Health will work with you , as a Medicare beneficiary, to facilitate reimbursement of the facility costs. The Scionti Prostate Center , along with Vituro Health , will offer HIFU at our new Lakewood Ranch Medical Center facility. HIFU procedures performed at Lakewood Ranch will be submitted to Medicare for C-Code ( facility fee) reimbursement.
There is still no coverage of HIFU professional fees by Medicare and this will not occur until CMS issues an official CPT code with reimbursement attached to it. This means that a significant portion of the costs of the HIFU procedure must be paid by the Medicare patient, even if the facility costs are covered.
Dr. Stephen Scionti, director of the Scionti Prostate Center and Medical Director of Vituro Health has performed all of his HIFU procedures to date, at the Vituro Health Sarasota HIFU Center of Excellence located at Sarasota Interventional Radiology Center. The new C- Code does NOT apply to this treatment facility. This facility has performed more HIFU procedures than any other US facility and has a dedicated on-site full time engineering team. However, Dr Scionti and his team at Vituro Health will now offer HIFU in an outpatient hospital setting in anticipation of future reimbursement of the facility fees.
Please note that Dr. Scionti personally performs 100% of all HIFU procedures and never allows interns, residents, or trainees to treat his patients.
The Scionti Prostate Center in conjunction with Vituro Health, will work to assist our patients in obtaining reimbursement from the MAC that covers Florida (First Coast Servicing Organization).
This blog will be continuously updated as the reimbursement polices evolve, so stay tuned and return to sciontiprostatecenter.com to stay informed of changes.