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Building Digital Health and Therapeutic Solutions for the Future: What's Required for Success?
Published in Oleksandr Sverdlov, Joris van Dam, Digital Therapeutics, 2023
In general, digital therapeutic products can be either Rx-only, OTC-only, or both. For example, reSET and reSET-O from Pear Therapeutics, and Akili's EndeavorRx are Rx-only, whereas Welldoc's BlueStar has both Rx and OTC clearances. If the regulatory pathway is Rx, then it is almost a foregone conclusion that there must be a code involved in the payment pathway. That code can be an existing reimbursement code, such as the American Medical Association's Current Procedural Terminology (CPT), the Centers for Medicare and Medicaid Services Healthcare Common Procedural Coding System (HCPCS), or the FDA's National Drug Code (NDC) and National Health-Related Item Code (NHRIC), or a new code for either the digital therapeutic or a broader class of digital therapeutics. Continuing with this pathway, the unit measure is most likely per user—that is, a reimbursed price per user. In such arrangements, the element of risk rarely figures in: the price is what it is and is decided by a third party.
Financial Aspects of a Mechanical Circulatory Support Program
Published in Wayne E. Richenbacher, Mechanical Circulatory Support, 2020
The physician reimbursement is based upon the code describing the procedure, the relative value of that procedure and the conversion formula. The Physicians’ Current Procedural Terminology (CPT) codes provide the basis for payment as it describes physician provided services (Table 12.3).5 An ICD-9-CM code is needed to indicate the reason the service was performed or the diagnosis and the Health Care Financing Administration (HCFA) Common Procedural Coding System (HCPCS) may be required to describe what supplies were used.6 These coding systems standardize the reporting procedures of physicians and form the basis from which reimbursement is determined.
Bill Review
Published in Julie Dickinson, Anne Meyer, Karen J. Huff, Deborah A. Wipf, Elizabeth K. Zorn, Kathy G. Ferrell, Lisa Mancuso, Marjorie Berg Pugatch, Joanne Walker, Karen Wilkinson, Legal Nurse Consulting Principles and Practices, 2019
Billing information can appear as line-item invoices, official claim forms (e.g., CMS-1500 for services rendered by healthcare professionals and the uniform billing form UB-04 for hospital services), or simply a summary statement to the patient. Whatever the format, line-items containing the appropriate codes for services and diagnoses must be present to adequately evaluate the charges. Although ICD-10 codes were official in September 2015, the earlier version, ICD-9 codes, are encountered on claims prior to that date. The CPT and HCPCS codes are updated annually.
A descriptive analysis of wheelchair repair registry data
Published in Assistive Technology, 2023
Alexandria M. James, Gede Pramana, Richard M. Schein, Anand Mhatre, Jonathan Pearlman, Matthew Macpherson, Mark R. Schmeler
The cleaning and extraction process had three sub-processes. The first process filtered out service ticket records with missing serial numbers. This was necessary to avoid potential duplication of cases as customers can get their devices repaired over time, several service tickets could be generated. A serial number can then be used to determine the number of service tickets and the number of repairs a device has over its lifetime. The second process attempted to determine devices’ age by purchase date and filter out the devices without one. A program written in C# language was developed to either decode purchase date from serial number or initiate web service calls to manufacturer’s website (if available). The third process categorized devices into HCPCS code categories based on device model. The HCPCS is a set of healthcare procedure codes primarily used for billing and identifying items and services. The fourth process then filtered out service tickets associated with devices older than 10 years. Devices older than 10 years are very likely to have incomplete repair records showing inaccurately low number of repairs. Devices that could not be categorized due to missing model information were excluded.
Medicaid and Medicare Part B spending on immunomodulators and biosimilars
Published in Journal of Dermatological Treatment, 2022
Alyssa M. Thompson, Swetha Atluri, Kyla N. Price, Jennifer L. Hsiao, Vivian Y. Shi
The Centers for Medicare and Medicaid Services (CMS) historical database was accessed to extract the 2012–2018 Part-B spending data on immunomodulators commonly used for dermatologic conditions: adalimumab, certolizumab, etanercept, ustekinumab, rituximab, infliximab, and its biosimilars. The Consumer Price Index (CPI) was used to adjusted for inflation after 2012 to reflect 2012 U.S. dollar amounts. CMS determines the average spending per dosage unit (ASPDU) as the total Part-B spending divided by the number of dosage units. These units were identified with a given Healthcare Common Procedure Coding System (HCPCS) code and associated base dosage. The maintenance dose used for a chronic skin condition was divided by the base dose associated with the HCPCS code. This value was then multiplied with the ASPDU to calculate the average annual spending per maintenance dose (AASPMD) for each immunomodulator.
Healthcare costs in patients with advanced non-small cell lung cancer and disease progression during targeted therapy: a real-world observational study
Published in Journal of Medical Economics, 2018
Karen E. Skinner, Ancilla W. Fernandes, Mark S. Walker, Melissa Pavilack, Ari VanderWalde
Basic demographic and clinical characteristics were assessed. Demographics included insurance status, age, sex, and race, which, together with admitting diagnosis and length of hospital stay, were used to enable matching of hospitalization events to the National (Nationwide) Inpatient Sample (NIS), which is part of the Healthcare Cost and Utilization Project (HCUP). Clinical characteristics that were obtained included performance status (Eastern Cooperative Oncology Group performance status, or provider documented impairment), histology, metastatic disease sites, EGFRm status, comorbid conditions, and smoking history. The occurrence of disease progression was determined from pathology reports, radiological scans, lab values, or provider progress notes. Healthcare Common Procedure Coding System/Current Procedural Terminology (HCPCS/CPT) codes were collected from the EMR data for outpatient procedures and physician office visits.