Wednesday, December 16, 2020

Which Two Things Are Enough Like the Other? NTAP and Product Similarity

CMS sometimes issues product-specific policies (e.g. the NCD on Provenge, the NCD on the Exact Sciences Cologuard test) and sometimes categorical policies (the NCD on transvascular valve implants, TAVR, which applies on a rolling basis to all similar valves the FDA approves).

Today at MedCityNews, Niall Brennan, former Chief Data Officer at CMS, has an interesting article on the definition of "similar" in New Technology Add-on Payments, the DRG supplement program (NTAP).  Essay here.  Brennan is CEO of the Health Care Cost Institute, HCCI.

I've always thought of these as product specific.  And usually that's an easy one: either there was only one product of the type being reviewed, or the product was a drug which by definition is usually unique.   I have a memory that CMS may have once or twice considered two products closely together, in parallel and consciously crosswalked to each other, but they were still two products with both being reviewed.

Brennan lays out the vision of some NTAP categories where they may be a profusion of products, besides the index product studied by CMS, or there may be disputes about whether some new product is similar enough to a benchmark product to be under the same NTAP.   

Can new products not reviewed by CMS tag along with an NTAP-eligible ICD10 procedure code that fits them?   I wouldn't be sure they could - but this is the point that Brennan's essay is about.  He writes;

Traditionally, a substantial similarity determination has been applied via new NTAP applications, and CMS has determined whether products are substantially similar and have told applicants whether they are eligible for coverage under the initial NTAP. Where things start to get problematic is if, instead of CMS determining substantial similarity, other vendors unilaterally assert substantial similarity in order to “piggyback” on an existing NTAP.

It's true that normally coding decisions are made by the hospital or other provider, if the real-world service is close enough to a CPT or ICD10 procedure code to fit.  It's a new viewpoint to note that the ICD10 procedure code could be locked to a special payment rule designed for one product, although the ICD10 procedure code itself is applicable to more than one product.