Transcript Slide 1

Practice Management Curriculum
Adapting to Changes
in Medicare
2007
Practice Management Curriculum
Who should attend
• Physician Leader of the Practice
– President of the PA, Founder
• Practice Administrator
– CEO, Executive Director, COO
• Contracting Officer
– Contract Administrator, Director of Billing
• Clinical Manager
– Medical Director, Nursing Team Leader
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Practice Management Curriculum
After this session, you will be able to:
• Identify changes in Medicare coding and
reimbursement for 2007
• Assess the degree to which your practice has made
the necessary changes to adapt to new Medicare
regulations
• Understand the role of the physician practice leader
and the administrator in adapting to these changes
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Practice Management Curriculum
Today’s Topics
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Medicare Physician Fee Schedule 2007
Hospital Outpatient Prospective Payment System 2007
Drug Reimbursement
Part D Update
Oncology Coding Update
– ICD-9, CPT, HCPCS
– Drug administration coding review
• Role of the physician practice leader and administrator
• Resources
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Practice Management Curriculum
Medicare Physician Fee Schedule 2007
Final rule published 12/1/06
• Annual Update
– Final rule reported 5.0% decrease in conversion factor;
Congressional action on 12/9 holds CF at 2006 rate
($37.8975)
• Practice Expense Relative Values
– Methodology revised; four year phase in period
– Payment for most drug administration services will
decrease slightly
– CMS projects 1% decrease in oncology payments when
change is fully implemented in 2010
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Practice Management Curriculum
Medicare Physician Fee Schedule 2007
• Physician Work Relative Values
– Work relative value increased for many E/M
codes, across all specialties
– CMS estimates increase in overall payments for
oncology, perhaps as much as 3%
– Budget neutrality requirement results in 10.06%
decrease to physician work relative values for all
codes across the fee schedule
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Practice Management Curriculum
RVU Changes 2006 – 2007
(includes budget neutrality adjuster)
Code
Description
2006
2007
%
Change
99211
Level 1, established patient, office visit
$21.60
$20.09
-7.0
99212
Level 2, established patient, office visit
$38.65
$36.76
-4.9
99213
Level 3, established patient, office visit
$52.68
$59.12
+12.2
99214
Level 4, established patient, office visit
$82.62
$90.20
+9.2
99215
Level 5, established patient, office visit
$120.14
$122.03
+1.6
99241
Level 1 office consultation
$50.40
$48.51
-3.8
99242
Level 2 office consultation
$92.09
$89.44
-2.9
99243
Level 3 office consultation
$122.79
$122.41
-0.3
99244
Level 4 office consultation
$173.19
$179.63
+3.7
99245
Level 5 office consultation
$223.97
$222.84
-0.57
Practice Management Curriculum
RVU Changes 2006 - 2007
Code
Description
2006
2007
%
Change
90765
IV infusion, initial, up to 1 hour
$77.31
$75.04
-0.3
90766
…each add’l hour
$25.77
$24.25
-5.9
90767
…add’l sequential infusion, up to 1 hour
$42.45
$39.79
-6.3
90768
…concurrent infusion
$24.63
$22.74
-7.7
90772
Therapeutic, diagnostic injection, sc or im
$18.57
$19.33
+4.1
96409
Chemotherapy admin, IV push, initial
$122.41
$119.76
-2.2
96411
…each add’l substance/drug
$70.87
$68.97
-2.7
96413
Chemotherapy admin, IV infusion, initial
$172.81
$165.99
-3.9
96415
…each add’l hour
$39.03
$37.14
-4.9
96417
…each add’l sequential infusion
$84.51
$81.48
-3.6
Practice Management Curriculum
Medicare Physician Fee Schedule 2007
• Imaging Procedures
– Continuation of 2006 policy that reduces technical
component by 25% for second and subsequent imaging
procedures in the same family
– In addition, payment for technical component in
freestanding imaging centers (including physician
practices) is capped at the hospital outpatient payment rate
– When both imaging cuts apply, multiple imaging
adjustments are taken first
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Practice Management Curriculum
Imaging Payment Determination for Services Subject to
Multiple Imaging Reduction and Hospital OP Cap
CPT
Code
Payment Rate
for Technical
Component
25% Multiple
Hospital OP
Imaging Reduction Cap Rule
Final Payment
for Technical
Component
7xxx1
$341.89
$256.42
$316.55
$256.42
7xxx2
$552.86
$414.65
$391.83
$391.83
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Practice Management Curriculum
Medicare Physician Fee Schedule 2007
• IVIG Preadministration Services
– CMS has extended this payment for 2007
– Use code G0332, defined as preadministration-related
services for intravenous infusion of immunoglobulin, per
infusion encounter; paid at approximately $71
– Bill this code in addition to appropriate drug administration
code and J-code for the IVIG
• Colorectal Cancer Screening Services
– Effective 1/1/07 Medicare has waived the beneficiary
deductible requirement for covered CRC screening
services; copayments will still apply
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Practice Management Curriculum
Medicare Physician Fee Schedule 2007
• No mention of 2007 Oncology Demo Project in the
fee schedule
• It is ASCO's understanding that the 2006 Oncology
Demonstration Project expired on December 31, 2006
and the codes are no longer payable
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Practice Management Curriculum
Tax Relief and Health Care Act
Medicare Improvements and Extension Act of 2006
• Passed by Congress 12/9/06; signed by President
12/20/06
• Freezes Medicare conversion factor at 2006 rate
($37.8975)
– Bill does not address SGR or change payment rates beyond
2007
• Extends GPCI floor beyond 12/31/06
– Applies only to GPCI for physician work component
• Minimum GPCI value for 2007 will be 1.0
– Especially important for rural providers
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Practice Management Curriculum
Tax Relief and Health Care Act
• Creates 1.5% bonus incentive payment for physicians
who report on quality measures
– Reporting period will be 7/1/07 – 12/31/07
– Reporting will be based on Medicare Physician Voluntary
Report Program (PVRP) measures
• CMS has identified 66 measures for 2007; allowed to
change the list by posting changes no later than 4/1/07
• Changes to be based on consensus-based process in
January 2007
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Practice Management Curriculum
Tax Relief and Health Care Act
• 1.5% bonus incentive payment, continued
– Measures must be reported for at least 80% of clinically
relevant encounters and payment will be calculated based
on claims for 2007 services that are submitted by 2/28/08;
payment will be made in a lump sum
– Further details regarding implementation and oncologyspecific measures have not yet been released
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Practice Management Curriculum
Tax Relief and Health Care Act
• Establishes a fund ($1.35 billion) to promote physician
payment stability and physician quality initiatives in
2008
• Requires that physicians submitting claims for antianemia drugs given as part of cancer treatment provide
information on hemoglobin or hematocrit levels;
effective for drugs furnished on and after January 1,
2008
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Practice Management Curriculum
Tax Relief and Health Care Act
• Recovery Audit Contractor program expanded from California,
Florida and New York to the entire country
– Program allows audit and recovery activity to review claims
submitted in fiscal year of the audit and the four prior fiscal
years
– Requires CMS to have program operating in all states by
1/1/10
• CAP: contractor can now bill Medicare when it ships the drug
(subject to returning the money if the drug is never
administered), whereas under prior law the contractor couldn't
bill until the drug had been administered
– CAP drugs now subject to post-payment review
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Practice Management Curriculum
Hospital Outpatient Prospective Payment System
Final Rule for 2007
• Payment for drugs, biologics, radiopharmaceuticals
– Separately billable drugs paid at ASP + 6%
– Medicare will pay separately for drugs costing more than
$55 per day; drugs costing less than $55 are not reimbursed
separately
– Anti-emetics are reimbursed separately regardless of their
daily cost
• CMS is continuing payment for pre-administration
services for IVIG; approximately $75/administration
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Practice Management Curriculum
Hospital Outpatient Prospective Payment System
• Drug administration services
– New: separate payment for second and subsequent
hours of drug administration services
– New: CMS will now use all of the CPT codes for
drug administration in the hospital outpatient
department, instead of the 2006 mixture of CPT
codes and C-codes
• CMS estimates average 3% increase in Medicare
payments for all outpatient services
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Practice Management Curriculum
Drug Reimbursement
• Minor changes to the ASP calculation in the fee
schedule but no fix to the issue of “underwater” drugs
– ASP payment limits continue to be updated quarterly
• www.cms.hhs.gov/providers/drugs/default.asp
– Still essential to monitor ASP pricing limits and compare to
your acquisition costs
– ASP was not addressed in the Tax Relief bill
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Practice Management Curriculum
Drug Reimbursement
• Drugs administered in the physician office (and
hospital OP department) are paid at ASP + 6% with a
few exceptions
– Drugs furnished through a covered item of durable medical
equipment are paid at 95% of AWP as published on
10/1/03. This payment limit will not be updated for 2007.
– Payment allowance limits for influenza, Pneumococcal and
Hepatitis B vaccines are 95% of AWP
– New drugs not included in ASP or NOC pricing files are
paid at 106% of WAC or invoice pricing
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Practice Management Curriculum
Competitive Acquisition Program (CAP)
• CAP continues as an alternative to ASP + 6%
– Very few oncologists have participated
• New in 2007: CAP contractor can bill Medicare
when it ships the drug rather than waiting until the
drug is administered (must return the money if the
drug is never administered)
• Updated list of drugs available under CAP for 2007
– www.cms.hhs.gov/CompetitiveAcquisforBios/15_Approved_Ve
ndor.asp#TopOfPage
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Practice Management Curriculum
Medicare Part D
• 2007 formularies must include all antineoplastic
drugs available on 4/1/06
• New antineoplastic drugs must be reviewed for
formulary inclusion within 90 days (instead of 180
days as for most drug classes)
– The exceptions process is available during the 90 day
review period
• Specialty tier with non-appealable copay is allowed,
but copay is limited to 25%
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Practice Management Curriculum
Coding in 2007
These lists are not all inclusive; check the coding books for additional new codes and/or changes.
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Practice Management Curriculum
ICD-9 Code Changes
Effective 10/1/06
• Increased specificity for hematologic disorders
– Myelodysplastic syndrome 238.7x
– Neutropenia 288.0x
• Drug induced neutropenia 288.03
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Aplastic anemia 284.0
Elevated white count 288.6x
Decreased white count 288.5x
Neutropenic splenomegaly 289.53
Myelofibrosis 289.83
Anemia of chronic disease 285.29
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Practice Management Curriculum
ICD-9 Code Changes
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Neoplasm-related pain 338.3
Mucositis due to antineoplastic therapy 528.01
Elevated CEA 795.81
Elevated CA 125 795.82
Other abnormal tumor markers 795.89
Elevated PSA 790.93
Estrogen receptor positive status V86.0
Estrogen receptor negative status V86.1
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Practice Management Curriculum
CPT Code Changes
Effective 1/1/07
• New patient vs. established patient
– A new patient is one who has not received any professional
services from the physician or another physician of the
same specialty who belongs to the same group practice
(same tax ID number), within the past three years
• Consultations
– Must be requested by a physician or “other appropriate
source”
– Follow up visits to a consultation are reported using
established patient codes in the office/outpatient setting;
subsequent hospital care codes in the inpatient setting
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Practice Management Curriculum
CPT Code Changes
• Anticoagulation management
99363, 99364
– Not separately payable by Medicare (bundled)
• Medical genetics counseling by a genetics counselor
96040
– Not separately payable by Medicare (bundled)
– For genetic counseling and education provided by a
physician, use Evaluation and Management codes
• Additional hours of hydration (90761),
therapeutic/diagnostic administration (90766) and
chemotherapy administration (96415) no longer
have 8 hour time limit
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Practice Management Curriculum
HCPCS Code Changes
• Codes of interest
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J1562
J0894
J8650
J9261
J1740
Immune globulin 100 mg.
Decitabine 1 mg.
Nabilone (oral) 1 mg.
Nelarbine 50 mg.
Ibandronate sodium 1 mg.
• Vectibix continues to be billed with J9999
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Practice Management Curriculum
Drug Administration Services
∙ Hydration
∙ Therapeutic, prophylactic, and diagnostic
injections and infusions
∙ Chemotherapy administration
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Practice Management Curriculum
“Initial” service codes
• Only one initial code is reported per encounter
• The initial code that best describes the key or primary reason
for the encounter should be reported, irrespective of the order
in which the infusions/injections occur
• Subsequent or concurrent codes should be reported for
additional infusion/injection services
Hydration
90760
Therapeutic/diagnostic, infusion
90765
Therapeutic/diagnostic, push
90774
Chemotherapy, push
96409
Chemotherapy, infusion
96413
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Practice Management Curriculum
Each additional hour
• Used to report additional hours of infusion, after the first hour,
of an individual drug
• To report these codes, infusion time must be > 30 minutes
beyond the first hour
• Infusions lasting 30 minutes or less (after the first hour) should
be rounded down and not reported
• New in 2007: 8 hour time limit has been removed
Hydration
90761
NOTE: 90761 is also used if hydration is provided as a secondary or
subsequent service after a different initial service
Therapeutic/diagnostic infusion
90766
Chemotherapy infusion
96415
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Practice Management Curriculum
Additional sequential infusion
• Used for a sequential infusion of an additional substance/drug
• Additional hours of sequential infusion are billed using the
“each additional hour” codes
Therapeutic/diagnostic, add’l sequential infusion, 90767
up to 1 hour
Chemotherapy, each add’l sequential infusion
(different substance/drug), up to 1 hour
96417
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Practice Management Curriculum
Concurrent infusion
• The concurrent infusion code (90768) is used when
drugs are administered at the same time
• Only one concurrent code may be billed per patient
encounter
• There is no concurrent chemotherapy code
• AMA CPT Assistant, November 2006
– “In order to report a concurrent administration, the drugs
cannot simply be mixed in one bag; there must be more
than one bag.”
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Practice Management Curriculum
Infusion Time
• The infusion time begins when the infusion starts.
Infusion time reflects the time the drug/substance is
actually being administered. Drug preparation time is
not included as infusion time.
• Rounding
– After the first hour of infusion, round infusion times to the
nearest 30 minutes. For infusions of 30 minutes or less,
round down. For infusions greater than 30 minutes, round
up.
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Practice Management Curriculum
Push
• Intravenous or intra-arterial push is defined as:
a) an injection in which the healthcare professional who
administers the substance/drug is continuously present to
administer the injection and observe the patient, or b) an
infusion of 15 minutes or less.
Therapeutic/diagnostic intravenous push, single or intial
substance/drug
90774
...each additional sequential intravenous push of a new
substance/drug
90775
Chemotherapy intravenous push, single or initial
96409
…each additional sequential intravenous push substance/drug 96411
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Practice Management Curriculum
Therapeutic/diagnostic subcutaneous or
intramuscular injections
• Use code 90772 for therapeutic/diagnostic sc or im
injections
• 90772 may be billed for each injection administered
during a patient encounter
• Use the -59 modifier when reporting injections on the
same day as drug administration services
– The National Correct Coding Initiative (NCCI) created
edits on code 90772 which requires the use of a modifier.
If the drug or substance is unrelated to an anesthetic,
providers should use the -59 modifier to bypass the edit.
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Practice Management Curriculum
Reminders
• Hydration services may be billed only
– When it is the only service performed during a
patient encounter; or
– When it is performed before or after chemotherapy
administration (do not bill for hydration at the
same time as chemotherapy). Use modifier -59 to
indicate a “distinct procedural service”
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Practice Management Curriculum
More Reminders
• Evaluation and management services (level
2 through 5) may be reported in conjunction
with drug administration services
– If a significant separately identifiable E/M service
is performed
– Bill the appropriate E/M service code with
modifier -25
– A different diagnosis is not required
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Practice Management Curriculum
More Reminders
• When billing for chemotherapy administration, the
following services are included and are not reported
separately:
–
–
–
–
–
–
Use of local anesthesia
IV start
Access to indwelling IV, subcutaneous catheter or port
Flush at conclusion of infusion
Standard tubing, syringes and supplies
Preparation of chemotherapy agent(s)
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Practice Management Curriculum
A Training Tool for New Staff:
A Building Block Approach to Coding
for Drug Administration
• A systematic approach
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Why was the patient here?
What did we give them?
How did we give it?
How long did it take?
We thank Lawrence Martinelli, MD, Infectious Disease Society of America and CPT Advisor, for the use of
these Building Block slides, originally presented at the 2005 CPT Symposium
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Practice Management Curriculum
Why are they here?
• The reason for the visit
– Sick patient, needs hydration
– Chemotherapy administration, will also see provider
– Follow up visit, intractable nausea/vomiting, needs drug
therapy
• This determines which “initial” code to use
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Practice Management Curriculum
What did we give them?
• Hydration?
• Anti-emetics or other drugs?
• Chemotherapy?
• This determines which category of administration
code(s) to bill
• And don’t forget to bill for the J-codes
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Practice Management Curriculum
How did we give it?
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•
•
•
IV infusion?
IV push?
SC or IM injection?
A combination?
• This determines which specific administration code(s)
to bill and if there are concurrent, subsequent, and/or
sequential services.
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Practice Management Curriculum
And finally,
how long did it take?
• ≤ or > 15 minutes (push vs. infusion)
• One “hour”
• Additional “hours”
– Round to nearest 30 minutes
• Remember that infusion times are measured by when the
infusate is actually running; pre- and post-infusion times are
not included
• Documentation of start/stop times for each agent is
recommended
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Practice Management Curriculum
Role of the Physician Practice Leader
• Stay current on Medicare rules and regulations
• Reinforce to your partners the importance of
Medicare compliance
• Work with your state society to establish productive
relationships with your Medicare carrier and
commercial payers
• Support your Practice Administrator as they
implement policies to deal with these changes
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Practice Management Curriculum
Role of the Administrator
• Update your coding books, reference materials, fee schedule,
charge ticket annually or as changes occur
• Ensure that your staff is knowledgeable about reimbursement
issues for all payers
• Establish and implement policies to immediately respond to
changes as they occur
• Enroll in Medicare list serves to stay up-to-the-minute on
changes
• Work with local and state societies (oncology societies,
MGMA) on reimbursement and policy issues
• Work cooperatively with your physician leader in providing
leadership for your staff in this challenging environment
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Practice Management Curriculum
ASCO Resources
• Coming soon…Practical Tips for the Oncology
Practice, 4th Edition
– Detailed information about
coding, billing, Medicare
coverage guidelines
– Includes excerpts from
Medicare coverage manuals
• Available in early 2007
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Practice Management Curriculum
ASCO Resources
• Ask a Coding Question
– Call 703-299-1054 or
– Email [email protected]
• Cancer Policy Today
– E-newsletter for ASCO members; available by
request for administrators
– Email [email protected]
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Practice Management Curriculum
ASCO Resources
• Journal of Oncology Practice
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Focus on Quality
Practical Tips
For Your Patients
Legal Corner
Research in Practice
Business of the Business
Original Research
• Manuscripts and letters to the editor may be sent to
[email protected]
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Practice Management Curriculum
www.cms.hhs.gov
• To access the physician page
– www.cms.hhs.gov/physicians/
• To access manuals
– www.cms.hhs.gov/manuals/
• To access the drug pricing page
– www.cms.hhs.gov/providers/drugs/default.asp
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