Transcript Medicare 101: Policy and Process

2007: What’s New?
Bobbi Buell
Version 1.0
January, 2007
Disclaimer (from CMS)
“
This presentation was current at the time it was printed or downloaded. This presentation was prepared as a tool to
assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been
made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct
submission of claims and response to any remittance advice lies with the provider of services.
The Centers for Medicare & Medicaid Services (CMS) employees, agents, and staff make no representation,
warranty, or guarantee that this compilation of information is error-free and will bear no responsibility or liability
for the results or consequences of the use of this presentation. This publication is a general summary that explains
certain aspects..implementation, but is not a legal document. This presentation was current at the time it was printed
or downloaded. This presentation was prepared as a tool to assist providers and is not intended to grant rights or
impose obligations. Although every reasonable effort has been made to assure the accuracy of the information
within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance
advice lies with the provider of services.
The Centers for Medicare & Medicaid Services (CMS) employees, agents, and staff make no representation,
warranty, or guarantee that this compilation of information is error-free and will bear no responsibility or liability
for the results or consequences of the use of this presentation. “
From the CMS NPI Power Point
That goes ditto for me!
I
Session Objectives

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
Provide update on changes in Medicare
physician payment for 2007
Show impact of new reimbursement changes
Explain all applicable coding changes
Update information about Evaluation &
Management Services
Discuss optimal strategies for 2007.
Medicare – the big picture



$336 billion spent in 2005
2.7% of GDP in 2005
7.3% of GDP by 2035
Medicare Part B




Physician services, outpatient hospital, DME, some
drugs, physical therapy.
Paid for by general revenue and beneficiary premiums
Premiums are set to cover 25% of projected cost---this
means patients will be paying more and more.
Beneficiary out of pocket costs and premiums will
grow faster than income.
Expenditure growth will exceed GDP growth by at
least 6% over the next decade
Part B Patient Costs 2007



Part B･Deductible: $131 / year
Standard Premium: $93.50 / month from $88.50
Income-Adjusted for wealthier beneficiaries
Income-related monthly adjustment amounts
Single = Less than or equal to $80,000 = $0.00 = $93.50
Joint Return= Less than or equal to $160,000 =$0.00 = $93.50
Single =Greater than $80,000 and less than or equal to $100,000 = $12.50 = $106.00
Joint =Greater than $160,000 and less than or equal to $200,000 = $12.50 = $106.00
Single =Greater than $100,000 and less than or equal to $150,000 = $31.20 = $124.70
Joint = Greater than $200,000 and less than or equal to $300,000 = $31.20 = $124.70
Single= Greater than $150,000 and less than or equal to $200,000 = $49.90= $143.40
Joint = Greater than $300,000 and less than or equal to $400,000 = $49.90= $143.40
Single = Greater than $200,00 = $68.60 = $162.10
Joint = Greater than $400,000 = $68.60 = $162.10
Part C



Medicare managed care plans (Medicare
Advantage)
Paid for by Part A and B funding streams.
Expected that more people will join over the
next decade, but estimates were not reached
when Part D kicked in.
Part C Eligibility

Medicare Advantage Eligibility
Must be enrolled in Medicare Parts A & B;
enrollees are still in the Medicare program,
 Must continue to pay the Part B premium ($93.50 /
month in 2007),
 Must live in the plan’s service area,
 Must not have end-stage renal disease (ESRD) at
time of enrollment

Medicare Part D


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Prescription drug coverage
Paid for by general revenue and beneficiary
premiums
More out of pocket costs for beneficiaries
More coverage for cancer
More unpaid work for practices, but most
practices are not bogged down.
Medicare physician payment basics

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Payments are based on RVUs for each code
The pool of RVUs is fixed – any changes must
be budget neutral--we had one of the few
exceptions in 2004-2005.
The Medicare conversion factor determines the
overall level of Medicare payments
A formula spelled out in the Medicare statute
determines the annual update to the conversion
factor and that has been a disaster.
How RVUs Are Used

3 inputs go into the total RVUs



Work = Face-to-face physician time, plus intensity
of work
Practice expense = practice expense relative to
other procedures (with no intensity of expense)
Malpractice insurance costs (< 5%) = malpractice
risk

Equation is
((W*WGPCI)+(PE*PEGPCI)+(M*MGPCI)) times the
conversion factor = Fee Schedule Allowable for all
codes except labs and drugs

This year there is a budget neutrality withhold that
changes the equation.
Just This Year…Medicare ONLY



There is a budget neutrality factor of 10.1%…
Steps to calculate your payment:
((WRVU*0.8994(ROUND))*WGPCI)+(PE*PEGPCI)….
etc.
1.
Work RVU X 0.8994
2.
Round this result to two places using the EXCEL
formula
3.
Apply this as the WORK RVU in the formula on the
preceding page.
How does CMS determine the
update?



A formula spelled out in the Medicare statute
determines the annual change
Known as the Sustainable Growth Rate or SGR
system or Medicare Boomerang
There are three components
Sustainable growth rate (SGR)
 Medicare Economic Index (MEI)
 Annual update adjustment factor (UAF)

SGR



Put in place to control growth in spending on
physician services
Link changes in spending to factors affecting the
cost of providing services to Medicare
beneficiaries and to economic growth
SGR used to set an annual target for spending
on physician services
SGR formula

SGR is the product of four factors
Change in physician fees
 Change in Medicare fee for service enrollment
 Change in real per capita GDP
 Change in law and regulation affecting spending on
physician services

Calculating the annual fee schedule
update

Annual update to the conversion factor is the
product of:
Medicare Economic Index (MEI)
 Update Adjustment Factor

Update Adjustment Factor Formula
.75 × Target spending06 – Actual spending06
Actual spending06
+
.33 × Target spending 96 – 06 – Actual spending96 – 06
Actual spending05 × SGR06
Annual update



Statute defines a floor and ceiling for the UAF
UAF can’t be more than MEI +3% or less than
MEI -7%
Final 2007 update = MEI – 7%
Flaws with UAF



Setting of target – SGR and all its flaws
Calculation of actual expenditures
Cumulative aspect of formula
Sources of spending growth

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Increasing volume and intensity of office visits
Minor procedures
Imaging services
Laboratory tests
Physician-administered drugs
Here’s the deal…

SGR system is fatally flawed
Cannot account for technological advances and
expansion of medical knowledge
 Inappropriately linked to GDP
 Including the cost of Part B drugs overstates
spending that is under physician control
 Cumulative nature of system means the problem can
only get worse without a permanent fix…that’s why
we have Band-Aids like this year and last year.

Alternatives to SGR

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Annual update linked to MEI?
Pay for performance? 2007 PVRP is a start for
this!
New formula to calculate the target?
Separate targets by region, type of service
Watch for a discussion this Spring when MedPac
goes to Congress with recommendations!
This Year’s SGR Fix

The fix is in!

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A freeze next year of the Conversion Factor (stays at
$37.8975)---but allowables are NOT frozen.
A 1.5% reporting sweetener after July 1 for reporting
PVRP quality measures, if you report for = or > 80%
of reportable services. But, you will see no payment
until 2008.
A PVRP measure for Oncology will be the revised
disease status codes from 2006.
GPCI floor will be reinstated to support rural areas.
Establishes a fund to promote payment ‘stability’ in
2008.
Increases payment for ESRD of 1.6%.
This Year’s SGR Fix

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Extends the treatment of certain physician pathology services
for technical component.
Extends MMA rate for brachytherapy. Allows brachytherapy
to be paid at hospital costs for another year.
Clarifies the payment process under CAP--post-payment
review process.
Requires reporting of hemoglobin and hematocrit as ‘quality
indicators’ for cancer anti-anemia drugs in 2008.
Providers will be paid for administration of Part D vaccines in
their offices in 2007.
Extends the Recovery Audit Contractor Audits beyond test
states.
2007 Physician payment changes


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Five year review of RBRVS
New practice expense methodology
DRA cut to in-office imaging
Five year review of RBRVS


CMS proposed large increases for many
evaluation and management (EM) services
For example, 99214 payment will increase from
$83 to $90
E&M Is Better?
Code 2006 Code 2007 Descriptor
99211
99211 Office/outpatient visit, est
99212
99212 Office/outpatient visit, est
99213
99213 Office/outpatient visit, est
99214
99214 Office/outpatient visit, est
99215
99215 Office/outpatient visit, est
99241
99241 Office consultation
99242
99242 Office consultation
99243
99243 Office consultation
99244
99244 Office consultation
99245
99245 Office consultation
2007 $
2006 $
Difference
$20.09
$21.60
-7%
$36.76
$38.66
-5%
$59.50
$52.68
13%
$90.20
$82.62
9%
$122.03
$120.14
2%
$48.51
$50.40
-4%
$89.44
$92.09
-3%
$122.41
$122.79
0%
$179.63
$173.19
4%
$222.84
$223.97
-1%
Five year review of RBRVS

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Budget neutrality requirement
CMS instituted 10% reduction to be applied to
all work RVUs as we saw previously.
Alternative was 5% reduction in conversion
factor
Impact of budget neutrality options varies by
service due to weight of the work RVUs, but
70% of all physician services are reduced in
2007.
Practice expense



New method will cut Medicare payments to
Oncology by an estimated 5-7% over five years
depending upon what codes you use
PE RVUS for drug administration, imaging and
other technical component procedures decrease
PE RVUs for EM increase
New practice expense formula


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Calculate direct practice expense portion of
RVUs with a “bottom-up” approach instead of
former “top-down” method
Eliminate non-physician work pool (NPWP)
Use supplemental practice expense data from
specialties.
Include clinical labor in indirect cost formula
2007 Drug Administration
Code 2006 Code 2007 Descriptor
2007 $
2006 $
Difference
90760
90760 Hydration iv infusion, init
$61.39
$63.29
-3%
90761
90761 Hydrate iv infusion, add-on
$18.95
$20.09
-6%
90765
90765 Ther/proph/diag iv inf, init
$75.04
$77.31
-3%
90766
90766 Ther/proph/dg iv inf, add-on
$24.25
$25.77
-6%
90767
90767 Tx/proph/dg addl seq iv inf
$39.79
$42.45
-6%
90768
90768 Ther/diag concurrent inf
$22.74
$24.63
-8%
90772
90772 Ther/proph/diag inj, sc/im
$19.33
$18.57
4%
90773
90773 Ther/proph/diag inj, ia
$18.19
$18.95
-4%
90774
90774 Ther/proph/diag inj, iv push
$57.23
$57.60
-1%
90775
90775 Ther/proph/diag inj add-on
$26.15
$26.91
-3%
96401
96401 Chemo, anti-neopl, sq/im
$58.36
$52.68
11%
96402
96402 Chemo hormon antineopl sq/im
$42.45
$45.86
-7%
96405
96405 Chemo intralesional, up to 7
$121.65
$113.31
7%
96406
96406 Chemo intralesional over 7
$145.15
$145.91
-1%
96409
96409 Chemo, iv push, sngl drug
$119.76
$122.41
-2%
96411
96411 Chemo, iv push, addl drug
$68.97
$70.87
-3%
96413
96413 Chemo, iv infusion, 1 hr
$165.99
$172.81
-4%
96415
96415 Chemo, iv infusion, addl hr
$37.14
$39.03
-5%
96416
96416 Chemo prolong infuse w/pump
$179.63
$185.70
-3%
96417
96417 Chemo iv infus each addl seq
$81.48
$84.51
-4%
96420
96420 Chemo, ia, push tecnique
$109.90
$110.66
-1%
96422
96422 Chemo ia infusion up to 1 hr
$181.91
$192.90
-6%
96423
96423 Chemo ia infuse each addl hr
$78.07
$78.83
-1%
96425
96425 Chemotherapy,infusion method
$178.50
$179.26
0%
96440
96440 Chemotherapy, intracavitary
$370.64
$405.12
-9%
96445
96445 Chemotherapy, intracavitary
$360.03
$393.76
-9%
96450
96450 Chemotherapy, into CNS
$300.15
$325.54
-8%
96521
96521 Refill/maint, portable pump
$145.91
$153.11
-5%
96522
96522 Refill/maint pump/resvr syst
$110.28
$110.66
0%
96523
96523 Irrig drug delivery device
$27.67
$28.04
-1%
96542
96542 Chemotherapy injection
$182.29
$192.52
-5%
MEDICARE 2007 PART B
Other components

Multiple imaging codes-TC component reduced by 50% was proposed
for multiple imaging in related families--will be a reduction of 25%
2007 in -TC



These codes must fall into the same “family”
MRI, MRA, CT, CTA, Ultrasound
Hard on physicians that own their own equipment/free-standing imaging

DRA Reduction: certain imaging codes’-TC will be compared with
imaging APCs and will be reduced to the HOPD level

Multiple imaging reduction taken first; then the DRA Reduction

Huge reductions seen estimated by some Oncology practices (35-40%).
2007 Medicare Payments for OfficeAdministered Drugs

Payments for drugs based on 106% of manufacturer’s
average sales price (ASP + 6%)

Manufacturers report the ASPs for their drugs to the
Centers for Medicare & Medicaid Services (CMS) within
30 days after the end of each calendar quarter

Payment amounts for multiple-source drugs are determined
by weighting each drug’s ASP by its sales volume for each
NDC within the category.
2007 Medicare Payments for OfficeAdministered Drugs

Payments are adjusted quarterly with 2-quarter lag


For example, payment amounts for July-September quarter
are based on ASPs for January-March quarter. This hurts if
any sizable price increase is taken by a manufacturer.
New drugs are paid at 106% of wholesale acquisition
cost (WAC) until ASP data are collected, usually 2-3
quarters.
Principal Problems with ASP $


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“Underwater” drugs
 Some drugs are not available to some physicians at the
Medicare payment amount
 No way to account for it in a cost outlier system.
Price increases not reflected for 2-3 quarters which
 may cause payment amount to be less than the current drug
price
 other costs are not covered, e.g. supplies, handling, sales
tax, etc.
Prompt Pay Discount given to wholesalers taken out of ASP.
Drug admin payment and coding rules do not cushion the blow
as was projected.
RBRVS And Private Payers

Need to examine every aspect and component of
RBRVS

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Year of Fee Schedule
RVUs
Use of GPCIs
Conversion Factor
Use of Budget Update
Drug Payment
Additional Fees
Protocol Picture
Off-label Laws In Your State
Oncology Quality Demonstration
Projects (2005-2007)

2005 Demonstration Project

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2006 Demonstration Project

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Paid with intravenous chemotherapy
Measures level of nausea/vomiting/ fatigue pain
$130.00/day
Paid with office visits (99212-99215)
Question about where in treatment; whether treatment is on
NCCN/ASCO guidelines; and stage of disease.
$23.00/day
2007 No Demonstration Project

Code changes released 11/1/2006
G-code Changes 1/1/2007

Codes for the focus of the visit (G9050-G9055) were reclassified to coverage code “I”: This means that, as of
1/1/2007, these codes are not covered by Medicare.

Codes for adherence to clinical guidelines (G9056-G9062)
were re-classified to coverage code “I”: Again, it seems that
Medicare as of January 1, 2007 will not cover these codes.

Codes for disease status (G9063-G9130) had a pricing change
to price “00” meaning they will not be paid in 2007.
Several long descriptors for disease status were changed or
swapped, along with some additions.
These codes will be used in the PVRP starting in July.


Hospital Outpatient Prospective
Payment (APCs)
Elements of the payment system

Unit of payment – the individual service
 Can bill for multiple services on same day

Classification system – ambulatory payment classification (APC)
groups

Relative weights
 Single value for each APC that reflects relative costliness of that
service compared to others, based on median costs
 Exception: New technology APCs

Conversion factor – transforms relative weight into payment
Hospital Outpatient
Prospective Payment
Base payments
 Base payment covers the hospital’s costs of
providing the service (physician paid separately)
 Base payment built on total cost-based paymentincluding coinsurance-in 1996
 60 percent of payment is adjusted by the hospital
wage index
 Updated annually using hospital market basket
Hospital Outpatient Payment

For Medical Oncology

Drug payments are weird




Pass-through for 2-3 years paid at ASP plus 6%
Drugs over $50 after pass-through are paid at ASP plus 6%
(until 1/1/2007) and then $55 is the threshold.
Many drugs bundled in with no payment
Spending on drugs is about 8% of HOPPS expenditures
(according to MedPac)

Drug administration has traditionally been paid at a
PER VISIT (not per hour) rate, which will change in
2007

Hospital-based Medical oncologists get paid at a
reduced professional fee for Evaluation &
Management based on a site of service differential
BUT Hospitals OPDs Are Different

Structurally

Hospital OPDs are well-diversified portfolios of servicessurgery, nuclear medicine, radiation, physical therapy, etc

Hospital OPDs are part of an inpatient facility where
revenues may come from the inpatient side

Hospital OPDs are often part of large purchasing
organizations which may decrease losses on unpaid drugs
and supplies
Hospital OPDs Are Different

Medicare

Co-payments are a larger piece of the
revenue stream and are not just 20%, which
is not frequent in Oncology.

Outlier payments for high loss cases

340B price breaks for Disproportionate
Share Hospitals

Exemption for cancer hospitals
Hospital OPDs Are Different

Private Payers

Better negotiating leverage based on community
profile and size

Better negotiating leverage based on higher
headcount of professional managers

Many payers still pay on charge-based systems
with drugs at AWP

Hospitals have not allowed Medicare to become the
standard of payment for outpatients.
Medicare Outpatient PPS 2007

Drugs

Separately paid drug threshold would rise from
$50 to $55. This does not include anti-emetics.

Separately paid drugs would be paid at ASP
plus 6%, not ASP plus 5% as proposed.

Pass through drugs would be paid the rate
established by the Competitive Acquisition
Program, generally ASP plus 6%
Medicare Outpatient PPS 2007


Drug Administration

Second and subsequent hours will be paid.
Payments for services by the hour rather than by the
visit.

New APCs with new rates.

CPT codes will be used instead of C-codes.
But, hospitals will receive a boost in all APCs with a
3.4% increase in the inflation rate rate for all APCs
Medicare OPPS 2007

Evaluation & Management Codes for Clinic
Visits
Five levels using CPT codes, not G-codes.
 Refining these levels.



Imaging will not have second and following
procedures reduced.
Future increases tied to Quality Measures
reporting starting in 2009.
HOPD Drug Admin 2007
CPT/
HCPCS
90760
90761
90765
90766
90767
90768
90772
90773
90774
90775
90779
96401
96402
96405
96406
96409
96411
96413
96415
96416
96417
96440
96445
96450
96521
96522
96523
De s cription
Hydration iv inf usion, init
Hydrate iv infusion, add-on
Ther/proph/diag iv inf , init
Ther/proph/dg iv inf , add-on
Tx/proph/dg addl seq iv inf
Ther/diag concurrent inf
Ther/proph/diag inj, sc/im
Ther/proph/diag inj, ia
Ther/proph/diag inj, iv push
Ther/proph/diag inj add-on
Ther/prop/diag inj/inf proc
Chemo, anti-neopl, sq/im
Chemo hormon antineopl sq/im
Chemo intralesional, up to 7
Chemo intralesional over 7
Chemo, iv push, sngl drug
Chemo, iv push, addl drug
Chemo, iv inf usion, 1 hr
Chemo, iv inf usion, addl hr
Chemo prolong inf use w /pump
Chemo iv inf us each addl seq
Chemotherapy, intracavitary
Chemotherapy, intracavitary
Chemotherapy, into CNS
Ref ill/maint, portable pump
Ref ill/maint pump/resvr syst
Irrig drug delivery device
Source: CMS-1506P 8/8/2006
APC
0440
0437
0440
0437
0437
0437
0438
0438
0438
0436
0438
0438
0438
0438
0439
0439
0441
0438
0441
0438
0441
0441
0441
0440
0440
0624
Re lative
w e ight
1.8090
0.3945
1.8090
0.3945
0.3945
0.3945
0.7942
0.7942
0.7942
0.1809
0.7942
0.7942
0.7942
0.7942
1.5848
1.5848
2.4851
0.7942
2.4851
0.7942
2.4851
2.4851
2.4851
1.8090
1.8090
0.5145
National M inim um
unadjus te unadjus te
d
d
Paym e nt copaym e n copaym e n
r ate
t
t
111.20
22.24
24.25
4.85
111.20
22.24
24.25
4.85
24.25
4.85
24.25
48.82
48.82
48.82
11.12
48.82
48.82
48.82
48.82
97.41
97.41
152.75
48.82
152.75
48.82
152.75
152.75
152.75
111.20
111.20
31.63
12.65
4.85
9.76
9.76
9.76
2.22
9.76
9.76
9.76
9.76
19.48
19.48
30.55
9.76
30.55
9.76
30.55
30.55
30.55
22.24
22.24
6.33
Coverage with Evidence
Development


CMS moving towards more coverage with their own
trials…
Coverage with Evidence Development (CED) policies:



Coverage of drugs, devices, and other technologies when
provision of the service is accompanied by data reporting or
collection that benefits CMS.
Examples include FDG-PET Registry and coverage of
colorectal cancer drugs in off-label uses when provided as
part of an approved clinical trial.
CMS states intent to use data to inform permanent coverage
decisions in cases where the current trial structure does not
provide enough information about beneficiaries or
beneficiary access.
Off-Label Drug Coverage

By statute, Medicare must cover off-label uses of
drugs used in anticancer chemotherapy regimens if
the uses are supported by citations in:





U.S. Pharmacopoeia – Drug Information (“USPDI”)
American Hospital Formulary Service
AMA Drug Evaluations (Defunct)
CMS may also change the list of approved compendia
as appropriate for identifying medically accepted
indications
And, they should!
Off-Label Uses Not in the
Compendia
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The Medicare statute authorizes the carriers to
cover off-label uses of cancer drugs that are
not in the compendia based on studies in peerreviewed publications specified by CMS
CMS’s current list of 15 journals has not been
updated since legislation was passed in 1993
and it has always looked like a partial list!
Additional Journals
Recommended by ASCO

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Annals of Oncology
Biology of Blood and
Marrow Transplantation
Breast Cancer Research
and Treatment
International Journal of
Radiation Oncology,
Biology, Physics
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Gynecologic Oncology
Journal of the National
Comprehensive Cancer
Network
Journal of Thoracic
Oncology
Clinical Cancer Research
Medicare Coverage of Clinical
Trials
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In 2000, CMS issued a National Coverage Decision
(NCD) announcing coverage for routine costs of
clinical trials. Since then, they have waffled on the
coding a few times--except for the -QV.
Investigational devices, items, or drugs are not
covered, nor are costs of qualifying for the trial.
In July 2006, CMS announced it will be
reconsidering current policy to address issues that
have surfaced since implementation, particularly
coding and links to Evidence Development.
Medicare Contractor Reform

Carriers (Part B) and fiscal intermediaries (Part A) will be
merged into one entity called Medicare Administrative
Contractor (MAC)
 15 primary Part A/B MACs
 4 specialty MACs (home health and hospice)
 4 specialty MACs (durable medical equipment); first bid
awarded to CIGNA; protested by Palmetto.

Primary A/B MACs will serve newly defined geographical
regions

Issue of medical directors in each state unresolved

Transition from existing contractor to MAC: 6-13 months
Total transition between now and 2010.

Coding Changes 2006-2007
New Hem-Onc Codes 10/1/2006
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Changes/New Codes in Hem-Onc
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Malignant stromal tumor of the stomach added to
malignant connective tissue tumors (171.5) and benign
connective tissue tumors (215.5)
MDS codes (238.7x)
Constitutional aplastic anemia (284.0x)
Pancytopenias / Myelophthisis /Other (284.x)
Anemia of other chronic illnesses (285.29)-Revised
Neutropenia (288.0x- new fifth digits)
Hemophagocytic syndromes (288.4)
Decreased white cell count (288.5x)
Elevated white cell count (288.6x)
Neutropenic splenomegaly (289.53)
Myelofibrosis (289.83)
New Codes 10/1/2006

Neoplasm-related pain (338.3)

Mucositis due to anti-neoplastic therapy (528.01)

Abnormal tumor markers (795.8x)

Unspecified adverse effect of drug, medicinal, or
biological substance (995.2x)

Colonic polyps (V18.51)

Estrogen receptor status, positive or negative
(ER+/-) (V86.0-V86.1)

See your code book for more changes!
8 Codes Per Claim

Medicare to allow up to 8 diagnosis codes per claim-- You may have to
wait until next July but Medicare will permit you to report up to eight
diagnosis codes on a single claim. Expanding the number of ICD-9-CM
codes available on the CMS-1500 form was mandated by HIPAA.

CMS plans to update Medicare claims processing systems in three phases
so all carriers are ready to accommodate this change by July 2007.

The only exception to the current policy is for clinical lab services. Clinical
lab claims with more than four ICD-9 codes are manually reviewed, but
"this process has not always worked effectively," CMS says in Transmittal
1095, an update to the Medicare Claims Processing Manual.

This is very good news for Medical Oncology and profiling our
performance by patient.
CPT 2007
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Changes to consultation codes
 To reflect 2006 changes
 Clarification (?) of who can request a consult.
New codes for warfarin management (we’ll get into that)
Ventilator Assist and Management 94002-94005
Medical Genetics Counseling by a genetics counselor, each 30
minutes = 96040
Additional hours of hydration, therapeutic, chemotherapy
infusions no longer have the eight hour time limit
Warfarin Management
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99363--Anticoagulant Management for an outpatient
taking warfarin, physician review and interpretation
of INR testing, patient instructions, dosage
adjustment, and ordering of additional tests; first 90
days of therapy, minimum of 8 INRs.
99364-- Each additional 90 days of therapy,
minimum 3 INRs.
“B” status by Medicare--hard edit and will not be
paid.
Warfarin Management

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May be any outpatient setting--but not inpatient.
May not be used for periods less than 60 days (CPT)
for the subsequent code. Use 99211, if less than 60
days.
May only be used with E&M, IF the E&M does not
include anything having to do with warfarin therapy.
Use -25 on the E&M if this is the case.
If started in the hospital, the subsequent code must be
used as the initiation of therapy did not start as an
outpatient.
HCPCS Highlights (Many More
Drug Changes)
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A9568 New code for TC-99M arcitumomab; A9549 deleted.
G0377 Administration of Part D Vaccine in Your Office
($19.33)
J0394 Apomorphine Hcl
J1562 Immune globulin 100 mg sc
J0894 Decitabine 1 mg
J8650 Nabilone oral, 1 mg
J9261 Nelarbine 50 mg injection
Review of Concurrent Infusions

Non-chemo infusions

In one bag
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Under or equal to 15 minutes
Over 15 minutes
Piggy-back
Chemo infusions
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In one bag???
Piggy-back
Consultations

Transmittal 788, CR #4215
 No shared visits for consultations in either office or hospital. Either the
NPP or MD should charge for the consult. This is an area of dispute.
 3 R’s have been more formalized and one has been added…
 REQUEST from another physician must be clearly documented in
BOTH the receiving and referring physician charts. Referring MDs
must have it in their plan of care, but there is no need for you to
check every record.
 The REASON for the consult must be clearly documented.
 Opinion RENDERED by the consultant.
 REPORT goes back to the referring physician.
 99211 may not be used for a consult.
 Only ONE consultation may be billed per inpatient stay.

No shared or split visits.
Consultations

Consultations (Cont’d)
Consultations may be billed based on time for
counseling/coordination of care, but an opinion
must be rendered.
 If care for a diagnosis is transferred prior to the
encounter, the encounter is not a consult. This is a
highly-debated issue.
 Also, if care is continuous before the consult for the
same/original problem, an additional consult may
not be billed.

E/M Medical Necessity (Trailblazer)
1.
The guiding principle of Medicare is whether
an item or service was “medically necessary”.
For E&M, this means


Frequency of service/ intensity of service.
Separate from whether criteria was met, does the
H&P meet the patient’s actual needs at the time
of service?
E/M Medical Necessity (Trailblazer)
2.
Information used by Medicare is contained within the medical
record documentation of the history, physical, and medical
decision-making. Medical necessity is based on these
attributes:

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Number, acuity, and severity of problems addressed in the E&M criteria.
The context of the service in terms of other services previously rendered
for the same problem.
Complexity of documented co-morbidities that influence physician work.
Physical scope encompassed by the problems, i.e. number of physical
systems affected by the problem.
E/M Medical Necessity Tips
(Trailblazer)

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Identify presenting complaints and/or reasons for the visit.
 Demonstrate the history, physical and MDM associated with
each.
 Demonstrate how physician work was affected by comorbidities or chronic problems noted.
Ensure that the nature of the presenting problem is consistent
with the level billed (99213 = low to moderate severity).
Become familiar with the clinical examples in CPT Appendix C.
Empire Medicare: Wastage

Recent reviews by Medicare contractors indicate that providers are not adequately documenting, in their medical records, the provision
and administration of drugs in the office setting. Empire Medicare Services expects that providers adhere to the following guidelines:

Physicians and non-physician providers should enter the drug ordered in their plan of care for the encounter

The dose and route should be included along with the name of the drug

The encounter should be dated and signed in the medical record (or electronically if using EMR).

The person actually administering the drug should enter into the record that he/she administered the drug, include the dose, route,
and site of administration, and sign/date that entry

It is recommended that providers include the drug lot number when documenting the administration of the drug.

If the drug was administered by the ordering provider, it would be sufficient for that person to enter given next to the order in the
plan of care (and also include the site of administration and lot number).

A provider may indicate that the drug will be administered over a number of dates in the future, in a single plan of care. However,
each subsequent administration of the drug must be separately documented as noted above.

Signatures should be legible (you may want to print your name under the signature, if necessary).

If the full amount of a single-use vial is not administered, the provider or staff administering the drug should enter a note in the
patient’s medical record indicating the amount not administered (discarded) as wastage.These guidelines are intended to
document the provision and administration of drugs that are covered under the Medicare incident to benefit (the drug is
administered by the physician/non-physician provider or staff in the office). Use of these documentation guidelines will not extend
Medicare coverage to any drug not otherwise covered (e.g., drugs that are usually self-administered, drugs that are not Food and
Drug Administration (FDA) approved, drugs provided for indications that are not considered medically necessary, etc.). Drugs
provided in the physician office may not be billed to Medicare unless they are also administered by or incident to the same
physician/group.

Furthermore, providers should not bill Medicare for visits (Evaluation & Management (E&M) services) when the purpose of the
encounter was for the administration of the drug.

Providers should retain drug invoice records to document the purchase of the drug, if requested by a Medicare contractor.

Posted: 10/24/2006
Best Practices

Negotiate private contracts with an iron fist--the train has left the station for
Medicare..
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Understand your RBRVS and how the payer is using it.
Know whether EVERY payer is paying you correctly---electronically compare
your paid rates to contracted rates using an EOB analyzer.
Figure out their bundling rules and whether or not they meet coding standards.
Understand the ASP/ AWP relationship for each payer.
Ascertain the balance billing terms for each patient’s plan.
Never give up asking for a facility fee to make up for unpaid costs in RBRVS,
if you are paid at an equivalent rate to Medicare.
Have a lawyer review every contract.
Do not give up the idea of being out-of-network for small, but odious contracts.
Successful Best Practices
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Collections! Collections! Collections! Cash! Cash! Cash!
Do not give up money for denied claims--appeal and
learn from the experience.
Audit chemo prospectively; peer review E&M.
Prepare for chaos around the NPI. Make sure you have
everything settled in your practice 60 days before the
deadline (5/23/07).
Use the highest quality care guidelines and detailed ICD9 coding in the future--you will be rewarded for it down
the road.
Automate everything you can that will help with
understanding your data and benchmarking.
Get together with local hospital outpatient clinics and
figure out ways as a group to take care of patients.
Participate in the struggle!
Use Our Web Site
Often!
Go to http://www.p4pbis.com