Transcript Changes to Oncology Coding 2009

Changes to Oncology Coding 2009
Bobbi Buell
Version 8.0
February-March 2009
Disclaimer
• Payers differ on their guidelines. Please verify coding for
each payer and claim.
• This is not legal or payment advice.
• This content is abbreviated for Medical Oncology. It
does not substitute for a thorough review of code books,
regulations, and Carrier guidance.
• This information is good for the date of the information
and may contain typographical errors.
• CPT is the trademark for the American Medical
Association. All Rights Reserved.
• All denial data from RemitDATA. Copyrighted to them
and all rights reserved.
Session Objectives
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Discuss the Stimulus Package Provisions
Discuss Fee Schedule for 2009
Discuss CPT Changes for 2009
Discuss Drug Administration Coding for 2009
Discuss Anti-Emetic Policies from NGS
Discuss Coding/Options for PQRI 2009
Discuss Coding for E-Prescribing 2009
Discuss the Status of RACs and Other Audits
Discuss What You Need to Do Next
Stimulus Package (AMA)
• COBRA
▫ Sixty-five percent temporary COBRA premium subsidy for
workers who have been involuntarily terminated between Sept. 1,
2008, and Dec. 31, 2009.
▫ Subsidy available for up to 9 months.
▫ Subsidy would not be considered income for purposes of other
federal/state program eligibility.
▫ To be eligible for the subsidy, an individual must have a modified
adjusted gross income below $145,000 (or $290,000 for joint
filers); if the taxpayer’s income exceeds this threshold, then the
premium subsidy must be repaid. For taxpayers with AGI
between $125,000 and $145,000 ($250,000 and $290,000 for
joint filers), the amount of the premium subsidy that must be
repaid is reduced proportionately.
http://www.ama-assn.org/ama/pub/legislation-advocacy/current-topics-advocacy/hr1-stimulus-summary.shtml
Stimulus Package (AMA)
• Medicaid
▫ $87 billion in additional federal matching funds is provided (from Oct. 1, 2008Dec. 31, 2010). Increases FMAP (Federal Medical Assistances Programs) for all
states by 6.2%. Holds states harmless against a drop in their FMAPs for FYs 2009,
2010, and first quarter of FY 2011 (e.g., if 2008 FMAP is higher than 2009, the
state gets the higher 2008 rate).
▫ States with large increases in unemployment would receive an additional FMAP
increase. It is estimated that the conference agreement would provide about 65%
of its spending via the hold harmless agreement and across-the-board increases,
and about 35% via the unemployment-related increase. States must comply with
current Medicaid prompt pay requirements in order to receive FMAP increase.
 Extends through June 30, 2009, the current moratorium on 4 Medicaid regulations relating to
provider taxes, targeted case management services, school-based services, and outpatient hospital
services; states the sense of the Congress that the HHS Secretary should not promulgate as final
the proposed regulations relating to cost limits on public providers, GME payments, and
rehabilitative services.
▫ Provides for a temporary increase in state DSH allotments for FY 2009 and 2010.
http://www.ama-assn.org/ama/pub/legislation-advocacy/current-topics-advocacy/hr1-stimulus-summary.shtml
Stimulus Package (AMA)
• Health Information Technology
▫ Provides approximately $19 billion for Medicare and Medicaid
HIT incentives over five years. Officially establishes the Office of
the National Coordinator for Health Information Technology
(ONCHIT) within HHS to promote the development of a
nationwide interoperable HIT infrastructure; President Bush
already created ONCHIT by Executive Order in 2004.
▫ Establishes HIT Policy and Standards Committees that are
comprised of public and private stakeholders (e.g., physicians
▫ HHS would adopt through the rule-making process an initial set
of standards, implementation specifications, and certification
criteria by December 31, 2009.
▫ ONCHIT would be authorized to make available an HIT system to
providers for a nominal fee.
http://www.ama-assn.org/ama/pub/legislation-advocacy/current-topics-advocacy/hr1-stimulus-summary.shtml
Stimulus Package (AMA)
• Health Information Technology Incentives
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Provides financial incentives through the Medicare program to encourage physicians and hospitals to adopt
and use certified electronic health records (EHR) in a meaningful way (as defined by the Secretary and may
include reporting quality measures). Authorizes ONCHIT to provide competitive grants to states for loans to
providers.
Medicare incentive payments would be based on an amount equal to 75% of the Secretary’s estimate of
allowable charges, up to $15,000 for the first payment year. Incentive payments would be reduced in
subsequent years: $12,000, $8,000, $4,000, and $2000, after 2015. Physicians who report using an EHR
that is also capable of e-prescribing would be eligible for EHR incentives only. Early adopters, whose first
payment year is 2011 or 2012, would be eligible for an initial incentive payment up to $18,000. In 2014, the
payment limit would equal $12,000. Adopters, whose first payment year is 2015, would receive $0 payment
for 2015 and any subsequent year. Physicians who do not adopt/use a certified HIT system would face
reduction in their Medicare fee schedule of -1% in 2015, -2% in 2016, and -3% in 2017 and beyond. Eprescribing penalties would sunset after 2014.
For eligible professionals in a rural health professional shortage area, the incentive payment amounts would
be increased by 10 percent.
Incentives under the Medicaid program are also available for physicians, hospitals, federally-qualified health
centers, rural health clinics, and other providers; however, physicians cannot take advantage of the incentive
payment programs under both the Medicare and Medicaid programs. Eligible pediatricians (non-hospital
based), with at least 20 percent Medicaid patient volume, could receive up to $42,500, and other physicians
(non-hospital based), with at least 30 percent Medicaid patient volume, could receive up to $63,750, over a
six-year period.
Allows HHS to increase penalties beginning in 2019, but penalties cannot exceed -5%. Exceptions would be
made on a case-by-case basis for significant hardships (e.g., rural areas without sufficient Internet access).
http://www.ama-assn.org/ama/pub/legislation-advocacy/current-topics-advocacy/hr1-stimulus-summary.shtml
Stimulus Package (AMA)
• More HIPAA
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▫
▫
▫
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Federal privacy/security laws (HIPAA) are expanded to protect patient health information. HIPAA
privacy and security laws would apply directly to business associates of covered entities. Defines
actions that constitute a breach of patient health information (including inadvertent disclosures) and
requires notification to patients if their health information is breached.
Allows patients to pay out of pocket for a health care item or service in full and to request that the
claim not be submitted to the health plan.
Requires physicians to provide patients, upon request, an accounting of disclosures of health
information made through the use of an EHR.
Prohibits the sale of a patient’s health information without the patient’s written authorization, except
in limited circumstances involving research or public health activities.
Requires personal health record (PHR) vendors to notify individuals of a breach of patient health
information.
 Non-covered HIPAA entities such as Health Information Exchanges, Regional Health
Information Organizations, e-Prescribing Gateways, and PHR vendors are required to have
business associate agreements with covered entities for the electronic exchange of patient health
information.
Authorizes increased civil monetary penalties for HIPAA violations.
Grants enforcement authority to state attorneys general to enforce HIPAA.
http://www.ama-assn.org/ama/pub/legislation-advocacy/current-topics-advocacy/hr1-stimulus-summary.shtml
Stimulus Package (AMA)
• Comparative Effectiveness Research (“CER”)
▫ The government will increase funding for CER by $1.1 billion.
▫ Both the Report on the Conference Agreement and that actual ARRA language provide
that the FCC-CER will not mandate coverage, reimbursement, or other policies of public
or private payers.
▫ CER will not include national clinical guidelines or coverage determinations as ARRA
incorporates by reference the provisions in the Medicare Modernization Act of 2003
that explicitly preclude this.
▫ Establishes the Federal Coordinating Council for Comparative Effectiveness Research
(FCC-CER), an advisory board that will be comprised of up to 15 representatives of
federal agencies—at least half will be physicians or other experts with clinical expertise.
The FCC-CER will coordinate CER to reduce duplication of efforts and encourage
coordinated and complementary uses of resources, coordinate related health services
research, and make recommendations to the President and Congress on CER
infrastructure needs.
▫ The Agency for Healthcare Research and Quality (AHRQ) will receive $700 million for
CER; AHRQ must transfer $400 million to NIH to conduct or support CER
http://www.ama-assn.org/ama/pub/legislation-advocacy/current-topics-advocacy/hr1-stimulus-summary.shtml
Medicare Physician Payment Basics
• 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.
What Happened to the Conversion
Factor?
• Section 131 of the MIPPA substitutes a positive update to
payment rates under the MPFS of 1.1 percent for the
negative update that would have resulted from the
application of the statutory formula that includes the
sustainable growth rate. Section 133(b) of the MIPPA
also requires CMS to make a technical change in how a
statutorily required budget-neutrality adjustment is
applied. Section 133(b) of the MIPPA requires that the
budget-neutrality adjustment be applied instead to the
conversion factor…so, we end up at $36.0666 from
$38.0870. THIS HELPS PROCEDURAL SPECIALTIES
AND HURTS US.
Impact of 2009 PFS Changes
Code Num be rDe s criptor
Work
96360 Hydration initial
96361 Hydration Add-on
96365 Therapeutic initial
96366 Therapeutic Add-on
96367 Therapeutic Sequential
96368 Therapeutic Concurrent
96372 Therapeutic Injection
96374 Therapeutic Push initial
96375 Therapeutic Push seq
96401 Chemo injection non-h
96402 Chemo injection horm
96409 Chemo Push initial
96411 Chemo Push Sequent
96413 Chemo inf usion initial
96415 Chemo inf usion add-on
96416 Chemo inf usion long
96417 Chemo inf usion seql
96523 Irrigate implanted dev
PE
0.17
0.09
0.21
0.18
0.19
0.17
0.17
0.18
0.1
0.21
0.19
0.24
0.2
0.28
0.19
0.21
0.21
0.04
M al
1.33
0.33
1.63
0.39
0.73
0.36
0.4
1.29
0.52
1.65
0.82
2.8
1.51
3.73
0.67
4.17
1.76
0.65
0.07
0.04
0.07
0.04
0.04
0.04
0.01
0.04
0.04
0.01
0.01
0.06
0.06
0.08
0.07
0.08
0.07
0.01
Total RVUs 2009Total RVUs
1.57
0.46
1.91
0.61
0.96
0.57
0.58
1.51
0.66
1.87
1.02
3.1
1.77
4.09
0.93
4.46
2.04
0.7
2008 RVU change 2008
1.61
-0.04 $
0.49
-0.03 $
1.97
-0.06 $
0.64
-0.03 $
0.97
-0.01 $
0.6
-0.03 $
0.56
0.02 $
1.54
-0.03 $
0.68
-0.02 $
1.73
0.14 $
1.09
-0.07 $
3.16
-0.06 $
1.81
-0.04 $
4.27
-0.18 $
0.97
-0.04 $
4.63
-0.17 $
2.12
-0.08 $
0.72
-0.02 $
$
60.56
18.28
73.89
23.61
38.09
22.09
20.57
57.89
25.52
64.75
40.75
119.21
68.18
161.49
36.18
175.20
79.60
27.42
2009 $
$
56.62
$
16.59
$
68.89
$
22.00
$
34.62
$
20.56
$
20.92
$
54.46
$
23.80
$
67.45
$
36.79
$
111.81
$
63.84
$
147.51
$
33.54
$
160.86
$
73.58
$
25.25
Change
Change w /4%
$
(3.94) $
(1.67)
$
(1.69) $
(1.03)
$
(5.00) $
(2.25)
$
(1.61) $
(0.73)
$
(3.47) $
(2.08)
$
(1.53) $
(0.71)
$
0.35 $
1.19
$
(3.43) $
(1.25)
$
(1.72) $
(0.76)
$
2.70 $
5.39
$
(3.96) $
(2.49)
$
(7.40) $
(2.93)
$
(4.34) $
(1.79)
$
(13.98) $
(8.08)
$
(2.64) $
(1.30)
$
(14.34) $
(7.91)
$
(6.02) $
(3.08)
$
(2.17) $
(1.16)
Impact of PFS Changes for 2009
Code Num berDescriptor
Work
PE
99211 Office visit, established
0.17
99212 Office visit, established
0.45
99213 Office visit, established
0.92
99214 Office visit, established
1.42
99215 Office visit, established
2
99241 Office Consultation
0.64
99242 Office Consultation
1.34
99243 Office Consultation
1.88
99244 Office Consultation
3.02
99245 Office Consultation
3.77
Mal
0.34
0.55
0.75
1.09
1.38
0.66
1.08
1.45
1.93
2.3
0.01
0.03
0.03
0.05
0.08
0.05
0.1
0.13
0.16
0.21
Total RVUs 2009Total RVUs 2008 RVU change 2008 $
0.52
0.54
-0.02 $
19.81
1.03
1.03
0 $
37.33
1.7
1.68
0.02 $
59.80
2.56
2.53
0.03 $
89.89
3.46
3.43
0.03 $
121.50
1.35
1.34
0.01 $
47.99
2.52
2.5
0.02 $
89.12
3.46
3.43
0.03 $
122.26
5.11
5.06
0.05 $
179.01
6.28
6.25
0.03 $
220.90
2009 $
$
18.75
$
37.15
$
61.31
$
92.33
$ 124.79
$
48.69
$
90.89
$ 124.79
$ 184.30
$ 226.50
Change
Change w 4%
$
(1.06) $
(0.30)
$
(0.18) $
1.30
$
1.51 $
3.97
$
2.44 $
6.13
$
3.29 $
8.28
$
0.70 $
2.65
$
1.77 $
5.40
$
2.53 $
7.52
$
5.29 $
12.66
$
5.60 $
14.66
Other Proposed Medicare FS Changes
2009
• Non-payment for preventable conditions is now part of
inpatient payment. CMS discusses the possibility of it in
physician payment and is still looking for comments.
• Nurse Practitioners who enrolled in the Medicare Program on
or after 1/1/2003 must have a Masters’ Degree or DNP.
• Reinstates the ability to use electronic facsimile transmission
of prescription until January 1, 2012. But, this is unrelated to
getting the incentive in 2009.
• G0332 is out!
Change in the Enrollment Methodology
• Establishment of an Effective Billing Date for Physicians and NonPhysician Practitioners: The final rule establishes the effective date
of billing for physicians and non-physician practitioners as the later
of: (1) the date of filing of a Medicare enrollment application that
was subsequently approved by a Medicare contractor; or (2) the
date an enrolled physician or non-physician practitioner first
started furnishing services at a new practice location. In addition,
physicians and non-physician practitioners who meet all program
requirements may bill retrospectively:
▫ For services furnished up to 30 days prior to the effective date, rather than the 23
months allowed under current regulations; and
▫ For services furnished up to 90 days prior to the effective date if the President has
declared an emergency under the Robert T. Stafford Disaster Relief and
Emergency Assistance Act
Enrollment in Medicare
• Billing for 30 days prior to that date is permitted in
certain circumstances
▫ When the enrolling physician or NPP met all program
requirements including state licensure requirements,
▫ The services were furnished at the enrolled practice
location,
▫ And circumstances prevented enrollment prior to providing
services to Medicare beneficiaries
PECOS
• Starting January 1, enrollment for physicians or other providers in a
new location will be much more strict in terms of what you can bill-now it's 23 months; next year, it will be 30 days. The Internet-based
Provider Enrollment, Chain and Ownership System (PECOS) will
allow physicians and non-physician practitioners to enroll, make a
change in their Medicare enrollment, view their Medicare
enrollment information on file with Medicare, and check on the
status of a Medicare enrollment application via the Internet.
• Is supposed to reduce enrollment time.
• Physicians and non-physician practitioners in the District of
Columbia and the States shown above who wish to access Internetbased PECOS may go to this place to check it out:
https://pecos.cms.hhs.gov/pecos/login.do
PECOS
• Physician or NPP cannot use PECOS in order to:
▫ Change his/her name or social security number
▫ Change an existing business structure
 To sole proprietorship from Professional Association,
Professional Corporation or LLC, or vice versa
▫ Reassign benefits to another supplier if that supplier does not
have a current Medicare enrollment record in PECOS
• For more information
http://www.cms.hhs.gov/MedicareProviderSupEnroll
After Revocation of Billing Privileges
• The final rule provides that a physician or non-physician
practitioner is not allowed to bill for services furnished after
certain reportable events, including:
▫ A Federal exclusion or debarment, or felony conviction;
▫ A State license suspension or revocation; or
▫ A practice location is determined to be not operational by CMS or
its contractor.
• For all other revocation actions, individual practitioners will
be required to submit all outstanding claims within 60 days of
the effective date of revocation.
Provider Reporting of Certain Events
• Revised Reporting Responsibilities for Physicians and NonPhysician Practitioners: The rule requires physicians and
non-physician practitioners and physician and non-physician
practitioner organizations to notify their Medicare contractor
of a
▫ change of ownership,
▫ final adverse action,
▫ or change of location within 30 days of the reportable event.
• Failure to notify the designated contractor of a change related
to a final adverse action or a change of location may result in
an overpayment from the date of the reportable event.
Lab Services
• Technical Component of Pathology Services for Hospital
Patients - Section 136 of the MIPPA allows independent
laboratories to bill Medicare directly for the technical component of
physician pathology services furnished to hospital inpatient and
outpatients until December 31, 2009, rather than requiring that it
be bundled into the payment to the hospital.
• Clinical Laboratory Fee Schedule Update - Section 145 of the
MIPPA sets the clinical laboratory fee schedule update at the
Consumer Price Index for all Urban Consumers (CPI-U) minus 0.5
percentage points for each of the calendar years 2009 through 2013,
but repeals a competitive bidding demonstration program for
clinical laboratory services that had been required under the MMA.
• Must maintain ordering and referring information for 7
years.
Fee Schedule: Carry-over
• Anti-Markup Provisions (Delayed until 1/1/2009)
▫ CMS proposes to prohibit the markup of purchased
diagnostic services for both the technical and professional
components performed by outside suppliers.
▫ Two approaches this year:
 Physicians “who do not share the practice” will be subject to the
anti-markup. This includes contractors who serve several
physicians. This means they must be in the practice ≥ 75% of the
time.
 Physicians who do not share the building will be subject to antimarkup. If the physician who provides the professional component,
or supervises the technical component, is an owner, employee, or
independent contractor of the billing physician and provides or
supervises the service in a building in which the ordering physician
provides the full range of services that the ordering physician
generally provides.
Telehealth Services
•
•
•
The final rule incorporates the requirement in section 149 of the MIPPA that, effective for services
furnished on or after January 1, 2009, CMS add three new facility types to the list of authorized
telehealth originating sites: a hospital-based or CAH-based renal dialysis center (including
satellites), a skilled nursing facility (SNF), and a community mental health center (CMHC).
The final rule also adopts the proposal to add new HCPCS codes specific to the telehealth delivery
of follow up inpatient consultations. The new codes will enable practitioners to bill for follow-up
inpatient consultations delivered via telehealth. This provision effectively restores follow-up
inpatient consultations to the list of Medicare covered telehealth services. They had been
included prior to 2006, but ceased to be on the list of Medicare telehealth services, when the CPT
Editorial Panel of the American Medical Association (AMA) deleted the specific codes for followup inpatient consultations and advised practitioners to report follow-up inpatient consultation
using more general codes (i.e. codes describing subsequent hospital care) CMS did not add these
more general codes to the list of Medicare telehealth services because, in addition to follow-up
inpatient consultation, the subsequent hospital care codes could be used to report services
involving the on-going (day to day) management of a hospital inpatient, which CMS believed
would not be appropriately furnished via telehealth.
The new codes are G0406-G0408 (with -GT modifier).
CPT Changes 2009
• CPT decided to ‘go green this year and changed
the numbering for the Hydration and
Therapeutic codes so they are in the same
section as the Chemo codes.
▫ All Hydration and Therapeutic codes will be “963”
codes instead of “907” codes.




90761 = 96361
90767 = 96367
90772 = 96372
ETC.
Source: CPT 2009
Crosswalk available at http://www.asco.org
CPT Changes 2009
• The Chemotherapy Section name has changed to
“Chemotherapy or Highly Complex Drug or
Highly Complex Biologic Agent” Administration
▫
▫
▫
▫
The word “highly complex” used with frequency
Will payers change admin codes on some drugs?
CMS leaves this up to the MACs and Carriers.
Other payers may be more strict with drug
administration, but let’s wait and see what the
AMA says.
Descriptor Source: CPT 2009
Drug Admin Coding
• 2005 Drug Administration Coding in REVIEW
▫ General Principals that live to this day







One INITIAL code per day is the one that best describes the
service that the patient is having that day, unless you are in a
hospital.
Before/after infusions and pushes must always be categorized
as SEQUENTIAL or concurrent to sequential. They must be a
different substance to merit a separate code.
Hours following EACH infusion’s initial hour must be over 30
minutes.
Any infusion of 15 minutes or less is coded as a push.
One concurrent code per day regardless of substances or hours.
Hydration coding differs from non-chemo and chemo
administration.
Port flushes are billable IF they are the only service of the day!
Common Coding Errors & Omissions
• Using more than one initial code per date of
service
• Billing port flush with evaluation and
management and/or administration codes
• Assorted administration code omissions
Initial 2009 Administration Codes
96360
Hydration IV infusion, 1st h
96365
Therapeutic IV infusion, 1st h
96374
Therapeutic IV injection
96409
Chemo IV push
96413
Chemo IV infusion, 1st h
Billing Port Flush with Administration and/or E&M
Service
“Pay for 96523, irrigation of implanted venous access
device for drug delivery systems, if it is the only
service provided that day. If there is a visit or other
drug administration service provided on the same
day, payment for 96523 is included in the payment
for the other service.”
Port Flush Billing Procedures
• 96523 is payable with lab.
• Do not use 96374-96375 for port access--this is
erroneous at best.
• Do not change practice patterns to accommodate a
port flush…
Routes of Drug Administration
from NGS
• Not only does the indication for the use of the drug need to meet
medical necessity requirements, but the route of administration is also
subject to medical necessity criteria.
• Contractors must continue to apply the policy that not only the drug is
medically reasonable and necessary for any individual claim, but also
that the route of administration is medically reasonable and
necessary. That is, if a drug is available in both oral and injectable
forms, the injectable form of the drug must be medically reasonable
and necessary as compared to using the oral form. ( Pub 100-02,
Chapter 15, Sect 50.2 - Determining Self-Administration of Drug or
Biological (Rev. 91; Issued: 06-20-08; Effective/Implementation Date:
07-21-08)).
• Medication given by injection (parenterally) is not covered if standard
medical practice indicates that the administration of the medication by
mouth (orally) is effective and is an accepted or preferred method of
administration. (Pub 100-02, Chapter 15, Section 50.4.3)
Oral Anti-emetics
• For anti-emetic medication, CMS states:
It is recognized that a limited number of
patients will fail on oral anti-emetic drugs.
Intravenous anti-emetics may be covered
(subject to the rules of medical necessity) when
furnished to patients who fail on oral antiemetic therapy. (Pub 100-02, Chapter 15,
Section 50.5.4)
Chapter 15, Section 50.2
• Policy about determining whether or not a drug
USUALLY is self-administered.
▫ For the purposes of applying this exclusion, the term
“usually” means more than 50 percent of the time for all
Medicare beneficiaries who use the drug. Therefore, if a
drug is self-administered by more than 50 percent of
Medicare beneficiaries, the drug is excluded from coverage
and the [Part B] contractor may not make any Medicare
payment for it. In arriving at a single determination as to
whether a drug is usually self-administered, contractors
should make a separate determination for each indication
for a drug as to whether that drug is usually selfadministered
Chapter 15, Section 50.2
• Reasonable and Necessary
▫ “Contractors will make the determination of
reasonable and necessary with respect to the
medical appropriateness of a drug to treat the
patient’s condition. Contractors will continue to
make the determination of whether the
intravenous or injection form of a drug is
appropriate as opposed to the oral form.”
Chapter 15, Section 50.2
• Conditions under which a drug is self-administered
▫ “For the purposes of determining whether a drug is usually
self-administered, an acute condition means a condition
that begins over a short time period, is likely to be of short
duration and/or the expected course of treatment is for a
short, finite interval. A course of treatment consisting of
scheduled injections lasting less than 2 weeks, regardless of
frequency or route of administration, is considered acute.
Evidence to support this may include Food and Drug
administration (FDA) approval language, package inserts,
drug compendia, and other information.”
HCPCS Changes 2009 (1/1/2009)
• New Codes:
J0641
J1267
J1453
J1459
INJECTION, LEVOLEUCOVORIN CALCIUM, 0.5 MG
INJECTION, DORIPENEM, 10 MG
INJECTION, FOSAPREPITANT, 1 MG
INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON-LYOPHILIZED (E.G.
HCPCS Changes: New Codes
J8705 TOPOTECAN, ORAL, 0.25 MG
J9033 INJECTION, BENDAMUSTINE HCL,
1 MG
J9207 INJECTION, IXABEPILONE, 1 MG
J9330 INJECTION, TEMSIROLIMUS, 1 MG
HCPCS Changes
J1572 INJECTION, IMMUNE GLOBULIN,
(FLEBOGAMMA/FLEBOGAMMA
DIF), INTRAVENOUS,
J2788 INJECTION, RHO D IMMUNE
GLOBULIN, HUMAN, MINIDOSE, 50
MICROGRAMS (250 I.U.)
J2790 INJECTION, RHO D IMMUNE
GLOBULIN, HUMAN, FULL DOSE,
300 MICROGRAMS (1500 I.U.)
HCPCS Deleted Codes
Q4097 INJECTION, IMMUNE GLOBULIN
(PRIVIGEN), INTRAVENOUS, NONLYOPHILIZED (E.G.
Q4098 INJECTION, IRON DEXTRAN, 50
MG
J9182 Etoposide 100 mg
• BACK
IN ACTION
J1750
INJECTION, IRON DEXTRAN, 50
MG
MIPPA Legislation - PQRI
• The Medicare Improvements for Patients and
Providers Act (MIPPA), passed in July 2008,
contained several new authorities and
requirements for quality reporting and PQRI for
2009 and beyond.
• Section 131 directly impacts PQRI
• Section 132 contains the new electronic
prescribing incentive provisions.
Source of PQRI/ E-Prescribing Slides
• From Slides of Sylvia W. Publ, MBA,
RHIA, Consortium for Quality
Improvement and S&C Operations,
CQISCO, CMS
• December 17, 2008
• Subject to Disclaimers
Value-Based Purchasing
and PQRI
• Key mechanism for transforming Medicare from
passive payer to active purchaser.
▫ Current Medicare Physician Fee Schedule is
based on quantity and resources consumed,
NOT quality or value of services.
• Value = Quality / Cost
▫ Incentives can encourage higher quality and
avoidance of unnecessary costs to enhance the
value of care.
PQRI Legislative Background
TRHCA – Tax Relief & Health Care Act,
2006
•
Established 2007 PQRI, 7/1-12/31/07,
authorized 1.5% incentive subject to a cap,
claims-based reporting by eligible
professionals (EPs) of up to 3 individual
applicable measures for 80% of eligible
cases
MMSEA - Medicare, Medicaid, and SCHIP
Extension Act of 2007
•
Authorized 2008 PQRI, 1.5% incentive,
eliminated cap Incentive
•
Required alternative reporting periods
and alternative reporting criteria for
2008 and 2009
▫
Requires alternative reporting for
measures groups and for registrybased reporting
MIPPA - Medicare Improvements for
Patients and Providers Act
Section 131: 2009 PQRI
• Authorized PQRI 2009 raised incentive to
2%, adds qualified audiologists as eligible
professionals, no effect on 2007 or 2008
incentive payments
• Requires CMS to post on our web site
names of EPs who satisfactorily report
quality measures for 2009 PQRI
Section 132: e-Prescribing Incentive
Program
• Authorized separate 2% incentive payment
to EPs who successfully use a qualified
eprescribing system
• eRx measure removed from 2009 PQRI -separately posted measure specifications.
• The Secretary has the authority to update
the codes of the electronic prescribing
measure in the future.
• Requires names of eligible professionals
who are successful e-prescribers be posted
on the CMS web site
PQRI :
Eligible Professionals
• Physicians
▫ MD/DO
▫ Podiatrist
▫ Optometrist
▫ Oral Surgeon
▫ Dentist
▫ Chiropractor
• Therapists
▫ Physical Therapist
▫ Occupational
Therapist
▫ Qualified SpeechLanguage Pathologist
• Practitioners
▫ Physician Assistant
▫ Nurse Practitioner
▫ Clinical Nurse
▫ Specialist
▫ Certified Registered Nurse
▫ Anesthetist
▫ Certified Nurse Midwife
▫ Clinical Social Worker
▫ Clinical Psychologist
▫ Registered Dietician
▫ Nutrition Professional
▫ Audiologist
2009 PQRI Quality Measures
• 153 PQRI quality measures for 2009
▫ Includes 101 measures from the 2008 PQRI and 52
new measures
▫ E-prescribing measure (Measure #125) removed, as
required by MIPPA as a separate program
▫ 18 measures reportable only through registries
▫ By December 31, 2008, measure specifications will be
available at: http://www.cms.hhs.gov/pqri
Hematology-Oncology Measures 2009
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
MDS And Acute Leukemias Cytogenetic Testing (ICD-9 codes changed for 2009)
MDS Documentation of Iron Stores
Multiple Myeloma: Treatment With Bisphosphonates (Minor language and ICD-9 changes for 2009)
CLL Baseline Flow Cytometry (ICD-9 codes changed for 2009)
Hormonal Therapy for Stage IC-III ER/PR + Breast Cancer (CPT II codes changed; language change)
Chemotherapy for Stage III Colon Cancer Patients (Updated language, CPT II codes changed, language changes)
Breast Cancer Patients Who Have pT and pN category and histological grade for their cancer (Language changes, minor coding
changes)
Colorectal Cancer Patients Who Have pT and pN category and histological grade for their cancer (Language changes, minor coding
changes)
Inappropriate use of bone scan for staging low risk cancer patients (Denominator code change, language change)
Adjuvant hormonal therapy for high-risk prostate cancer patients (Language, Instruction changes, minor coding changes)
Three-dimensional radiotherapy for patients with prostate cancer (CPT II changes, language changes, reporting frequency)
Melanoma: Follow Up Aspects of Care (2009)
Melanoma: Continuity of Care (2009)
Melanoma: Coordination of Care (2009)
Oncology Med/Rad: Plan of Care for Pain (2009) goes with
Oncology Med/Rad: Pain Quantified (2009)
Oncology: Radiation Dose Limits to Normal Tissues (2009)
Oncology Recording of Clinical Stage for Lung and Esophageal Cancer (2009)
Notice #73 #74 #101 and #103 are gone
2009 PQRI Measures Groups
• 7 measures groups:
▫
▫
▫
▫
▫
▫
▫
*
Diabetes Mellitus
Chronic Kidney Disease
Preventive Care
Coronary Artery Bypass Graft (CABG) (new)
Rheumatoid Arthritis (new)
Perioperative Care (new)
Back Pain* (new)
Measures in this measures groups are reportable only as a measures
group, not as individual measures
• ESRD measure group removed for 2009
2009 PQRI Reporting Periods
• Reporting period: January 1, 2009 –
December 31, 2009
• 2 reporting periods for reporting measures
groups and registry-based reporting:
▫ January 1, 2009 – December 31, 2009
▫ July 1, 2009 – December 31, 2009
2009 PQRI Satisfactory
Reporting Options
• Criteria for claims-based submission of
individual measures (1 option):
▫ Reporting period: January 1, 2009 –
December 31, 2009
▫ 3 PQRI measures or 1-2 measures
if < 3 apply*
▫ 80% of applicable Medicare Part B FFS
patient claims for 1-3 measures
* If < 3 measures, measures are subject to measure
applicability validation (MAV)
2009 PQRI Satisfactory
Reporting Options (ctd.)
• Criteria for registry-based reporting of
individual measures (2 options):
▫ Reporting period: January 1, 2009 – December 31,
2009
 ≥ 3 PQRI measures
 80% of applicable Medicare Part B FFS patient
claims for ≥ 3 measures
▫ Reporting period: July 1, 2009 – December 31, 2009
 ≥ 3 PQRI measures
 80% of applicable Medicare Part B FFS patient
claims for ≥ 3 measures
2009 PQRI Satisfactory
Reporting Options (ctd.)
• Criteria for measures groups (6 options: 3 for claimsbased submission and 3 for registry-based reporting):
▫ Reporting period: January 1, 2009 – December 31, 2009
 30 consecutive patients for 1 measures group OR
 80% of applicable Medicare Part B FFS patient claims for 1
measures group, with a minimum of 30 applicable patients
▫ Reporting period: July 1, 2009 – December 31, 2009
 80% of applicable Medicare Part B FFS patient claims for 1
measures group, with a minimum of 15 applicable patients
▫ Criteria for claims-based submission of measures groups
identical to criteria for registry-based reporting of
measures groups except only Medicare Part B FFS patients
can be included in consecutive patient sample for claimsbased submission of measures groups
Measure Applicability Validation
Satisfactorily Report ≥
80% on ≥ 3 Measures
Satisfactorily Report ≥
80% on < 3 Measures
Not Subject to MAV
Subject to MAV
Did EP report at least
1 measure included in
a MAV Clinically
Related Cluster?
Step 1 - Clinical
Relation Test:
No
Eligible for
Incentive
Payment
Yes
Step 2 - Minimum
Threshold Test:
Did EP report number
eligible claims above
threshold ≥ (30 pts)?
Yes
Not Eligible for
Incentive
Payment
Did EP report number
eligible claims below
threshold < (30 pts)?
Yes
Eligible for
Incentive
Payment
PQRI Process
Visit Documented in
the Medical Record
Critical
Step
Encounter Form
Coding & Billing
N-365
NCH
Analysis Contractor
Confidential
Report
National Claims
History File
Carrier/MAC
Incentive Payment
E-Prescribing Incentive Program
• MIPPA authorized a new incentive program, separate from
PQRI, for EPs who are successful
e-prescribers
• For 2009, successful e-prescribers are eligible for a incentive
payment equal to 2% of estimated allowed charges submitted
by 2/28/2010
• 2009 E-Prescribing Incentive Reporting Period: January 1,
2009 – December 31, 2009
• MIPPA also requires that names of eligible professionals who
are successful e-prescribers be posted on the CMS web site
2009 Successful E-Prescribers
• “Successful E-Prescriber” is defined as an EP
who reports the e-prescribing measure established for PQRI
(i.e., Measure #125) for at least 50% of applicable Medicare
Part B FFS patients using a qualified system
• E-prescribing measure is reportable only through claims
• Limitation to applicability of incentive payment
▫ Denominator codes for the e-prescribing measure must
comprise at least 10% of an EP’s total allowed charges for
all covered services furnished by the EP during the
reporting period
2009 E-Prescribing Process
Critical
Step
PBM
Visit Documented in Rx TransMedical Record & Rx mitted to
Generated
Pharmacy
Encounter
Form
Coding & Billing
N-365
NCH
Analysis Contractor
Confidential
Report
National Claims
History File
Carrier/MAC
Incentive Payment
Reporting Scenarios
E-Prescribing
A 70 year old male patient presents to the
clinician’s office for medical care.
Scenario 1:
The clinician discusses
current medications and
prescribes new
medication, updates
active medication list in
eRx system, transmits
prescription electronically
to pharmacy
Reports G8443
Scenario 2:
The clinician documents
there is no change in meds,
no prescription generated.
Reports G8445
Scenario 3:
Pt has mail order pharmacy
that cannot accept eRx &
asks for hard copy.
Physician updates meds in
eRx system, eRx system
provides hard copy of
prescription to patient.
Reports G8446
All of these scenarios represent successful 2009 reporting
What is Not E-Prescribing
•
•
•
•
Calling in a prescription for NH patient
Patient seen in ED and is sent home with a prescription
Faxing a prescription to a pharmacy
Sending a prescription via PDA (exception: depends on
software used – must meet e-prescribing system
qualifications)
• Knowingly sending a computer-generated fax initiated at
the doctor’s office to a pharmacy (exception: if sent via
qualified e prescribing system and pharmacy system
generates message as a fax, it is e-prescribing)
• Office visits provided as part of a global surgical package
• Medicare Advantage patients (exception: some private feefor-service plans - can e-prescribe, but this does not count
toward incentive payment calculation)
Billing Parameters for PQRI
Reporting Measures with Claims
C
PQRI Tools: Where to Begin
• Gather information and educational
materials from the PQRI web page:
www.cms.hhs.gov/pqri on the CMS website
(e.g., Measures/Codes, Educational
Resources, Tool Kit web pages).
• Gather information from other sources,
such as your professional association,
specialty society or the American Medical
Association.
Understanding the Measures:
PQRI Quality-Data Codes
Quality-Data Codes translate clinical actions so they can be
captured in the administrative claims process
• The measure requirement was met
– OR –
• The measure requirement was not met due to documented
allowable performance exclusions (i.e., using CPT II
performance exclusion modifiers)
– OR –
• The measure requirement was not met and the reason is not
documented or is not consistent with an accepted performance
exclusion (i.e., using the 8P reporting modifier)
Understanding the
Measure Construct
NUMERATOR
CPT II Code or Temporary G Code
(describes clinical action required for
performance)
÷
DENOMINATOR
ICD-9-CM & CPT Cat I Codes
(Describes eligible cases for a measure: the
eligible patient population as defined by
denominator specification)
Understanding the Measures:
The Performance Modifiers
• Unique modifiers used with CPT II Codes only
• Performance Measure Exclusion Modifiers indicate that an action
specified in the measure was not provided due to medical, patient or
systems reason(s) documented in the medical record:
▫ 1P- Performance Measure Exclusion Modifier due to Medical
Reasons
▫ 2P- Performance Measure Exclusion Modifier used due to Patient
Reason
▫ 3P- Performance Measure Exclusion Modifier used due to System
Reason
• One or more exclusions may be applicable for a given measure. Certain
measures have no applicable exclusion modifiers. Refer to the measure
specifications to determine the appropriate exclusion modifiers.
Understanding the Measures:
The Reporting Modifier
Performance Measure Reporting Modifier
• facilitates reporting a case when the patient is
eligible but the action described in a measure is
not performed and the reason is not specified
or documented
▫ 8P Modifier: action not performed, reason
not otherwise specified
Understanding the Measures:
Performance Time Frame
• Some measures have a Performance
Timeframe related to the clinical action
that may be distinct from the reporting
frequency.
▫ Perform within 12 months or annually
▫ Most Recent result
 Clinical test result needs to be obtained,
reviewed, reported one time.
 It need not have been performed during the
reporting period.
Understanding the Measures:
Reporting Frequency
• Each measure has a Reporting Frequency
requirement for each eligible patient seen during
the reporting period
▫ Report one-time only
▫ Report once for each procedure performed
▫ Report for each acute episode
PQRI Measure #71 Changes for 2009
• Coding Changes
▫ Different instructions
▫ Deleted: 3302F, 3303F, 3305F, 3306F, 3307F, 3309F,
3310F, 3311F, 3312F
▫ Added:
 3370F = AJCC Breast Cancer Stage 0 documented
 3372F = AJCC Breast Cancer Stage I: T1 mic, T1a, or T1b
documented
 3374F = AJCC Breast Cancer Stage I: TIC, Tumor Size >1 cm- 2cm
 3376F = AJCC Breast Cancer Stage II documented
 3378F = AJCC Breast Cancer Stage III documented
 3380F = AJCC Breast Cancer Stage IV documented
http://www.cms.hhs.gov/PQRI/15_MeasuresCodes.asp
PQRI Coding 2009
• Coding Example--Measure #71 Hormonal Therapy for Stage IC-III. ER/PR + Breast CA
▫
▫
Report once per reporting period for all females 18 and over having breast cancer seen during the
reporting period.
Numerator Coding for patients receiving tamoxifen and AIs and have Stage 1C-III, ER/PR+; coding
now depends upon the submission of one to three numerator codes in some cases.
 Tamoxifen/AI Prescribed (Three CPT II Codes [4179F & 3374F or 3376F or 3378F &
3315F] are required to report)
 Tamoxifen/ AI Not Prescribed for Medical, Patient, or System Reasons (Three CPT II
Codes [4179F-1-3P & 33xxF & 3315F ]
 Tamoxifen/ AI Not Prescribed due to Stage or ER/PR Negative [3370F or 3372F or 3380F
or 3316F]--ONE CODE ONLY
 Tamoxifen/ AI Not Prescribed; Reason Not Specified (Three CPT II Codes [4179F-8P &
33xxF & 3315F] are required to report)
 No documentation of cancer stage or ER/PR status [3370F-8P or 3316F-8P ONLY]
▫
Denominator Coding
 Patient is 18 years old or older
 Breast Cancer Dx Codes (174.0-174.6, 174.8, 174.9)
 E/M codes (99201-99205, 99212-99215)
http://www.cms.hhs.gov/PQRI/15_MeasuresCodes.asp
PQRI Errors
• Errors from 2007
▫ 1,711,975 (12.15%) of QDC submission attempts had a
missing NPI.
▫ 2,662,023 (18.89%) of QDC submission attempts occurred
with an incorrect HCPCS code.
▫ 1,963,196 (13.93%) of QDC submission attempts occurred
with an incorrect Dx code.
▫ 1,019,422 (7.24%) of QDC submissions had an incorrect
HCPCS and Dx code.
▫ 700,201 (4.97%) had only the QDC code and no other line
items were billed.
• “Physician Quality Reporting Initiative 2007 Reporting Experience” available at
http://www.cms.hhs.gov/pqri/
Oncology-Specific Errors
Measure
% OK
HCPCS
Wrong
Dx Wrong QDC
Only
NPI
Problem
#71 Breast
Cancer with
drug tx
83.70%
5.61%
4.04%
5.87%
13.38%
#73 Plan of
Chemotherapy
25.16%
52.70%
12.40%
8.00%
5.68%
#72 Stage III
Colon Cancer
56.25%
7.38%
12.00%
4.68%
9.31%
“Physician Quality Reporting Initiative 2007 Reporting Experience” available at http://www.cms.hhs.gov/pqri/
Hem-Onc Specific Errors
Measure
% OK
HCPCS
Wrong
Dx Wrong QDC Only
NPI
Problem
#70 Baseline
Flow in CLL
77.31%
7.13%
10.35%
3.28%
12.50%
#67 MDS
Baseline
Cytogenetic
Testing
66.63%
9.05%
9.47%
3.67%
10.31%
#69 Multiple
Myeloma Tx With
Biphosphonates
73.02%
12.21%
8.28%
4.46%
12.40%
#74 RT
Recommended
Breast Ca
15.45%
58.15%
1.03%
7.47%
7.31%
“Physician Quality Reporting Initiative 2007 Reporting Experience” available at http://www.cms.hhs.gov/pqri/
PQRI Things to Remember
• Patient must have the proper age, diagnosis and that
must be linked to the PQRI codes.
• Codes must be arrayed per measure specifications.
• Patient must meet the age requirement.
• Codes must be reported with the denominator CPT
or HCPCS codes.
• Claims must have an NPI.
• 80% is calculated by NPI.
• Get forms at http://www.amaassn.org/ama/pub/category/17432.html
Coding for E-Prescribing 2009
• You must use a QUALIFIED E-prescribing system AND
• Have an encounter with one of these codes
▫ 90801, 90802, 90803, 90804, 90805, 90806, 90807, 90808,
90809, 92002, 92004, 92012, 92014, 96150, 96151, 96152,
99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213,
99214, 99215, 99241, 99242, 99243, 99244, 99245, G101,
G0108, G0109.
▫ Notice some from original guidelines were removed.
Coding for E-prescribing 2009
• Report on all eligible patients:
▫ G8443--All prescriptions created during the encounter were
generated using an e-prescribing system.
▫ G8445--No prescriptions were generated during the encounter.
Provider does have access to a qualified e-prescribing system.
▫ G8446--Provider does have access to a qualified e-prescribing
system. Some or all prescriptions generated were printed or
phoned in as required by state regulation, patient request, or
pharmacy being able to receive electronic transmission.
Free E-Prescribing in Oncology!
• That’s right!
• Just for cancer
practices!
• www.oncologyerx.com
• For more information,
contact me!
Future Penalties for Not Electronically
Prescribing
• Eligible professionals who are not successfully using
electronic prescribing by 2012 will be penalized 1% of their
covered Medicare Part B charges.
▫ This means that these providers will be paid at 99% for their
covered Medicare Part B fee schedule services.
• Limitation applies as for incentives
• Fee reduction is prospective, providers will have to
electronically prescribe by a date to be determined to be sure
their fees are not reduced in 2012.
• This date will not be before 2010.
• Hardship exemption on a case-by-case basis for small
practices.
Future Penalties for Not Electronically
Prescribing
• In 2013 - 1.5% deducted from their covered
Medicare Part B services.
▫ Professionals will be paid at 98.5% of the
physician fee schedule for covered services.
• In 2014 and beyond penalty will increase to 2%.
▫ Professionals will receive 98% of the physician fee
schedule for the covered services they provide.
Part D Information
• The Secretary has the authority to change the
requirements for successful E-Prescribing in the
future.
• The MIPPA legislation allows for future use of
Part D data in lieu of claims-based reporting by
eligible professionals.
Recovery Audit Contractors (RACS)
• The Centers for Medicare & Medicaid Services (CMS) has updated
its Medicare recovery audit contractor (RAC) expansion schedule
map.
• According to the updated map, CMS intends to now implement the
permanent RAC program in 2 phases. The first phase will begin on
March 1, 2009 and involve about half the country. The second
phase will begin on August 1, 2009 or later.
• On February 6, 2009, CMS announced that the bid protests to the
permanent RAC program have been settled. Prior to the bid
protests, the CMS expansion schedule included 3 phases (with the
first phase beginning on October 1, 2008). However,
implementation was delayed due to the bid protests.
RAC Expansion
Who Else Can Ask For/ Deny/Review
Stuff
•
•
•
•
•
MACs/ Carriers per their own internal screens
CERT Auditors
Medical Integrity Contractors
Bundling and Medically Unlikely Edits
Private Insurance Companies on behalf of MA or
themselves.
Preparing for Review
1. Get personally involved with seeing that charts
are put together correctly.
2. Call the requestor, if you have questions…
3. Copy ALL records involved in the request—
office, hospital, lab.
4. Check for legibility and continuity of charts.
Find unfiled documentation, if that is an issue
5. When in doubt, send more rather than less--but do not send unrelated material.
Preparing for Review
6. Check for correct provider names, dates,
authentication.
7. Send to the correct contractor.
8. Make sure documentation gets there when it is
due. Send by traceable mail (Express, Fedex,
etc)
9. Keep a record of records checked out, why
request was made, and to whom.
Strategies for Success
• Know where your MAC is at as far as anti-emetics. NGS is an
aberration so far.
• Look at when and HOW your individual payers are going to adopt
the new CPT codes.
• Analyze the reasons for rejected, denied, or delayed claims and fix it.
If you do not have an EOB analyzer, you are behind the curve.
• Put together policies and procedures for the RAC coming to your
area.
• Really consider doing PQRI and e-prescribing---4% is nothing to
sneeze at.
• Enforce payments with private payers.
• Audit chemo prospectively; peer review E&M. Physicians must
review consults before it is too late! Transmittal 788, CR 4215
(2005).
• Look at your billing profiles from 10-1-07. Give $$ back before the
RACs collect it for you!
• Participate in the struggle!
Contact Info
• Contact
▫ [email protected]
▫ [email protected]
▫ 800-795-2633
• Newsletter is free!
• E-prescribing is free!
Thank You from onPoint Oncology LLC!