Transcript Changes to Oncology Reimbursement 2009

Changes to Oncology
Coding 2009
Bobbi Buell
Version 7.0
January 2009
Disclaimer
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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 Fee Schedule for 2009
Discuss CPT Changes for 2009
Discuss HCPCS Coding for 2009
Discuss ESA Coding Now
Discuss Coding for PQRI 2009
Discuss Coding for E-Prescribing 2009
Review some E/M Changes for 2008
Review Consult Coding
Discuss What You Need to Do Next
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.
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.

CMS previously applied a separate budget-neutrality adjustment to work
RVUs, but 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
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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
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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:
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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
PECOS
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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.
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On December 1, CMS announced that PECOS is now available in about
20 states, NOT including California.
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Physicians and non-physician practitioners in the District of Columbia and
the States shown above who wish to access Internet-based PECOS may go
to this place to check it out: https://pecos.cms.hhs.gov/pecos/login.do
After Revocation of Billing
Privileges
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The final rule provides that a physician or non-physician
practitioner is not allowed to bill for services furnished after
certain reportable events, including:
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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
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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
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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
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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
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Anti-Markup Provisions (Delayed until 1/1/2009)
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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:
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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.
This means that, if you have a Pathologist who contracts
with your office < 75% of their time, you may not mark up
their fees--TC or PC.
Telehealth Services
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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 followup 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 follow-up
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
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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.
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All Hydration and Therapeutic codes will be “963”
codes instead of “907” codes.
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90761 = 96361
90767 = 96367
90772 = 96372
ETC.
Source: CPT 2009
Crosswalk available at http://www.asco.org
CPT Changes 2009
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The Chemotherapy Section name has
changed to “Chemotherapy or Highly
Complex Drug or Highly Complex Biologic
Agent” Administration
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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
HCPCS Changes 2009
(1/1/2009)
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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
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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
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Changed Descriptors
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
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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
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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.
MIPPA Legislation – PQRI, Section
131
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PQRI 2009 incentive provided and raised to 2%
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Eligible professionals shall be paid 2% incentive of
estimated allowable charges submitted not later than 2
months after the end of the reporting period for 2009
quality measures.
Adds qualified audiologists in the definition of
eligible professionals.
No effect on 2007 or 2008 incentive payments.
Registries
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CMS received over 55 self-nomination requests for
registries to become “qualified” to submit quality
data for possible incentive payment on behalf of
their clients.
32 registries have been selected for “production”
(eligible to earn a payment incentive for their
providers)
The final list of “qualified” registries is posted on the
PQRI website at:
http://www.cms.hhs.gov/PQRI/20_Reporting.asp#To
pOfPage and go to the first download (“2008 List of
Qualified Registries”)
Registries
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Becoming a “qualified” registry is not a
guarantee by CMS that the registry will be
successful submitting data on behalf of their
clients.
These registries, however, have gone
through a complete evaluation of their
measure calculations and a test that their
system can successfully communicate with
our data warehouse.
6 Registry-Based Options
Reporting Period:
January 1, 2008 December 31, 2008
Reporting Period:
July 1, 2008 –
December 31, 2008
Individual Measures:
80% of applicable cases
Minimum 3 measures
Individual Measures:
80% of applicable cases
Minimum 3 measures
One Measures Group:
30 consecutive patients
OR
80% of applicable cases
One Measures Group:
15 consecutive patients
OR
80% of applicable cases
Do You Want to Use a
Registry?
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Depends upon the measures that you use.
Must be a registered registry with CMS and
approved for submission.
Must successfully report in 2008. This can
be a mystery right now. Not really known until
after 3/31/2009.
May charge you, so is it cheaper than doing it
claim by claim?
Hematology-Oncology
Measures 2009
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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
Coding #71 2008
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Coding Example--Measure #71 Hormonal Therapy for Stage IC-III. ER/PR + Breast CA
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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.
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Tamoxifen/AI Prescribed (Three CPT II Codes [4179F & 33xxF & 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 [3302F OR 3303F OR
3312F or 3316F]
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 [3305F-8P or 3316F-8P ONLY]
Denominator Coding
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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)
PQRI Measure #71 Changes
for 2009

Coding Changes
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Different instructions
Deleted: 3302F, 3303F, 3305F, 3306F, 3307F, 3309F,
3310F, 3311F, 3312F
Added:

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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 cm2cm
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.
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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
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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
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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
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
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
MIPPA Legislation – Successful
Electronic Prescriber, Section 132



The MIPPA provides for a 2% incentive payment to eligible
professionals who successfully prescribe (as defined by the
statute) their patient’s medications electronically beginning in
2009.
E-Prescribing measure will be removed from PQRI for 2009 and
added to the E-Prescribing incentive program as a stand-alone
benefit.
The Secretary has the authority to update the specifications of
the electronic prescribing measure in the future.
2008 PQRI – E-Prescribing Measure



Electronic Prescribing Structural Measure
(measure #125) qualifies as one of three
required measures in PQRI to earn an
incentive payment.
Requirement for 2008 PQRI is to report the
measure on 80% or more of eligible patients
BUT this goes to 50% in 2009.
No separate incentive for successful EPrescribing in 2008 PQRI
Qualified Electronic Prescribing
Systems – 2009


The measure assesses eligible professional’s use of
electronic prescribing using a qualified system.
As a qualified system, the program must be able to
perform the following tasks:
 Communicate with the patient’s pharmacy;
 Help the physician identify appropriate drugs and
provide information on lower cost alternatives for
the patient;
 Provide information on formulary and tiered
formulary medications; and
 Generate alerts about possible adverse events,
such as improper dosing, drug-to-drug interactions,
or allergy concerns.
Successful Reporting of the eRx
Measure for 2009


The measure is intended to be reported on for
EVERY patient visit in the denominator.
Successful reporting is defined as reporting the
measure on at least 50% of eligible patients or an
amount of electronic submission of claims under
Part D.

Limitation: CPT codes that make up the denominator
MUST account for at least 10% of the provider’s total
allowed charges for Medicare Part B covered services OR
a parameter of claims NOT submitted to Part D (not in
2009).
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 2008-2009

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.
Should You Go For It?

Let’s say you are a single Medical Oncologist
AND you want to know whether or not to go
for both incentives for your NPI




Your E/M revenue is $325,000
Your drug administration revenue, plus other
procedures is $275,000
Your Medicare % is 50%
Your PQRI plus E-Rx bonus would be $12,000.
Info Sources for ESAs…

View the policy itself at


View CMS FAQs


http://www.ascofoundation.org/portal/site/ASCO/menuitem.5d1b
4bae73a9104ce277e89a320041a0/?vgnextoid=24be6e750752
3110VgnVCM100000ed730ad1RCRD
View CMS Transmittals R1412, R1413, R80NCD at


http://www.cms.hhs.gov/mcd/ncpc_view_document.asp?id=12
View ASCO FAQs


http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=203
http://www.cms.hhs.gov/Transmittals/2008Trans/list.asp
View American Society of Hematology Guidelines (ASH) at

http://www.hematology.org/policy/practice/01242008.cfm
ESA/Anemia Billing Summary




If the patient has cancer and is on chemotherapy, submit the
“most recent” hemoglobin must be <10 (or Hct < 30%). Bill the H
or H results and use -EA. Follow Carrier guidelines for diagnosis
coding.
If the patient is on Radiotherapy, submit the latest H or H result,
use -EB, and get denied.
If the patient does not have chemotherapy-induced anemia (or
ESRD), submit the latest H or H, use -EC, and follow your
Carrier’s guidelines for coding and billing.
If the patient has cancer and is on an anemia drug which is not
self-administered, submit the latest H or H result. All other
guidelines are at Carrier discretion.
© 2008, RemitDATA, Inc. ALL RIGHTS RESERVED.
Drugs as % of Total
Reimbursement
72.7%
73.0%
72.0%
71.0%
69.7%
70.0%
69.0%
67.1% 66.6%
68.0%
66.9%
67.0%
66.0%
65.0%
64.0%
63.0%
Q1
Q2
Commercial
© 2008, RemitDATA, Inc. ALL RIGHTS RESERVED.
Q3
Medicare
66.3%
Drug Revenue as Multiple
of E&M Revenue
6.5
Q3
7.7
7.0
Q2
10.3
9.6
Q1
10.8
0
2
4
Medicare
© 2008, RemitDATA, Inc. ALL RIGHTS RESERVED.
6
8
Commercial
10
12
ESA as % of Total Drugs Paid
24.1%
25.0%
20.0%
14.2%
14.8%
15.0%
8.7%
10.0%
7.9%
8.4%
Q2
Q3
5.0%
0.0%
Q1
Commercial
© 2008, RemitDATA, Inc. ALL RIGHTS RESERVED.
Medicare
Medicare ESA Denial
Rates/Reasons
J0881 – Darbepoetin
Q3 Denial Rate – 26.7%
Most Common Denial Codes
Others
8%
50
38%
J0885 – Epoetin Alpha
Q3 Denial Rate – 28.1%
Most Common Denial Codes
Others
7%
11
2%
11
3%
4
4
8%
12%
18
12%
16
20%
18
23%
© 2008, RemitDATA, Inc. ALL RIGHTS RESERVED.
16
29%
50
37%
Commercial ESA Denial
Rates/Reasons
J0881 – Darbepoetin
Q3 Denial Rate – 16.5%
J0885 – Epoetin Alpha
Q3 Denial Rate – 9.1%
Most Common Denial Codes
Others
22%
18
38%
Most Common Denial Codes
Others
24%
18
30%
29
4%
4
50
5%
9%
96
10%
50
96
12%
16
16%
15%
© 2008, RemitDATA, Inc. ALL RIGHTS RESERVED.
16
17%
ESA Medicare Denial Results
Q3

What does this mean?

Medical necessity is #1 problem




Missing Information



Lack of knowledge of guidelines/ NCD
Poor review of LCDs
H/H dropping off claims---still!
H/H for all non-ESRD claims
Clearinghouse/formatting problems
Modifier confusion is an area of improvement.
© 2008, RemitDATA, Inc. ALL RIGHTS RESERVED.
ESA DSO COMPARISON
79
80
74
63
70
60
47
50
40
30
20
10
0
J0881 - Darbepoetin
Medicare Q3
© 2008, RemitDATA, Inc. ALL RIGHTS RESERVED.
J0885 - Epoetin Alpha
Commercial Q3
Medicare: Hospital Discharge
Day

Transmittal #1460, CR #5794, effective 4/1/2008





A Hospital Discharge Day service (99238-99239) is a face-toface service between the attending physician and the patient.
Only the attending physician of record shall report 99238-99239.
Other providers shall report subsequent hospital services (9923199233), if they perform concurrent services.
Reporting of the service is on the calendar day of the visit, even if
it differs from the discharge date.
Report only one discharge service (99238-99239) per patient per
stay. Do NOT report discharge services and subsequent services
the same date.
Discharge services may be billed for pronouncement of death on
the date of death.
Medicare: Inpatient/ Observation

Transmittal #1466, CR 5791

Initial Hospital Observation Services (CPT codes 99218-99220) and Observation Care Discharge
Services (99217)




When the observation care is less than 8 hours on the same calendar date report
an Initial Observation Care code. Do not report an Observation Care Discharge
Service.
When the patient is admitted for observation care and discharged on a different
calendar date report an Initial Observation Care and an Observation Care
Discharge.
In those rare instances when a patient is held in observation care status for more
than two calendar dates report an Office or Other Outpatient Visit (CPT 9921199215) for a visit before the discharge date.
The medical record must include documentation that:




Satisfies E/M guidelines for admission to and discharge from observation care to inpatient
hospital care.
Identifies the billing physician/NPP was present and personally performed the services
Indicates the number of hours that the patient remained in the observation care status
Identifies the admission and discharge notes were written by the billing physician/NPP
Medicare: Prolonged Services




On April 14, 2008, CMS issued Transmittal 1490CP, Change Request 5972,
Effective Date is June 2, 2008(meaning that’s when you are responsible for
it) with an Implementation Date of July 7, 2008
These services (99354-99355) are payable when billed on the same day
(and, on the same claim) as the companion evaluation and management
codes. Again, the time for the service refers to the typical/average time
units associated with the companion evaluation and management service
as noted in the CPT code.
Each additional 30 minutes of direct face-to-face patient contact
following the first hour of prolonged services may be reported by CPT
code 99355.
Prolonged service of less than 30 minutes total duration on a given
date is not separately reported because the work involved is included
in the total work of the evaluation and management codes. So, using
our 99213 example, you would not report anything of less than 45 minutes,
as that time frame is 30 minutes past the average visit time per CPT.
Medicare Prolonged Services






Code 99355 or 99357 may be used to report each additional 30 minutes beyond the first hour of prolonged
services, based on the place of service. These codes may be used to report the final 15 – 30 minutes of
prolonged service on a given date, if not otherwise billed. Prolonged service of less than 15 minutes beyond the
first hour or less than 15 minutes beyond the final 30 minutes is not reported separately.
Companion Codes must be correct in terms of pairing with Prolonged Services or claims for these codes will not
be paid…

The companion evaluation and management codes for 99354-99355 are the Office or Other Outpatient visit
codes (99201 - 99205, 99212 –99215), the Office or Other Outpatient Consultation codes (99241 – 99245),
the Domiciliary, Rest Home, or Custodial Care Services codes (99324 – 99328, 99334 – 99337), the Home
Services codes (99341 - 99345, 99347 – 99350); and/or

The companion evaluation and management codes for 99356-99357 are the Initial Hospital Care codes
(99221 - 99223, 99231 – 99233), the Inpatient Consultation codes (99251 – 99255); Nursing Facility Services
codes (99304 -99318).
There is a requirement for physician (or NPP) presence. Physicians may count only the duration of direct face-toface contact between the physician and the patient (whether the service was continuous or not) beyond the
typical/average time of the visit code billed to determine whether prolonged services can/cannot be billed and to
determine the prolonged services codes that are allowable.
Documentation is required in the medical record regarding the duration and content of the medically necessary
evaluation and management service and prolonged services billed. According to the Transmittal “the start and end
times of the visit shall be documented in the medical record along with the date of service.)”
Counseling/coordination of care can necessitate use of Prolonged Services---but you must use the highest level of
the code set involved first, e.g. 99215, 99245.
Medicare will not pay prolonged services codes 99358 and 99359, which do not require any direct patient face-toface contact (e.g., telephone calls).
Medicare Consultations
(Medicare)

Transmittal 788, CR #4215, December 2005
 No shared visits for consultations in either office or hospital. Either the NPP or
MD should charge for the consult. This is black and white in the transmittal.
 3 R’s have been more formalized and one has been added…







REQUEST from another physician for consultant’s opinion 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 in the
medical record.
Opinion RENDERED by the consultant with RECOMMENDATIONS for
treatment.
REPORT goes back to the referring physician.
99211 may not be used for a consult.
NO SPLIT OR SHARED VISITS!!!!!!!!
Consultations

Consultations (Cont’d)
 Consultations may be billed based on time for
counseling/coordination of care, but an opinion must
be rendered.
 Also, if care is continuous before the consult for the
same/original problem, an additional consult may
not be billed.
 Only ONE consultation may be billed per inpatient
stay.
Consultations
Transfer of Care

A transfer of care occurs when a physician or NPP requests that another physician or
NPP take over the responsibility for managing the patient’s complete care for the
condition, and does not expect to continue treating or caring for the patient for that
condition.

When this transfer is arranged, the requesting provider is not asking for an opinion or
advice to personally treat this patient and is not expecting to continue treating the
patient for the condition. The receiving physician or NPP shall document this transfer
of the patient’s care in the patient’s medical record or plan of care.

If a transfer of care occurs, report the appropriate new or established patient visit
code should be billed based on place of service.

51 Specialty Societies have objected to this language (including the AMA, ASCO, and
ASH), but this Transmittal is still in effect and has been the Medicare rule since
1/1/2006.
Consult vs. Referral (Not
Official)
Referral
Consult
Diagnosis and/or treatment known at
the time of the referral for a new or
existing problem.
Referring physician wants to ascertain
differential diagnoses and/or
treatments for the patient for a new
problem. Documents the consultation
request as part of their treatment plan.
Treatment known at the time of the
referral with or without report by
consultant.
Treatment plan to be communicated
by report by consultant to the referring
physician.
Referring physician does not expect to
further treat the patient for this
particular diagnosis.
Referring physician will continue to
treat the patient after the consultation.
Referring physician out of the picture.
Consultant generates a report with
their opinion and plan for treatment
and may update the referring
physician periodically .
COMMERCIAL PAYOR DSO
60
50
53
42
43
41
39
40
30
20
10
AETNA
BCBS
© 2008, RemitDATA, Inc. ALL RIGHTS RESERVED.
CIGNA
UNITED
HEALTH
OTHER
COMMERCIAL DSO BY
CATEGORY
45
45
46
44
43
42
40
40
38
38
36
34
CHEMO
DRUGS
© 2008, RemitDATA, Inc. ALL RIGHTS RESERVED.
E&M
Others
RADONC
Commercial
© 2008, RemitDATA, Inc. ALL RIGHTS RESERVED.
What’s Going On? Commercial





Duplicate Claims 32.1%
Unbundling 20.1%
Missing information 11.2%
Initial Procedure Not Billed 4.0%
Expenses Incurred After Coverage
Terminated 3.7%
© 2008, RemitDATA, Inc. ALL RIGHTS RESERVED.
MEDICARE
© 2008, RemitDATA, Inc. ALL RIGHTS RESERVED.
Biggest Problems--Medicare





44.7% Duplicate Claims
19.8% Missing Information
6.1% Medical Necessity
5.9% Initial Procedure Not Billed
5.0% Provider Not Eligible on This Date of Service
© 2008, RemitDATA, Inc. ALL RIGHTS RESERVED.
Strategies for Success







Look at when 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.
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. 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!