Transcript Advanced Workshop for Oncology Regulations, Billing and

Whitewater Management
Successfully Navigating Oncology
Management in Turbulent Times
Disclaimer
• This should not be the only source used for coding and billing.
All coding and billing decisions should be made on a case-bycase basis based upon documentation and insurance guidelines.
• All information contained herein is valid for the date of this
seminar only. This presentation is based on national guidelines.
Your Medicare Carrier may differ.
• Many coding guidelines are currently unknown. Check your
Carrier’s web sites as often as possible for changes.
• This presentation is a summary only. For Medicare
regulations, see www.cms.hhs.gov or your local Medicare web
site.
• Nothing in this presentation instructs practices on how to set
charges for products and services.
7/16/2015
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Meeting Agenda
•
•
•
•
•
•
•
Medicare Regulations 2005-2006: Part B Office
Medicare Drug Admin Coding 2005-2006
Other Medicare Initiatives 2005-2006
ICD-9-CM for 2006
Commercial Insurance Changes 2005
Survival Strategies 2005-2006
Ready! Set! Go for 2006!
7/16/2015
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Medicare Regulations
2005-2006
Office Based Oncology
Presentation References
• Medicare Physician Fee Schedule Final Rule,
November 15, 2004 and Proposed Rule for 2006
• Transmittals
 #129-OTN, 12/10/04
 #14, CR 3670, 12/30/04
 #148, 4/15/05
• ASCO (www.asco.org)
 Special alerts
 Presentations
• AMA Posting of Codes for 2006
7/16/2015
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Medicare Fee Schedule
Review
•
•
•
•
•
Work RVUs
Practice Expense RVUs
Malpractice RVUs
GPCIs
Conversion Factor
((WRVUs *WGPCI)+(PERVUs * PEGPCI)+
(MALRVUs * MALGPCI)) X The Conversion
Factor =
Medicare Fee Schedule Amount
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Medicare Physician Fee
Schedule
• Medicare Conversion Factor Bumped Up
 $37.8975 is the CF—published 11/15/04 and effective 1/1/05.
• 2006 Conversion Factor
• Still slated to decrease 4.3%
 Impacts 875,000 physicians
 Caused by the SGR sometimes known as the Medicare
boomerang
 Includes Part B drugs, which are not a fee schedule item.
For physicians that give drugs, this is the double hit.
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Medicare Fee Schedule 2006
• Proposed Rule: Impact on Oncologists
 Rule states an 8.1% increase in revenue based upon
VOLUME INCREASE
 The real truth about profit
• 4.3% decrease due to the conversion factor for all fee schedule
services
• 3.0% gross decrease (for drug admin) due to drug
administration transition
• 15.0% decrease due to lack of Demo
• So far, very few RVU changes in drug administration
• CMS projects this to be a 5.6% decrease overall in the the PR.
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Proposed Regulations
• Other components
 Multiple imaging codes -TC component will be
reduced by 50%
• These codes must fall into the same “family”
• MRI, MRA, CT, CTA, Ultrasound
• Hard on physicians that own their own
equipment/free-standing imaging
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Proposed Regulations
• Other Components
 Application of Stark to Nuclear Medicine in
office
• Group practice exceptions apply as they do in other
ancillary services.
• Check with your attorney if you are in a Joint
Venture.
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Proposed Regulations
• Other components
 ASP drug pricing tightened up. Will reportedly have no impact overall
revenue (according to CMS). But, studies by the Office of Inspector
General are ongoing for market pricing. Thus, some drug pricing will
change based on this formula:
• FOR SINGLE SOURCE DRUGS, the ASP will be the lower of
ASP plus 6% or WAC plus 6%.
• For BOTH single source drugs and multi-source, ASP will be
compared to WAMP or AMP. In 2005, if the ASP exceeds WAMP
or AMP by 5%, the payment will be the lesser of WAMP or 103%
of AMP. In 2006, this threshold will change…
 Opting out of Medicare provisions are shored up in terms of penalties.
Opting out is not really an option for many (if any practices)
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Recent Developments
• OIG Report: Adequacy of Medicare Part B Drug
Reimbursement to Physician Practices for the
Treatment of Cancer Patients – September 2005
• House Resolution 261 that urged CMS to extend
the oncology demonstration project beyond 2005
passed October 6, 2005
• OIG report in response to Grassley letter states
“concerns re: cost, beneficiary liability, utility of
data collected, and perceived disparity between
level of physician reimbursement & services
provided.” October 14, 2005
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Coding for Cancer Services
2005
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Medicare Physician Fee
Schedule
• 2005 Drug Administration Coding (Revised 4/15/2005,
effective 3/15/05)
 General Principals
• One INITIAL code per day is the one that best describes the
service that the patient is having that day.
• Before/after infusions and pushes must always be categorized as
SEQUENTIAL or concurrent to sequential.
• Hours following EACH infusion’s initial hour must start over 30
minutes.
• Any infusion 15 OR LESS minutes is a push.
• One concurrent code per day (G0350) as of 5/16/05, but start now!
The regulation is effective 3/15/05.
• Port flushes are billable IF they are the only service of the day!
(G0363)
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New Drug Administration
Coding
• Current Issues and Mysteries
 Billing of concurrent drugs with chemo
 Billing of concurrent non-chemo drugs
 Unbundling edits CCI Version 11.1--will other
things like this happen?
7/16/2015
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Coding for Therapeutic
Infusions
2005 Code
2006
Code
Description
2005
Transitional
Payment
G0345
90760
Initial Infusion, hydration, up to
one hour
$64.80
G0346
90761
Hydration, next 1-8 hours
$20.68
G0347
90765
IV infusion for
therapy/diagnosis, up to one
hour
$79.24
G0348
90766
IV infusion, next 1-8 hours
$26.54
G0349
90767
IV infusion, additional sequential $43.72
infusion, up to one hour
G0350
90768
IV infusion, concurrent infusion
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$25.37
16
Therapeutic
Injections/Pushes
2005
Code
2006
Code
Description
2005
Transitional
Payment
G0351
90772
Therapeutic or diagnostic
injection
$19.13
G0353
90774
IV push, non-chemo, single or
initial
$58.95
G0354
90775
IV push, each additional
sequential push
$27.71
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Chemotherapy
Injections/Pushes
2005 Code
2006
Code
Description
2005
Transitional
Payment
G0355
96401
Chemotherapy
administration, sc or im nonhormonal
$53.09
G0356
96402
Chemo admin, sc or im,
hormonal
$36.69
G0357
96409
Chemotherapy, IV push,
initial or single
$125.69
G0358
96411
Chemotherapy, IV push,
each additional substance
$73.00
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Chemotherapy Infusions
2005 Code
2006 Code
Description
2005
Transitional
Payment
G0359
96413
Chemotherapy,
intravenous, single or
initial drug, up to one
hour
$177.61
G0360
96415
Each additional 1-8
hours
$40.21
G0361
96416
Initiation of prolonged
infusion
$190.88
G0362
96417
Each additional
$86.66
sequential infusion, up to
one hour
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Miscellaneous Chemo
Procedures
2005 Code
2006 Code
Description
2005
Transitional
Payment
G0363
96523
Irrigation of a Venous
Access Device, billed when
no other drug delivery
service is performed that day
(T-status)
$28.88
96520
96521
Refilling and/or maintenance $157.31
of a portable pump
96530
96522
Refilling and maintenance of
an implanted pump
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$113.59
20
2006 Code Descriptions
Hydration, Therapeutic, Prophylactic, and Diagnostic/Injections and Infusions
Diagnostic Injections and Infusions (Excludes Chemotherapy)
Physician work related to hydration, injection, and infusion services predominantly involves affirmation
of treatment plan and direct supervision of staff.
If a significant separately identifiable Evaluation and Management service is performed, the appropriate
E/M service code should be reported using modifier 25 in addition to 90760-90779. For same day
E/M service a different diagnosis is not required.
If performed to facilitate the infusion or injection, the following services are included and are not reported
separately:
a. Use of local anesthesia
b. IV start
c. Access to indwelling IV, subcutaneous catheter or port
d. Flush at conclusion of infusion
e. Standard tubing, syringes, and supplies
(For declotting a catheter or port, see 36550)
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2006 Code Descriptors
• Hydration, Therapeutic Injections and Infusions
When multiple drugs are administered, report the service(s) and the specific materials or drugs for each.
When administering multiple infusions, injections or combinations, only one “initial” service code
should be reported, unless protocol requires that two separate IV sites must be used. The “initial” code
that best describes the key or primary reason for the encounter should always be reported irrespective of the
order in which the infusions or injections occur. If an injection or infusion is of a subsequent or concurrent
nature, even if it is the first such service within that group of services, then a subsequent or concurrent code
from the appropriate section should be reported (eg, the first IV push given subsequent to an initial one-hour
infusion is reported using a subsequent IV push code).
When reporting codes for which infusion time is a factor, use the actual time over which the infusion is
administered.
7/16/2015
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2006 Code Descriptors
• Hydration
Codes 90760-90761 are intended to report a hydration IV infusion to consist of a pre-packaged
fluid and electrolytes (eg, normal saline, D5-½ normal saline+30mEq KCl/liter), but are not used to
report infusion of drugs or other substances. Hydration IV infusions typically require direct physician
supervision for purposes of consent, safety oversight, or intraservice supervision of staff. Typically
such infusions require little special handling to prepare or dispose of, and staff that administer these
do not typically require advanced practice training. After initial set-up, infusion typically entails
little patient risk and thus little monitoring.
90760 Intravenous infusion, hydration; initial, up to 1 hour
(Do not report 90760 if performed as a concurrent infusion service)
90761 each additional hour, up to 8 hours (List separately in addition to code for primary
procedure)(Use 90761 in conjunction with 90760)
(Report 90761 for hydration infusion intervals of greater than 30 minutes beyond 1 hour
increments)
(Report 90761 to identify hydration if provided as a secondary or subsequent service after a
different initial service [90760, 90765, 90774, 96409, 96413] is provided)
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Code Descriptors 2006
Therapeutic, Prophylactic, and Diagnostic
Injections and Infusions
A therapeutic, prophylactic, or diagnostic IV infusion or injection (90765-90799) (other
than hydration) is for the administration of substances/drugs. The fluid used to
administer the drug(s) is incidental hydration and is not separately reportable.
These services typically require direct physician supervision for any or all purposes of
patient assessment, provision of consent, safety oversight, and intra-service supervision
of staff. Typically, such infusions require special consideration to prepare, dose or
dispose of, require practice training and competency for staff who administer the
infusions, and require periodic patient assessment with vital sign monitoring
during the infusion.
Intravenous or intra-arterial push is defined as: a) an injection in which the health
care professional who administers the substance/drug is continuously present to
administer the injection and observe the patient, or b) an infusion of 15 minutes or
less.(Do not report 90765-90779 with codes for which IV push or infusion is an inherent part of the
procedure (eg, administration of contrast material for a diagnostic imaging study)
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Code Descriptors 2006
• Therapeutic, Prophylactic, and Diagnostic Injections and Infusions
90765
Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify
substance or drug); initial, up to 1 hour
90766
each additional hour, up to 8 hours (List separately in addition to code
for primary procedure)
(Report 90766 in conjunction with 90765, 90767)
(Report 90766 for additional hour(s) of sequential infusion)
(Report 90766 for infusion intervals of greater than 30 minutes
beyond 1 hour increments)
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New Codes 2006
Therapeutic, Prophylactic, and Diagnostic Injections and
Infusions
90767
additional sequential infusion, up to 1 hour (List separately in addition
to code for primary procedure)
(Report 90767 in conjunction with 90765, 90774, 96409, 96413 if
provided as a secondary or subsequent service after a different
initial service. Report 90767 only once per sequential infusion of
same infusate mix)
90768
concurrent infusion (List separately in addition to code for primary
procedure)
(Report 90768 only once per encounter)
(Report 90768 in conjunction with 90765, 96413)
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Code Descriptors 2006
• Therapeutic, Prophylactic, and Diagnostic
Injections and Infusions
90772
90773
7/16/2015
Therapeutic, prophylactic or diagnostic injection (specify substance or
drug); subcutaneous or intramuscular
(For administration of vaccines/toxoids, see 90465-90466, 9047190472)
(Report 90772 for non-antineoplastic hormonal therapy injections)
(Report 96401 for anti-neoplastic nonhormonal injection therapy)
(Report 96402 for anti-neoplastic hormonal injection therapy)
(Do not report 90772 for injections given without direct physician
supervision. To report, use 99211)
intra-arterial
(90799 has been deleted. To report, use 90779)
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Code Descriptors 2006
• Therapeutic, Prophylactic, and Diagnostic
Injections and Infusions
90774
90775
90779
intravenous push, single or initial substance/drug
(90772-90774 do not include injections for allergen immunotherapy. For
allergen immunotherapy injections, see 95115-95117)
each additional sequential intravenous push of a new substance/drug (List
separately in addition to code for primary procedure)
(Use 90775 in conjunction with 90765, 90774, 96409, 96413)
(Report 90775 to identify intravenous push of a new substance/drug if
provided as a secondary or subsequent service after a different initial
service is provided)
Unlisted therapeutic, prophylactic or diagnostic intravenous or intra-arterial
injection or infusion
(For allergy immunizations, see 95004 et seq)
(90780 and 90781 have been deleted. To report, see 90760, 90761, 90765-90768)
(90782 has been deleted. To report, use 90772)
(90783 has been deleted. To report, use 90773)
(90784 has been deleted. To report, use 90774)
(90788 has been deleted. To report, use
7/16/2015
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New Code Descriptors 2006
• Chemotherapy Administration
Chemotherapy administration codes 96401-96549 apply to parenteral administration of nonradionuclide anti-neoplastic drugs; and also to anti-neoplastic agents provided for treatment of
non-cancer diagnoses (eg, cyclophosphamide for auto-immune conditions) or to substances such
as monoclonal antibody agents, and other biologic response modifiers. These services can be
provided by any physician. Chemotherapy services are typically highly complex and require direct
physician supervision for any or all purposes of patient assessment, provision of consent, safety
oversight and intra-service supervision of staff. Typically, such chemotherapy services require
advanced practice training and competency for staff who provide these services; special
considerations for preparation, dosage or disposal; and commonly, these services entail
significant patient risk and frequent monitoring. Examples are frequent changes in the infusion
rate, prolonged presence of nurse administering the solution for patient monitoring and
infusion adjustments, and frequent conferring with the physician about these issues.
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New Code Descriptors 2006
• Chemotherapy Administration
If performed to facilitate the infusion or injection, the following services are included and are
not reported separately:
a. Use of local anesthesia
b. IV start
c. Access to indwelling IV, subcutaneous catheter or port
d. Flush at conclusion of infusion
e. Standard tubing, syringes and supplies
f. Preparation of chemotherapy agent(s)
(For declotting a catheter or port, use 36550)
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Code Descriptors 2006
• Chemotherapy Administration
Report separate codes for each parenteral method of administration employed when chemotherapy is
administered by different techniques. The administration of medications (eg, antibiotics, steroidal
agents, anti-emetics, narcotics, analgesics) administered independently or sequentially as supportive
management of chemotherapy administration, should be separately reported using 90760, 90761,
90765, 90779 as appropriate.
Report both the specific service as well as code(s) for the specific substance(s) or drug(s) provided. The fluid used to
administer the drug(s) is considered incidental hydration and is not separately reportable.
When administering multiple infusions, injections or combinations, only one "initial" service code should be reported,
unless protocol requires that two separate IV sites must be used. The “initial” code that best describes the key or
primary reason for the encounter should always be reported irrespective of the order in which the infusions or
injections occur. If an injection or infusion is of a subsequent or concurrent nature, even if it is the first such
service within that group of services, then a subsequent or concurrent code from the appropriate section should
be reported (eg, the first IV push given subsequent to an initial one-hour infusion is reported using a
subsequent IV push code).
When reporting codes for which infusion time is a factor, use the actual time over which the infusion is administered
7/16/2015
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Code Descriptors 2006
Injection and Intravenous Infusion
Chemotherapy
•
Intravenous or intra-arterial push is defined as: a) an injection in which
the healthcare professional who administers the substance/drug is
continuously present to administer the injection and observe the patient,
or b) an infusion of 15 minutes or less.
96401
Chemotherapy administration, subcutaneous or intramuscular;
non-hormonal anti-neoplastic
96402
7/16/2015
(96400 has been deleted. To report, see 96401, 96402)
hormonal anti-neoplastic
96405
Chemotherapy administration, intralesional; intralesional, up
to and including 7 lesions
96406
intralesional, more than 7 lesions
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Code Descriptors 2006
• Injection and Intravenous Infusion
Chemotherapy
96409
intravenous, push technique, single or initial substance/drug
(96408 has been deleted. To report, use 96409)
96411
intravenous, push technique, each additional substance/drug (List
separately in addition to code for primary procedure)
(Use 96411 in conjunction with 96409, 96413)
(96412 has been deleted. To report, use 96415)
7/16/2015
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Code Descriptors 2006
• Injection and Intravenous Infusion
Chemotherapy
96413
Chemotherapy administration, intravenous infusion technique; up to 1
hour, single or initial substance/drug
(96410 has been deleted. To report, use 96413)
(96414 has been deleted. To report, use 96416)
96415
each additional hour, 1 to 8 hours (List separately in addition
to code for primary procedure)
(Use 96415 in conjunction with 96413)
(Report 96415 for infusion intervals of greater than 30 minutes
beyond 1-hour increments)
(Report 90761 to identify hydration, or 90766, 90767, 90775 to identify
therapeutic, prophylactic, or diagnostic drug infusion or injection, if
provided as a secondary or subsequent service in association with 96413)
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Code Descriptors 2006
Injection and Intravenous Infusion Chemotherapy
Code 96523 does not require direct physician supervision. Codes 96521-96523
may be reported when these devices are used for therapeutic drugs other than
chemotherapy
96521
Refilling and maintenance of portable pump
(96520 has been deleted. To report, use 96521)
96522
Refilling and maintenance of implantable pump or reservoir for drug
delivery, systemic (eg, intravenous, intra-arterial)
(For refilling and maintenance of an implantable infusion pump for spinal or
brain drug infusion, use 95990-95991)
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Code Descriptors 2006
Injection and Intravenous Infusion Chemotherapy
96523
Irrigation of implanted venous access device for drug delivery systems
(Do not report 96523 if an administration or E& M service is provided on
the same day)
(For collection of blood specimen from a completely implantable venous access
device, use 36540)
(96530 has been deleted. To report, use 96523)
96542
Chemotherapy injection, subarachnoid or intraventricular via subcutaneous
reservoir, single or multiple agents
(96545 has been deleted)
(For radioactive isotope therapy, use 79005)
(96545 has been deleted)
(For radioactive isotope therapy, use 79005)
96549
7/16/2015
Unlisted chemotherapy procedure
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Probable EM Changes 2006
•
CPT at last has decided to entirely eliminate the problematic
follow-up
 inpatient consult codes (99261-99263) and
 confirmatory consult codes (99271-99275). Starting Jan. 1,
2006, we’ll be left with only the office/outpatient consults (9924199245) and initial inpatient consults (99251-99255), which remain
unchanged.
Will you still be allowed to use inpatient consult codes 9925x only
once per admit? If so, will you be required to use the subsequent
hospital care codes 99231-99233 for any follow-up visits?
Remember that CPT and many payers have long said to use the
subsequent care codes if the consultant takes over management of
any part of the patient’s care.
 Source: Decision Health
7/16/2015
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Probable EM Changes
•
Nursing facility codes (99301-99313) and domiciliary/rest home codes
(99321-99333) also have been deleted. They’ve been replaced with expanded
code families that more clearly break out straightforward-, low-, moderate- and
high-complexity medical decision-making. In CPT 2006 you’ll see:
• 3 codes for “initial nursing facility care, per day” (99304-99306);
• 4 codes for “subsequent nursing facility care, per day” (99307-99310);
• 1 code for “E/M of a patient involving an annual nursing facility
assessment” (99318);
• 5 codes for “domiciliary or rest home visit for the evaluation and
management of a new patient” (99324-99328)
• 4 codes for “domiciliary or rest home visit for the evaluation and
management of an established patient” (99334-99337); and
• 2 monthly codes for “individual physician supervision of a patient (patient
not present) in home, domiciliary or rest home …” (99339-99340).

7/16/2015
Source: Decision Health
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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
• Hydration infusion confusion
• Assorted administration code omissions
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Initial 2006 Administration
Codes
90760
Hydration IV infusion, 1st h
$62.86
90765
Therapeutic IV infusion, 1st h
$76.86
90744
Therapeutic IV injection
$57.18
96409
Chemo IV push
$121.92
96413
Chemo IV infusion, 1st h
$172.27
7/16/2015
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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.”
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Port Flush Billing Procedures
• Check with your carrier to see if 96523 is
payable with lab
• Do not use 90774 for port access
• Schedule your patients for port flush on a
separate day than physician visit
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Hydration Infusion Confusion
“Codes 90760-90761 are intended to
report a hydration IV infusion to consist of a
pre-packaged fluid and/or electrolyte
solutions (eg, NS, D51/2NS + 30 meq
KCL/ltr), but are not used to report infusion
of drugs or other substances.”
7/16/2015
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Hydration Billing Procedures
• Use 90761 for hydration given sequential to either
chemotherapy or therapeutic infusion with the -59
modifier
• Use 90761 if hydration is sequential and extends
beyond 30 minutes or use multiples if hydration is
only service of the day and extends over 1 hour
and 30 minutes
• Do not bill for 90761 when hydration is
concurrent with the chemotherapy or therapeutic
infusion
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Commission of Omissions
• No initial code for date of service
• Omitted multiple hours for sequential
infusions
• Omitted concurrent infusions
• Incorrect units for drugs with new HCPCS
codes
7/16/2015
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MMA Initiatives
•
•
•
•
CAP (Competitive Acquisition Program)
Part D Medicare
Electronic Medical Record
The Cancer Demonstration Project
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Part D Medicare
• Why should you care?
 Injectable drugs can be on multiple formularies-patients may see their obligation as being less under
Part D, if they do not have Medigap.
 More patients will sign up for Medicare Advantage,
which will not benefit physicians necessarily.
 Patients will ask you!!!
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Part D Medicare
• The Basics
 Patients must enroll--not automatic!
 Coverage
•
•
•
•
•
Deductible = $250
Premium (estimate)= $32.20
Up to $2250 with 25% Co-pay
$2850 out of pocket
Then, at $5100, Medicare kicks in at 95% or a low
per prescription rate
 Differs for poor beneficiaries
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Compare Plans
• Assumptions
 Patients will pay the premiums anyway. These
are not part of the analysis.
 Both drugs are counted against the deductible.
 Both drugs have allowables of $25,000 per
year. Based on what we know about Part D, this
is dubious.
 THERE IS NO SUCH THING AS A
STANDARD PLAN!!!
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Compare Plans
• Part B
• Part D
 $124 deductible
 20% of $24,876 =
$4975
TOTAL OOP = $5099
7/16/2015
 $250 deductible
 $2000 with 25% copay = $500.00
 $2850 Donut Hole
 5% of remaining
$19,900 = $995
 Total OOP = $4595
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Oral Cancer Drugs
• Part D Caveats
 Patients must ENROLL in Part D--it is not automatic.
 Premiums higher each year and will be variable by
plan. But, premiums lower than Part B.
 Doughnut hole not covered by Medigap. Part B co-pay
is!
 “Poor” patients considered differently by Part D (and
for Part B premiums as well).
 Medicare Advantage and PDP Plans must be
‘actuarially equivalent’ and this may mean differing
OOP for these plans and can include tiered pricing for
drugs.
7/16/2015
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The Demonstration Project
7/16/2015
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The Demonstration Project
2006
• The Cancer Demonstration Project
• What’s going to happen next year?
 “As the data become more complete, CMS plans to analyze the
relationships between the reported symptoms and hospitalizations and
emergency department visits for related conditions (such as
intractable pain, dehydration, etc.). These analyses will inform us in
any future efforts CMS undertakes to obtain patient reported data, as
well as provide more insights about the use of G-codes for data
collection. “
 Will continue to discuss the validity of this with oncology practices.
 What does your data say about you?
7/16/2015
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The EMR
• Here is where we are (from CMS information):
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7/16/2015
The Veterans’ Health Information Systems and Technology Architecture (VISTA)is in
1300 sites in the VA system and is being adapted for small practice use.
VISTA Office Electronic Health Record (VOE EHR) was to be offered free of charge
through the Freedom of Information Act. This has been delayed.
10-15 practices can participate in a Beta test now.The Vista-Office evaluation software is
not “free” software. There is a small fee for obtaining the software on computer disk,
and there will be other fees an office will need to pay to use the software including
licensing and support fees for the database program and CPT® codes.
The added office staff cost associated with the implementation of an EHR will also be a
part of the total cost of ownership and will play a part in physicians' decisions to adopt
and test Vista-Office.
In addition, offices will generally need vendor support for installation, configuration, and
maintenance, similar to support with any other electronic health record. To address this
need, CMS has funded a Vista-Office Vendor Support Organization, WorldVistA, to
provide training for vendors. The evaluation of these vendor services is an important
objective of the initial VOE release.
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Pay for Performance
• Medicare Spending Facts
 Insurance for 42 million elderly and disabled
 In 2004, the largest component of the federal
budget.
 In 2004, the largest component of national
health spending.
 In 2006, the Prescription Drug Benefit will
substantially increase benefits.
7/16/2015
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Pay for Performance
• Medicare Modernization Act of 2003
 New way to assess Medicare financial status
• Medicare’s future challenges
 Growth of beneficiaries
 Decline in worker/beneficiary ratio
 Increasing life expectancy
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Pay for Performance
• House Ways and Means Committee
 June letter requesting
• CMS provide information on quality indicators and the system
for reporting them
• Seeking CMS recommendations on the financial incentives
needed to ensure provider participation
• Information on P4P demonstrations
• Lessons learned from P4P demonstrations
 Value-based purchasing
7/16/2015
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Pay for Performance
• CMS demonstration initiatives
 Hospital
• Paid more to report 10 quality measures – full market-basket
update
 Hospital
• Top 10% performance – additional 2% payment
• Next 10% performance – additional 1% payment
 Underway
• Nursing Homes
• Home Health
7/16/2015
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Pay for Performance
• CMS Director Dr. Mark McClelland
 “Linking a portion of Medicare payments to
valid measures of quality and effective use of
resources would give providers more direct
incentives and financial support to implement
innovative ideas and approaches that actually
result in improvements in the value of care that
our beneficiaries receive.”
7/16/2015
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Pay for Performance
• Committee Chairman William Thomas
 “Today, Medicare pays providers the same
whether they deliver excellent care or care that
is ineffective, poor quality or out-of-date.”
 “Unfortunately, since Medicare pays for
resource use, we pay for more and more
services when providers deliver ineffective and
inefficient care.”
7/16/2015
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Oncology ICD-9-CM
Changes
• 10/1/2005 with no grace period
• Volume depletion: Three new codes, which can be
used for patients who need volume replacement
 276.50 for volume depletion, unspecified;
 276.51 for dehydration;
 276.52 for hypovolemia.
7/16/2015
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Oncology ICD-9-CM
Changes
• Hematology: New thrombocytopenia codes are here
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287.30 is primary thrombocytopenia unspecified
287.31 is immune thrombocytopenic purpura
287.32 is for Evans’ Syndrome
287.33 for congenital and hereditary thrombocytopenic
purpura
 287.39 is for other primary thrombocytopenia
7/16/2015
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Oncology ICD-9-CM
Changes
• Kidney: For those of you who give ARANESP or
PROCRIT to kidney disease patients—listen up!
New codes are required as of October 1, 2005.
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585.1 is for chronic kidney disease, Stage 1
585.2 is for Stage 2
585.3 is for Stage 3
585.4 is for Stage 4
585.5 is for Stage 5
585.6 is for End Stage Renal Disease (like when you are
on dialysis)
 585.9 is for unspecified chronic kidney disease.
7/16/2015
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ICD-9-CM
• Chronic Kidney Disease
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585.1 Stage I chronic kidney disease. Kidney damage with normal or increased
glomerular filtration rate (GFR), greater than or equal to 90 ml/min/1.73m2
585.2 Stage II chronic kidney disease. Kidney damage with mild decrease in glomerular
filtration rate (GFR), 60-89 ml/min/1.73m2
585.3 Stage III chronic kidney disease. Kidney damage with moderate decrease in
glomerular filtration rate (GFR), 30-59 ml/min/1.73m2
585.4 Stage IV chronic kidney disease. Kidney damage with severe decrease in
glomerular filtration rate (GFR), 15-29 ml/min/1.73m2
585.5 Stage V chronic kidney disease. Kidney damage with glomerular filtration rate
(GFR) of less than 15 ml/min/1.73m not on dialysis
New code 585.6 End stage renal disease. Stage V chronic kidney disease with patient on
dialysis
New code 585.9 Chronic kidney disease, unspecified chronic renal insufficiency Chronic
renal failure NOS
• Genetic Counseling: V26.33
7/16/2015
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ICD-9-CM Changes
•
•
One of them is for V58.1, which will be deleted 10/1/2005 and will now
have a FIFTH DIGIT codes as of October 1. This change will impact the payment
of your claims. Here is the scoop from the ICD-9-CM Maintenance Committee.
V58.11 Encounter for antineoplastic chemotherapy
V58.12 Encounter for immunotherapy for neoplastic condition
“ Immunotherapy also called immune therapy and biologic therapy is a
treatment that stimulates the body’s immune defense system to fight infection
and disease. It is not classified as chemotherapy. Unlike traditional cytotoxic
chemotherapies that attack cancer cells themselves, immunotherapy is designed
to enhance the body’s defenses by mimicking the way natural substances
activate the immune system. These can stimulate the growth and activity of
cancer-killing cells, e.g.interleukin used in the treatment of malignant
melanoma and renal cell carcinoma.
We would guess that interferons now and future cancer vaccines in the pipeline
would also be included in this definition. Check with your Carrier bulletin
about interferon necessitating V58.12.
7/16/2015
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Commercial Insurance Default
Fee Schedule Changes- PPO
• Blue Cross of California Prudent Buyer PPO
 Fee Schedule changed July 1, 2005
 Drugs paid at ASP + 25%
 E & M codes paid at 3% above Medicare 2005 fee
schedule
 G-Codes paid at 90% of 2005 Medicare Allowable
 2004 Administration CPT paid at 25-50% of 2004
Medicare Fee Schedule
 No Payment for Demonstration G-Codes
7/16/2015
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Commercial Insurance Default
Fee Schedule Changes- PPO
• Blue Shield of California PPO
 Fee Schedule Changed April 1, 2005
 Drugs paid AWP – 15%
 E& M codes paid at 4% above 2004 Medicare
fee schedule.
 Administration CPT codes paid at 13-15%
above 2004 Medicare fee schedule including
transitional increase.
 No Payment for Demonstration Codes or
Administration G-Codes
7/16/2015
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Commercial Insurance Default
Fee Schedule Changes- PPO
• Cigna PPO
 Default Fee Schedule Changed April 15, 2005
 Drugs paid at AWP – 15%
 E&M codes paid at 15% above 2005 Medicare fee
schedule
 2004 Administration CPT Codes paid at 91% Medicare
2004 fee schedule including transitional increase.
 No Payment for Demonstration Codes or
G-Codes
7/16/2015
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Commercial Insurance Default
Fee Schedule Changes- PPO
• United Healthcare Options PPO
 Fee Schedule Changed September 1, 2005
 Drugs paid AWP – 15%
 E& M codes paid at 4% above 2004 Medicare
fee schedule.
 Administration CPT codes paid at 13-15%
above 2004 Medicare fee schedule including
transitional increase.
 No Payment for Demonstration Codes or
Administration G-Codes
7/16/2015
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Commercial Insurance Fee
Schedule Changes- HMO
• Fee Schedule Negotiated by IPAs
• Reimbursement for Drugs and Procedures
Depends on Carve Out
• Most IPAs have transferred some if not
most of the financial responsibility for
drugs back to the health plan
• Tremendous Variability in physician
payment structure
7/16/2015
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Commercial Insurance Fee
Schedule Changes- HMO
• IPA Example 1
 Drugs paid at 100% of 2003 Medicare fee
schedule
 E& M and Administration CPT codes paid at
95% 2003 Medicare fee schedule
7/16/2015
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Commercial Insurance Fee
Schedule Changes- HMO
• IPA Example 2
 Drugs paid at 100% 2005 AWP updated
quarterly
 E&M codes paid at 55% 2005 Medicare fee
schedule
 Administration CPT codes paid at 80% 2004
Medicare fee schedule without transitional
increase
7/16/2015
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Survival Strategies
7/16/2015
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Do Not Underestimate Part D
• Medicare Advantage Plans will increase.
This will create more complicated intake
and more chaos for patients. MA Plans do
not pay for the Demo.
• MA plans or patients may switch drugs
between Part B and Part D.
• Patients without Medigap may prefer to
bring their drug in and get the injection.
• Get ready to answer lots of questions!
7/16/2015
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Think Out of The Box
• It’s Time to be Creative
• What new services can you do? Alternative
therapies? Infusion Center? Rent-a-Nurse?
• Consolidation of Oncology Services and Offices
• Patient Payment Services?
• Pay for Performance?
• Pumps
7/16/2015
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Pay Attention to Other
Payers
• Understand how and when they will implement
the new codes. It may be immediately or in three
months. You need to know!
• Make sure your computer system can
accommodate three different drug admin coding
systems.
• Understand how and when they will calculate
ASP, if they decide to use it as a payment system.
• Monitor EOBs to see if they are fluctuating on
contract terms.
7/16/2015
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Manage Managed Care
Contracts
• What can you negotiate?
 ASP +
 Conversion factor for fee schedule services
 Addition of E&M services to chemotherapy
administration
 Following of CPT standards with grace period
 Daily or hourly facility/mixing/drug management fees
 Pay for performance---can you start this?
 Pharmacy fees
• Negotiated AWP amount
• Claim administration
• Patient counseling
7/16/2015
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Coping with Change
• Your check list
 Be sure you really understand what your cash needs are now. They have
changed over the last six months.
 Be prepared for coding “anarchy” on January 1, 2006. There is no grace
period for Medicare and we will have three coding systems to deal with.
 Be sure to schedule coding education for the end of the year. You do not
want to be scrambling on 1/1/2006.
 What will happen if there is a 20+% decrease in your professional service
profitability for Medicare patients? How will this impact your operation
and MD bonus structure?
 Prepare to answer questions about Part D next year for your patients.
They will be very confused.
 Make sure you have the electronic systems to support Pay for
Performance. How would you track patient outcomes?
 Participate in the struggle!
7/16/2015
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Contact Information
• Here is our contact information:
Bobbi Buell
[email protected]
800-795-2633
415-332-2793
650-618-8621 (FAX)
Patty Falconer
[email protected]
650-949-2526
650-745-1122 (FAX)
7/16/2015
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