Transcript Changes to Oncology Coding 2009

Changes to Oncology
Coding 2010
Bobbi Buell
Version 12.0
Winter 2009
Disclaimer
 Payers differ on their guidelines. Please verify coding for each payer and claim.
 RAC information is literally changing on a daily basis.
 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 cartoons are purchased JPEG files.
Session Objectives
 Discuss Proposed Fee Schedule for 2010
 Discuss Coding/Options for PQRI 2009-2010
 Discuss Coding for E-Prescribing 2009-2010
 Discuss ICD-9-CM Codes 2010
 Discuss HCPCS Codes 2010
 Discuss the Status of RACs
 Know What You Need to Do Next
Medicare Rules for 2010
Medicare Physician Payment Basics
 Payments are based on RVUs for each code
(WRUs+PERVUs+MalRVUs)
 The pool of RVUs is fixed – any changes must be budget neutral--
we had one of the few exceptions in 2004-2005.
 RVUs are multiplied times GPCIs for your area.
 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’s Happening to the Conversion
Factor in 2010?
 The SGR formula which has been flawed for years signals
that we will have a 21.2% DECREASE in the conversion
factor.
 Physician drugs are now included in the SGR formula,
allegedly skewing it upwards. CMS has eliminated Part B
drugs from the SGR meaning lower future reductions.
 But, for right now, we are stuck with a conversion factor of
$28.4061 down from $36.0666.
Impact of 2010 MPFS Changes
Other Fee Schedule Changes for
2010
 CMS has long had confusing rules relative to consults. So, the
easiest way to deal with the problem is to eliminate them
altogether. What this means is:
 New consults in the office will be coded as New Patients (99201-
99205). This means that no one in practice has seen the patient
at all for 36 months.
 Established consults in the office will be coded as Established
Patients (99212-99215)
 Hospital consults will be coded as Admissions (99221-99223)
with a new modifier signifying who was the admitting physician.
The new modifier is not official yet.
 TeleHealth consults are the exception. They have special Gcodes.
Budget Neutrality???
Consult Code
Maps to
Percentage
Mapped
2010 Price
99241
($48.69)
99201
99211
50%
50%
$38.95
$19.12
99242
($91.61)
99202
99212
50%
50%
$67.44
$38.95
99243
($125.15)
99203
99213
50%
50%
$97.74
$65.54
99244
($185.38)
992o4
99214
50%
50%
$151.48
$98.46
99245
($226.50)
99205
99215
50%
50%
$190.43
$132.73
Source: CMS Website; 2010 NF RVUs; 2009 CF and GPCIs =1
CPT Rule Changes 2010
 Concurrent Care
 “Concurrent care is provision of similar services (e.g. hospital visits) to the same
patient by more than one physician on the same day. When concurrent care is
provided, no special reporting is required.”
 Transfer of Care
 “Transfer of care is the process whereby a physician who is providing
management for all or some of a patient’s problems relinquishes this
responsibility to another physician who EXPLICITLY agrees to accept this
responsibility and, who from the initial encounter is not providing consultative
services.”
 “Consultation codes should not be reported by the physician who has agreed to
accept the transfer of care before the initial evaluation, but are appropriate to
report if the decision to accept the transfer of care cannot be made until after
the initial consultation…”
CPT Consultations 2010
 “A consultation is a type of evaluation and management
service provided by a physician at the request of another
physician or appropriate source to either recommend care for
a specific condition or problem or determine whether to
accept responsibility for ongoing management of the
patient’s entire care or for the care of a specific condition or
problem.”
CPT Consultations
 Evaluation and Management (E/M): Consultations: To clarify the two
situations under which consultations may be reported, the Evaluation and
Management (E/M) section subheading, "Consultations" has been
revised. These situations are: 1) to provide opinion/services for a
specific condition or problem, or 2) to allow a determination to be made
on whether to accept the ongoing management of the patient's entire
care or for the care of a specific condition or problem (i.e. transfer of
care AFTER an evaluation of the patient's problem). CPT outlined that
documentation of the written or verbal request for a consultation can be
done by either the consultant or by the requesting physician or other
appropriate source. You may remember that Medicare requires (until
January 1) that BOTH the requesting and consulting physicians document
the request. But, the request DOES need to be documented.
CPT Changes for Consultations 2010
 Patients and/or families cannot initiate consultations.
 Transfer of care definition in both office and hospital consults.
 All admitting E/M services are bundled into an inpatient
consultation on the date of admission.
 Only one consult in the hospital or nursing facility stay. This
includes inpatient and outpatient consultations.
 Documentation:
 Request
 Opinion
 Written report
Changes to 2010 Fee Schedule
 Accreditation Standards for Imaging Technical Component (-
TC)
 MIPPA limited payment to accredited suppliers, effective in
2012.
 Oncology practices are not an exception to the accreditation
rule, which they are under DME.
 The final rule does not include who the accrediting
organizations are. This should be posted by January 1, 2010.
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
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

FR requires CMS to post on our web site names of EPs
who satisfactorily report quality measures for 2009
PQRI
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 registry-based reporting
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.

FR 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
2009-2010 PQRI Quality Measures
 153 PQRI quality measures for 2009
 168 PQRI quality measures proposed so far for 2010; this
includes all ways of reporting.
 No earlier than November 15 and by December 31, 2009,
measure specifications will be available at:
http://www.cms.hhs.gov/pqri
Oncology PQRI Changes 2010
 The Oncology Pain Measures (#143 and 144) will be
reportable ONLY by registries.
 The Melanoma measures (#136-138) will only be reportable
by Registry in 2010. CMS is moving toward Registry reporting
and away from claims-based reporting.
 There will be a new measure, “Cancer Stage Documented”.
2010 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
 No Measures Groups for Oncology in 2010; but, will be 6
new ones if you are in a multi-specialty practice.
2010 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
 In 2010, 2 reporting periods apply to claims, registries, and
measures groups.
2009-2010 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)

Criteria proposed for 2010 annual reporting also includes that
each measure must have a minimum of 15 patients for each
measure. THIS WAS NOT APPROVED IN THE FINAL RULE!
New Reporting Option 2010
 EHR/EMR Reporting
 10 specific individual measures, but none in Oncology
 Must meet these criteria if Oncology does get EMR/ EHR reporting including

Be able to transmit data elements per specific CMS criteria

Be able to separate out and report on CMS FFS patients only

Be able to transmit TIN/NPI information

Be able to transmit in approved formats

Be able to transmit in a HIPAA secure format

Enter into legal arrangements that permit receipt of and transmission of
patient-specific data

Obtain permission by NPI number
 Must pass CMS test.
 “Group Practices” may report, but only if they have 200 providers.
PQRI Things to Remember
• Patient must have the right 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.ama-
assn.org/ama/pub/category/17432.html
Billing Parameters for PQRI
Reporting Measures with Claims
C
PQRI Error Report for 2008
Measure
Total QDCs
Valid QDCs
Valid %
Biggest
Error
% Error
QDCs
#71 Breast
Cancer
76,278
48,973
64.20%
Diagnosis
29.30%
#72 CRC Stage
III
49,702
12,790
25.73%
Diagnosis
68.69%
#73 Plan for
Chemo
32,734
7,960
24.32%
HCPCS
29.36%
#68 Iron Stores
with EPO
10,943
8,919
81.50%
Diagnosis
13.10%
#105 3-D RTx in
Prostate Cancer
61,761
59,753
96.75%
HCPCS
1.80%
Source: CMS Report “QDC Submission Error Report by Measure” at cms.hhs.gov
E-Prescribing: The Carrot and the Stick
Year
Successful**
Not
2009
2%
0%
2010
2%
0%
2011
1%
0%
2012
1%
-1%
2013
0.5%
-1.5%
2014+
0%
-2%
In 2009 and 2010, physicians who successfully e-prescribe may receive a bonus payment of 2 percent of their overall
Medicare reimbursement in addition to a potential 2 percent incentive related to PQRI for a potential bonus of 4 percent
in Medicare reimbursement.
***No double incentives for those participating in the ARRA EMR incentive program.
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
in 2009; in 2010, CMS proposes three methods—claims,
registries, and EHRs.
 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: 2009 Only
A 70 year old male patient presents to the
clinician’s office for medical care.
Scenario 1:
Scenario 2:
The clinician discusses
current medications and
prescribes new
medication, updates
active medication list in
eRx system, transmits
prescription electronically
to pharmacy
Reports G8443
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
Coding for E-Prescribing 2009-2010
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.
 In 2010, it is proposed that these codes be added to reporting
denominator and qualifications: 99304, 99305, 99306, 99307,
99308, 99309, 99310, 99315, 99316, 99341, 99342, 99343,
99344, 99345, 99347, 99348, 99349, 99350, and 90862
E-Prescribing Reporting: 2010
 Rule makes this much easier:
 Eliminates G8445 and G8446
 Report G8443 for at least 25 ENCOUNTERS per
Eligible Provider
 That’s It!!!!!!!!!!!
 Of course, you must e-prescribe…
Free E-Prescribing in Oncology!
• That’s right!
• Just for cancer practices!
• www.oncologyerx.com
• For more information,
contact me!
ICD-9-CM 2009-2010 (10-1-2009)
 New Codes for Cancer
 Merkel cell carcinoma, specified site 209.3_
 Merkel cell, carcinoma, unknown primary site 209.75
 Secondary neuroendocrine tumor 209.7_ (except above)
 Low grade myelodysplastic syndrome lesions, Refractory




anemia with excess blasts-1 (RAEB-1) 238.73
Neoplasms of unspecified nature, retina and choroid 239.81
Neoplasms of unspecified nature, other specified sites 239.89
Tumor lysis syndrome 277.88
Autoimmune lymphoproliferative syndrome 279.41
ICD-9-CM Coding 2009-2010 (10-1-2009)
ICD-9-CM Changes 2010 (10-1-2009)
 New Codes to Describe
Oncology Administrators,
Coders, Billers After Seeing
2010 Regs!!!
 799.21 Nervousness
 799.22 Irritability
 799.24 Emotional lability
 799.25 Demoralization
and apathy
Redundancy of CMS Auditors
Roles of Medicare Improper Payment Review Entities
Source: American Hospital Association
Where Did RACs Find Overpayments?
Most overpayments were collected from inpatient
hospital services for medical necessity and coding
Incorrectly Coded 35%
Other
17%
Outpatient 4%
No/Insufficient
Documentation 8%
SNF 2%
Doc/Ambulance/
Lab/DME/Other 4%
Inpatient
Hospital 85%
Rehab 6%
Medically Unnecessary 40%
95% from
Hospitals
39
Source: CMS, The Medicare Recovery Audit Contractor Program: An Evaluation of the 3-Year Demonstration, June 2008
RAC Appeals Experience to Date
RAC Demo Findings
40
RAC Jurisdictions
A
D
B
March 1, 2009
March 1, 2009
August 1, 2009
C
41
3
RAC Contacts at CMS
CMS Contact
Person
Phone
A
Ebony Brandon
410-786-1585
B
Scott Wakefield
410-786-4301
C
Amy Reese
410-786-8627
RAC
D
Kathleen Wallace 410-786-1534
42
RAC Websites
 Region A (Northeast states) Diversified Collection Services,
www.dcsrac.com/issues.html
 Region B (Great Lakes states) CGI, http://racb.cgi.com
 Region C (Mid Atlantic, South and Southeast states) Connolly
Healthcare, http://www.conn0llyhealthcare.com/RAC
 Region D (Midwest, West Coast, Southwest states)
HealthDataInsights www.healthdatainsights.com/RAC.aspx
Issues in Oncology 10-09
Issue
Date
Region(s)
Description
Source
Blood Transfusions
8.4.09
All Region B, D, plus Ala,
Fla, Georgia, S.C.
Blood transfusion
codes do not exceed
one unit
CMS Pub 100-04,
Chap 4, Sec 231.8
IV Hydration
8.4.09
All Region B, C, and D, plus
Ala, Fla, Georgia, N.C, S.C.
Hydration 1st hour
(96360) do not exceed
one unit
CMS Pub 100-04,
Transmittal 1019,
CMS Pub 100-04,
Chap 5, Sec 20.2
Once Per Lifetime
Codes
8.4.09
All Region B, C, and D, plus
Fla, Georgia, N.C, S.C.
Procedure not
possible more than
once per lifetime
CMS Pub. 100-08,
Chapter 3,
Section 3.6
Pegfilgastim, J2505
is 1 unit per 6 mg
8.4.09
All Region B, C, and D, plus
Fla, Georgia, N.C, S.C.
Units billed must be
multiples of 6 mg
CMS Pub `00-04,
Transmittal 949
Clinical Social
Worker
8.20.09
Florida Only
CSWs may not be
billed while patient is
inpatient
CMS 100-02,
Chap 15, Section
170
Pharmacy Supply
and Dispensing Fees
9.21.09
All Region A States
Pharmacy Fee May
only be billed on the
same day as a Part Bcovered oral/or
inhaled drug
CMS Pub. 100-04,
Chapter 17, Sec
80.7
What can providers do to get ready?
 Know where previous improper payments have been found
 Know if you are submitting claims with improper payments
 Prepare to respond to RAC medical record requests by
appointing a reliable, trustworthy liaison
45
Know Where Previous Improper
Payments Have Been Found
 Look to see what improper payments were
found by the RACs:
 Demonstration findings: www.cms.hhs.gov/rac
 Permanent RAC findings: will be listed on the RACs’
websites
 Look to see what improper payments have been
found in OIG and CERT reports
 OIG reports: www.oig.hhs.gov/reports.html
 CERT reports: www.cms.hhs.gov/cert
46
Prepare to Respond to RAC
Medical Record Requests
 Tell your RAC the precise address and
contact person they should use when
sending Medical Record Request
Letters
 Call RAC
 No later 1/1/2010: use RAC websites
 When necessary, check on the status
of your medical record (Did the RAC
receive it?)
 Call RAC
 No later 1/1/2010: use RAC47 websites
Who will be in
charge of
responding to
RAC Medical
Record requests?
What address will
we use?
Who will be in
charge of tracking
our RAC Medical
Record requests?
Appeal When Necessary
 The appeal process for RAC denials is
the same as the appeal process for
Carrier/FI/MAC denials
 Do not confuse the “RAC Discussion
Period” with the Appeals process
 If you disagree with the RAC
determination…
 Do not stop with sending a discussion letter
 File an appeal before the 120th day after the
Demand letter
48
Who will be in
charge of
deciding whether
to appeal a RAC
denial?
How will we keep
track of what we
want to appeal,
what we have
appealed, what
our overturn rate
is, etc.?
Learn from Your Past Experiences
Keep track of denied claims
Look for patterns
Determine what corrective
actions you need to take to
avoid improper payments
 Submit experience to me
49
Who will be in
charge of tracking
our RAC denials,
looking for
patterns?
How will we avoid
making similar
improper
payment claims in
the future?
 MACs/ Carriers per their
own internal screens
 CERT Auditors
Who Else Can Ask For/
Deny/Review Stuff
 Medical Integrity
Contractors
 Bundling and Medically
Unlikely Edits
 Private Insurance
Companies on behalf of
MA or themselves.
New HCPCS Codes 2010
Other HCPCS Changes
 J9170 for Docetaxel 20 mg has been deleted for dates of
service after 12/31/09
 -AI is for Principal Physician of Record, which may be use on
hospital consults---but this is not official yet.
Strategies for Success
 Run your numbers for 2010 without consultations for Medicare patients.
 Make sure your physicians are re-educated before the end of 2009 regarding the
proper coding and documentation for consults. Look for a CMS Transmittal before
12/31/09.
 Be aware of the new anemia code. This is sure to change some policies. Assess
what private payers or doing.
 Update your Superbills, EMRs, and CDMs for new codes.
 Put together policies and procedures for the RAC doing complex reviews. Make sure
clinicians are involved.
 Start getting prepared for “meaningful use” HIT incentives.
 Participate in the struggle! The fight is not over yet!
Contact Info
 Contact
 [email protected]
 [email protected]
 800-795-2633
 Newsletter is free!
 Send all RAC information to me at the ABOVE E-mails or
FAX to 650-618-8621
 Go to our website: http://www.onpointoncology.com
Thank You from onPoint Oncology LLC!