Transcript onPoint Oncology Capabilities

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Final Medicare Regulations 2015
Bobbi Buell MBA
800-795-2633
[email protected]
7/17/2015
Confidential – Do not distribute
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Agenda
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Medicare PFS Rule 2015
HOPPS Rule 2015
Biosimilars: What We Do and Do Not Know
PQRS
The Value-Based Modifier
The Oncology Care Model
Coding 2015
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Disclaimer
• The information described herein is gathered from third-party sources and is
subject to continual change and interpretation. It is provided for informational
purposes only and does not guarantee coverage or payment. It is always the
provider’s responsibility to determine and submit appropriate codes and modifiers
based on the services rendered and the provider’s medical judgment. Providers
should contact the payer for coding and billing guidance.
• CPT codes and descriptions only are copyright 2014 American Medical Association
(AMA). All rights reserved. The AMA assumes no liability for data contained or not
contained herein.
• All Medicare information is derived from the Final Rule.
• 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.
• CPT is the trademark for the American Medical Association. All Rights Reserved.
• This presentation should not be reproduced without the permission of the author
and is time sensitive
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Web Sites for 2015 Regulations
• This presentation is based on published rules
– Medicare Final Physician Fee Schedule (PFS) Rule—
http://www.cms.gov/Medicare/Medicare-Fee-forService-Payment/PhysicianFeeSched/PFS-FederalRegulation-Notices.htmlMedicare
– Hospital Outpatient Prospective Payment (HOPPS)
Rule--http://www.cms.gov/Medicare/Medicare-Feefor-ServicePayment/HospitalOutpatientPPS/HospitalOutpatient-Regulations-and-Notices-Items/CMS1613-FC.html
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Medicare Physician Payment Basics
• Payments are based on RVUs for each code (WRVUs+PERVUs+MalRVUs)
• RVUs are multiplied times GPCIs for your area. There is a work GPCI floor in
some areas of 1.00. Set to expire after CY 2013
(W*WGPCI+PE*PEGPCI+Mal*MalGPCI)
• The Medicare conversion factor determines the overall level of Medicare
payments (W*WGPCI+PE*PEGPCI+Mal*MalGPCI) times CF = $Your Total
Allowable for your area
• A formula spelled out in the Medicare statute determines the annual update to
the conversion factor. This conversion factor can only be changed by Congress.
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Fee Schedule: Does Not Include
Sequestration
• Sequestration:
– Medicare 2% across the board started on April 1, 2013
– Impacts everything including drugs
– The 2% comes out of the Medicare portion (80%)
• Drugs are paid at 104.304% ASP
• All patient payments excluded
– Will come out of EHR incentives and probably out of other
incentives paid during the sequestration period.
• Murray-Ryan Budget Deal extended the Sequester until 2023;
PAMA extended it to 2024
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SGR and PAMA
• Last April, the Senate passed the ‘‘Protecting Access to
Medicare Act of 2014’’. This bill has many provisions.
Here are some of the highlights:
– A 12-month extension of the 0.5% increase in the
conversion factor of the fee schedule, i.e. no change in the
current schedule
– A delay in review of short-stay records, sometimes known
as the Two-Midnight Rule for hospitals
– A delay in ICD-10-CM until (the earliest) 10-1-2015
– Elimination of the limitation on deductibles in EmployerSponsored Health Plans
– Change of payment and policies for clinical lab tests
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PAMA (Cont’d)
• Other Provisions:
– Revisions under ESRD Payment
– Quality incentives for computed tomography
diagnostic imaging and promoting evidence-based
care
– Ensuring accurate valuation of services under the
physician fee schedule by allowing CMS to revalue codes
– Increasing the Sequester to 4% for the first 6
months of 2024 and to 0% for the last 6 months
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What About The 2015 Conversion
Factor ?
• Placeholder
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Fee Schedule: Specialty Impact (w/o
Sequester or CF)
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Hematology Oncology = +1%
Nurse Practitioners = +1%
Radiation Oncology = 0%
Independent Radiation Centers = +1%
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PFS Final Drug Admin Changes
With CF
Placeholder for Fee Schedule
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Mis-Valued Services
• Medicare will look at codes that ‘cost too much
per year’, e.g. over $10 million. Codes impacting
you are
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96372
96375
96401
96409
• CMS decided not to do this in the Final Rule
• But, CMS will try to post RVU changes by January
15 the year preceding the change
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Global Services
• Big Change for Surgeons
– Surgical procedures have 10-day and 90-day global
periods
– E/M services cannot be billed during that time
– CMS proposes to do away with 10-day global
period in 2017 and the 90-day in 2018
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Telehealth Services 2015
• The definition of these services has not
changed
• Expanded the services included in them to
include
– Psychiatry codes 90845, 90846, 90847
– Prolonged Services 99354-99355
– Annual Wellness Visits G0438-G0349
• No expansion of telehealth services beyond
HPSA areas
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Chronic Care Management
• Furnished to patients with 2 or more chronic conditions
– Conditions must be expected to last 12 months or more and the
patient may suffer significant exacerbation, morbidity, or
mortality
– Patients must have 24/7 access to the practice, caregivers and
electronic medical records
– Chronic care management codes include the following:
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Continuity of care with a healthcare professional
Development and revision of a patient-centered care plan
Communication with other professionals
Medication management
Coordination with other professionals
Care transition coordination
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Billing for Chronic Care Management
(2015)
• Use of CPT code 99490 for a 30-day period for a
minimum of 20 minutes
– 99490: Chronic care management services furnished to patients with multiple (two
or more) chronic conditions expected to last at least 12 months, or until the death
of the patient, that place the patient at significant risk of death, acute
exacerbation/decompensation, or functional decline; 20 minutes or more; per 30
days
• Can be billed by specialists as specifically stated
by CMS as long as requirements are met
• Must fulfill ‘incident to’ requirements, except
direct supervision for off-hours care
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Requirements for Billing for Chronic Care Management (CCM) Services and
Elements Included in the Required Comprehensive Care Plan.
Edwards ST, Landon BE. N Engl J Med 2014;371:2049-2051.
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More Chronic Care Management
• Payment requirements include:
– It will pay approximately $40 per 20 minutes per
month
– There is cost-sharing
– You must use an EMR
– Only one physician may bill per month
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Chronic Care Management (2015)
• Billing requirements
– Cost-sharing will not and cannot be waived
– Must give the patient the scope of services for billing in
writing
– Must have a copy of their care plan in writing
– Patient must be informed of their right to stop services
– Beneficiary must know that only one physician can bill per
month
– Patient must agree to liability for services
– This agreement must be informed by a discussion
– Beneficiary may revoke permission
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Colorectal Screening
• There are no patient payments for
colonoscopy, although there is frequently
anesthesia for which there are patient
portions
– CMS proposes to make anesthesia part of the
procedure
– And, thereby, waive the patient portion of the
anesthesia
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Open Payments (Sunshine Act)
• There were four provisions , most of which were
pretty minor
– Deleted the words ‘covered device’ as they are
duplicative
– Deleted the Continuing Education exclusion in its
entirety
– Required the marketed name of the drug or biological,
unless the payment is not directed to any specific
product
– Required the disclosure of any stock or form of
ownership-in-kind transferred by a manufacturer or
GPO
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Final HOPPS Rule 2015
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HOPPS Rule
– The OPPS conversion factor will increase from $72.672 to
$74.144
– CMS will also impose a 2 percent reduction in the CF on
any hospital that does not report the required quality
measures. This reduced conversion factor for 2015 will be
$72.661.
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Bundling of Services 2015 Edition
• CMS finalized the Comprehensive-APC policy as
proposed for 25 out of the proposed 28 C-APCs..
• For CY 2015, CMS will conditionally package all
ancillary services and ‘add-on’ codes assigned to
APCs with a geometric mean cost of $100 or less
(before applying the conditional packaging status
indicator to the services within these APCs).
Exceptions to the ancillary services packaging policy
include preventive services, psychiatry-related
services, and drug administration services.
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Packaging of Services: Hem-Onc
• Drug administration
– Again, will not be bundled
– CMS alluded to the fact that they ‘may do something else’
with drug administration services in the proposed rule
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Drug Payments
• Drugs will continue to be paid at ASP, plus 6% (minus the
Sequester)
• The packaging threshold for drugs was supposed to be $90 as
proposed but went to $95
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Select APC National Payment Rates
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HCPCS
APC Group
2014 Nat’l
2015
Proposed
Difference
96360
0438
$105.90
$108.20
$2.30
96361
0436
$29.50
$32.57
$3.07
96365
0439
$172.18
$173.53
$1.35
96367
0437
$43.78
$53.52
$9.74
96401
0438
$105.90
$108.20
$2.30
96409
0439
$172.18
$173.53
$1.35
96413
0440
$299.53
$285.00
($14.53)
96415
0437
$43.78
$53.52
$9.74
96417
0437
$43.78
$53.52
$9.74
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Off-Campus Provider-based Facilities
• CMS would like to gather data on these
practices due to the high volume of physician
acquisitions by hospitals
• CMS proposes to require a modifier (Modifier
–PO) on claims from off-campus providerbased facilities. This will be voluntary in 2015
and mandatory in 2016.
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Outlier Payments: 2015 Threshold
• The cost of the service must exceed the threshold
1.75 times the APC rate, plus $2775 ($2900 in 2014)
• The target is 1% of the HOPPS spending for outliers
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Physician Certification of Inpatient
Stays
• CMS proposes modifying the current requirement
that Medicare Part A payment will only be made
for such services “which are furnished over a
period of time, [if] a physician certifies that such
services are required to be given on an inpatient
basis.” Instead, they propose to change the
interpretation of the section to require a
physician certification only for long-stay cases of
20 nights or more and outlier cases.
• There should be a physician order for services
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BIOSIMILARS
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What Do We Know?
• Will be paid by Medicare at the drug ASP plus 6%
of the reference product
• Will have their own HCPCS code retroactive to
launch, but may not be able to bill right away
until the claims processing system can process
the new code
• Whether EACH and every biosimilar will have
their own code is not known
• Will be covered under Part D, if not qualified for
Part B
• Sequestration may affect biosimilars less
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What We Don’t Know
• How private payers will react in terms of
substitution on Pathways or during the prior
authorization process
• How long it will take private payers to adopt
the HCPCS code
• Whether each biosimilar will go from a Q-code
to a J-code
• Whether biosimilars will inspire CMS to
negotiate drug proces
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Physician Compare, PQRS and Other Quality
Programs
MEDICARE PHYSICIAN FEE SCHEDULE
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Physician Compare Website
• CMS required to create the Physician Compare
website
– Section 10331 of the Patient Protection and
Affordable Care Ac
• Purpose
– Allow consumers to make more informed healthcare
decisions by providing useful information
– Incentivize physician to optimize performance
– Eventually, to reward patients for for quality physician
choices
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Physician Compare Website
• Currently (at minimum)
– Physician Education
– Physician Board Certification
– Accepting Medicare patients
– Group and Hospital affiliations
– Participates in EHR MU
– Participates in E-Rx
– Participates in PQRS
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PQRS 2015 (Proposed)
• In 2015, there will be no bonus for PQRS.
There will be a 2% reduction in 2017 based
on 2015 data. Plus, the practice or EP may
not qualify for the Value Modifier
• BOTTOM LINE: PQRS is essential. Period.
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PQRS 2014
• PQRS Changes
– Most providers will have to report 9 measures
from 3 NQF Domains for the incentive; as well as 2
measures from a cross-cutting measures set.
– Reporting threshold is 50% of Medicare FFS
patients for a one-year reporting period, unless
you report via QCDR or a Measures Group
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Clinical Data Registries (CMS)
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What’s Changed In Oncology
• 3 New Measures, but they will be reported by
Pathologists
• Breast Cancer Measure has been corrected
• Many Oncology measures no longer a claimsbased, but switch to Registry
• ASCO’s QOPI is QCDR for PQRS
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A Measures Group for Oncology!
• Report 20 consecutive over 18 years old mostly
FFS Medicare patients who meet criteria for one
or all measures per EP as applicable:
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71 Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen
Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer
72 Colon Cancer: Chemotherapy for Stage III Colon Cancer Patients
110 Preventive Care and Screening: Influenza Immunization (Patients over 18)
130 Documentation of Current Medications in the Medical Record
143 Oncology: Medical and Radiation – Pain Intensity Quantified
144 Oncology: Medical and Radiation – Plan of Care for Pain
194 Oncology: Cancer Stage Documented
226 Preventive Care and Screening: Tobacco Use: Screening and Cessation
Intervention
 Registry only
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Want to Report Measures Group?
• Select a qualified Medicare PQRS Registry
• Report 20 mostly Medicare FFS patients per
the instructions of your Registry per Eligible
Provider for whom the measures group is
applicable. This can be any time before the
end of the reporting period (end of February
2014).
• Pay the Registry bill after data submitted.
• You’re done!
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Quality And Resource Use Reports
• The QRURs are annual reports that provide groups of
physicians with:
– Comparative information about the quality of care furnished,
and the cost of that care, to their Medicare fee-for-service (FFS)
patients
– Beneficiary-specific information to help coordinate and improve
the quality and efficiency of care furnished Information on how
the provider group would fare under the value-based payment
modifier (VBM)
• 2012 QRURs were produced and made available to all
groups of physicians with 25 or more eligible professionals
(EP) (which includes physicians and other practitioners)
• 2013 QRURs distributed to all physicians this Fall.
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QRUR for All Physicians
• Late Summer 2014: QRURs for all groups and solo
practitioners outlining success or failure at PQRS
• Drill down tables including beneficiaries attributed to
the group, their resource use, specific chronic diseases
– Drill down table including all hospitalizations for for
attributed beneficiaries
– Drill down table of individual EP PQRS reporting
(December 2014)
• Good presentation on reading QRUR reports at
http://www.cms.gov/Outreach-andEducation/Outreach/NPC/Downloads/2012-NPCQRUR-092413-Presentation.pdf
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Quality Program Overview
Carrots
2007-2011
• PQRS
• E-Rx
• EHR
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Sticks
2012-2015
• E-Rx Penalties
• PQRS Penalties
• EHR Penalties
Carrot
Sticks
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2015-2017
• Value Modifier
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Section 3007 of the Affordable Care Act
• Payment Modifier under fee schedule based on
cost versus quality of care comparison
– Quality and cost composite measures
• Outcome measures risk-adjusted
• Costs risk-adjusted and exclude geographic adjustments
– Budget neutral, so will be quoted each year
– Timing
• 2015—Specific large groups ≥ 100
• 2016—Groups ≥ 10
• Not later than 2017---all physicians and groups
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What is the Value-Based Modifier
(VM”)?
• VM assesses both the quality and cost of care
under the Medicare Fee Schedule
• Begins phase in of VM starting in 2015
(reporting 2013) and phase-in will be
complete in 2017 (reporting 2015)
• Implementation is based on participation in
PQRS
• But, incentives and penalties are separate
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Summary Value Modifier 2015 > 2017
• Using 2015 data, all group and solo physicians
will be included in the Value Modifier
– Groups under 10 physicians will not have
downside risk, if they participate in PQRS
– For groups of ≥ 10 there can be downside risk up
to 4%
– There will be an informal review process, but no
formal or judicial review
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What About EP VM Reporting?
• If a group chooses NOT to report as a group by
their Tax ID number, CMS will calculate a group
quality score if at LEAST 50% of the EP’s within
the group successfully report
– At least 50% must report successfully per criteria to
avoid $ adjustment
– EP’s may report on qualified measures using these
CMS-approved mechanisms:
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•
•
•
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Claims
Registry
EHR
Clinical Data Registries
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THE ONCOLOGY CARE MODEL
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Why This Model?
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Cost of cancer care on an upward slope
Need a multi-payer model
Pathways only effective for a few years
Episode of care model works
– MS-DRGs
– United Healthcare in cancer
– Capitation
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The OCM
• Starts with fee-for-service payment
• Compares your costs for a 6-month period for
ALL care and discounts it by 4%
– For gain-sharing
– No downside risk for 3 years
• Pays $160 per month for chemotherapy care
coordination
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What Must You Do?
1.
2.
3.
4.
5.
6.
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Provide 24/7 patient access to an appropriate clinician who has real-time access to patient’s medical
records Aim to better meet patients’ needs by providing around-the-clock access to a clinician who
can provide real-time, individualized medical advice
Use an ONC-certified EHR and attest to Stage 2 of meaningful use (MU) by the end of the third
model performance year OCM. Practices must demonstrate progress by attesting to MU Stage 1 by
end of the first model performance year.
Utilize data for continuous quality improvement The Innovation Center will provide participating
practices with rapid cycle data feedback reports to aid in quality improvement.
Provide core functions of patient navigation Practices are required to provide patient navigation to
all OCM patients. The National Cancer Institute provides a sample list of patient navigation activities
(see Appendix B of the RFA) .
Document a care plan for every OCM patient that contains the 13 components in the Institute of
Medicine Care Management Plan Plan components include treatment goals, care team, psychosocial
support, and estimated patient out-of-pocket cost (see Appendix A of the RFA for full list)
Treat patients with therapies consistent with nationally recognized clinical guidelines Practices must
report which clinical guidelines (NCCN or ASCO) they follow for OCM patients, or provide a rationale
for not following the clinical guideline
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How Does The Performance Based
Payment Work?
• CMS will calculate benchmark episode expenditures for
participating practices
– Based on historical data
– Risk-adjusted, adjusted for geographic variation
– Trended to the applicable performance period
• A discount will be applied to the benchmark to determine a target
price for OCM-FFS episodes
– Example: Benchmark = $100 Discount = 4% Target Price = $96
– If actual OCM-FFS episode Medicare expenditures are below target
price, the practice could receive a performance-based payment
• Example: Actual = $90 Performance-based payment up to $6
• The amount of the performance-based payment may be reduced
based on the participant’s achievement and improvement on a
range of quality measures
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Questions?
• Is the $160 enough to coordinate care and
maintain the requirements of the program? Look
at the Wellpoint payment…
• What will be bundled in the $160?
• Do you want to take risk on costs over which you
have no control?
• Will efficient practices be penalized?
• Gain-sharing an accounting nightmare?
• Quarterly quality reporting?
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MORE CODING
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Latest Update: ICD-10-CM
• For dates of service on or after October
1, 2015…
– ICD-9-CM and ICD-10-CM will be used for a long
time
– Get ready!
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Rights
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Our Webinars
• Placeholder of SGR
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Modifier -59
• Gets coders around the Cruel Coding Edits
• Shows payers, particularly Medicare, that an
exceptional situation has occurred that
requires different coding
• CMS believes that -59 has misused and
abused—this has lead to a future refinement
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New Modifiers
• Since the definition of Modifier 59 is so broad - CMS
created 4 new HCPCS modifiers that are much more
specific:
– XE: Separate Encounter - a service that is distinct because
it occurred during a separate encounter
– XS: Separate Structure - a service that is distinct because it
was performed on a separate organ/structure
– XP: Separate Practitioner - a service that is distinct because
it was performed by a different practitioner
– XU: Unusual Non-Overlapping - the use of a service that is
distinct because it does not overlap usual components of
the main service
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Advance Care Planning
99497-99498
• 99497: "Advance care planning including the explanation
and discussion of advance directives such as standard forms
(with completion of such forms, when performed), by the
physician or other qualified health care professional; first
30 minutes, face-to-face with the patient, family
member(s), and/or surrogate”
• 99498: "Advance care planning including the explanation
and discussion of advance directives such as standard forms
(with completion of such forms, when performed), by the
physician or other qualified health care professional; each
additional 30 minutes (list separately in addition to code for
primary procedure)”
• Not yet paid by Medicare, but the door is not closed
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Other HCPCS Changes
HCPC
A9606
C2624
C2644
C9025
C9026
C9027
C9136
C9349
C9442
C9443
C9444
C9446
C9447
G0277
G0279
G0464
G6003
G6004
G6005
G6006
G6007
G6008
G6009
G6010
G6011
G6012
G6013
G6014
G6015
G6016
G6017
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LONG DESCRIPTION
Radium ra-223 dichloride, therapeutic, per microcurie
Implantable wireless pulmonary artery pressure sensor with delivery catheter, including all system
components
Brachytherapy source, cesium-131 chloride solution, per millicurie
Injection, ramucirumab, 5 mg
Injection, vedolizumab, 1 mg
Injection, pembrolizumab, 1 mg
Injection, factor viii, fc fusion protein, (recombinant), per i.u.
Fortaderm, and fortaderm antimicrobial, any type, per square centimeter
Injection, belinostat, 10 mg
Injection, dalbavancin, 10 mg
Injection, oritavancin, 10 mg
Injection, tedizolid phosphate, 1 mg
Injection, phenylephrine and ketorolac, 4 ml vial
Hyperbaric oxygen under pressure, full body chamber, per 30 minute interval
Diagnostic digital breast tomosynthesis, unilateral or bilateral (list separately in addition to g0204 or
g0206)
Colorectal cancer screening; stool-based dna and fecal occult hemoglobin (e.g., kras, ndrg4 and
bmp3)
Radiation treatment delivery, single treatment area,single port or parallel opposed ports, simple
blocks or no blocks: up to 5mev
Radiation treatment delivery, single treatment area,single port or parallel opposed ports, simple
blocks or no blocks: 6-10mev
Radiation treatment delivery, single treatment area,single port or parallel opposed ports, simple
blocks or no blocks: 11-19mev
Radiation treatment delivery, single treatment area,single port or parallel opposed ports, simple
blocks or no blocks: 20mev or greater
Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment
area, use of multiple blocks: up to 5mev
Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment
area, use of multiple blocks: 6-10mev
Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment
area, use of multiple blocks: 11-19mev
Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment
area, use of multiple blocks: 20 mev or greater
Radiation treatment delivery,3 or more separate treatment areas, custom blocking, tangential
ports, wedges, rotational beam, compensators, electron beam; up to 5mev
Radiation treatment delivery,3 or more separate treatment areas, custom blocking, tangential
ports, wedges, rotational beam, compensators, electron beam; 6-10mev
Radiation treatment delivery,3 or more separate treatment areas, custom blocking, tangential
ports, wedges, rotational beam, compensators, electron beam; 11-19mev
Radiation treatment delivery,3 or more separate treatment areas, custom blocking, tangential
ports, wedges, rotational beam, compensators, electron beam; 20mev or greater
Intensity modulated treatment delivery, single or multiple fields/arcs,via narrow spatially and
temporally modulated beams, binary, dynamic mlc, per treatment session
Compensator-based beam modulation treatment delivery of inverse planned treatment using 3 or
more high resolution (milled or cast) compensator, convergent beam modulated fields, per
treatment session
Intra-fraction localization and tracking of target or patient motion during delivery of radiation
therapy (eg,3d positional tracking, gating, 3d surface tracking), each fraction of treatment
Confidential – Do not distribute
ADD_DATE
20150101
ACT_EFF_DT
20150101
20150101
20140701
20141001
20141001
20150101
20150101
20150101
20150101
20150101
20150101
20150101
20150101
20150101
20150101
20140701
20141001
20141001
20150101
20150101
20150101
20150101
20150101
20150101
20150101
20150101
20150101
A
A
A
A
A
A
A
A
A
A
A
A
A
20150101
20150101
A
20150101
20150101
A
20150101
20150101
A
20150101
20150101
A
20150101
20150101
A
20150101
20150101
A
20150101
20150101
A
20150101
20150101
A
20150101
20150101
A
20150101
20150101
A
20150101
20150101
A
20150101
20150101
A
20150101
20150101
A
20150101
20150101
A
20150101
20150101
A
20150101
20150101
A
20150101
20150101
A
TERM_DT
ACTION_CODE
A
85
Introducing assistPoint.com
• One web site with every cancer drug program application on
it—uninsured, co-pay card, and links to Foundations
• Other information is there also: Coding and Reimbursement
Guides, Package Inserts, NDCs
• For Industry-sponsored forms
– Auto-populated forms with all pertinent information for
quick enrollment
– Transmitted to portal or program by fax, e-mail, or portal-toportal
– Auto-signature options
• Tracking of workflow on-site
7/17/2015
Confidential – Do not distribute