Transcript Medicare 2010-2011

Medicare 2011
Seminars
January, 2011
Agenda
 What’s Going On Right Now
 Medicare PFS Final Rule 1/1/2011
 PQRI and E-Prescribing 2010-2011
 Meaningful Use Final Rule 7-13-2010
 Coding 2011
 Follow Up Items For Practices
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DISCLAIMER
 Much is not known about Health Reform and The Final Rule for
Physician Services in 2011. This is what we know right now.
 Payers differ on their guidelines. Please verify coding for each
payer and claim.
 All Medicare and RAC information is literally changing on a daily
basis. What is presented herein may or may not be valid for
2010.
 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.
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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. (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 and that has been a disaster.
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History of the Debacle
http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/medicare/the-medicare-physician-payment-schedule.shtml
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The Medicare Fee Schedule
Nightmare
 We had 5 different conversion factors in 2010!
 Started off with last year’s conversion factor--$36.0666
 Went to $36.0864 in January
 Went to $28.3895 when Congress was deliberating and
then will be (?) paid back—Could return December 1.
 Went to $36.8729 June 1
 This was renewed for December
 And, this year…
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SGR Fix For One Year
 Congress passed a one-year patch to SGR (Medicare
and Medicaid Extenders Act of 2010 or MMEA)
 Signed by President Obama on 12/15/10
 Congress is expected to work on a permanent solution to
the ongoing SGR crisis in 2011
 Congress is expected to also finalize a funding
mechanism for items left out of the SGR Patch
 But, we can relax a little bit…or can we?
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MMEA (Signed into Law 12-15-2010)
 Physician fee schedule update will be 0%
 Changes to relative value units (RVUs) used to calculate fee
schedule rates must be budget neutral
 To make these changes budget neutral, the conversion factor must
be adjusted for 2011
 CMS released the 2011 MPFS to implement the 0% update and
RVU changes– “We expect all 2011 claims to be processed timely,
in compliance with the new legislation”
 CF = $33.9764
 Some PE RVUs changed slightly
 On the Palmetto web site
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MMEA
 Also extends the existing 1.0 floor on the physician
work geographic practice cost index (GPCI) through
12/31/11
 Will be reflected in the revised 2011 MPFS
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Medicare Physician Fee
Schedule FINAL Rule
November 2, 2010
FINAL MPFS 2011
 On November 2, 2010, the Centers for Medicare & Medicaid
Services (CMS) posted a proposed notice for Medicare
payments in the physician fee schedule for calendar year
(CY) 2011.
 Many of these provisions were specified in Health Reform
(“ACA”). The final rule (CMS-1502-P) affects physicians and
office payment for services paid under the resource-based
relative value scale/system (RBRVS), also known as, the
Medicare Physician Fee Schedule.
 Here are the highlights of Rule which becomes effective for
dates of service on or after 11-2-2010.
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https://www.cms.gov/PhysicianFeeSched/PFSFRN/list.asp#TopOfPage
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FINAL MPFS 2011
 Practice Expense: CMS continues for the second year
(at a 50/50 blend), the phasing-in over four years the
implementation of the American Medical Association
(AMA) Physician Practice Information Survey (PPIS)
data administered in 2007/08 for practice expense (PE)
indirect per hour rate. Oncology is still using the AMA
SMS data series. Of interest is this year's calculation of
practice expense for drug administration because many
of our codes were bumped up slightly to include some
supplies.
https://www.cms.gov/PhysicianFeeSched/PFSFRN/list.asp#TopOfPage
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FINAL MPFS 2011
 Related –TC of Imaging Codes Get Cuts: Well, of course, this is
happening in July 2010. But, what it means is that, as of July 6,
you will get a cut of 50% for secondary –TCs of related procedures
in the same family of imaging procedures. This has been
expanded to include more and unrelated procedures. SEE
ADDENDUM F of the fee schedule for additional procedure
reduction codes.
 Telehealth Services: To perform telehealth services, there must
be two-way communication between provider and patient, plus you
must be in HPSA (Health Provider Shortage) area or outside an
MSA. Additional services proposed as allowable in 2011 are
99231-99233 (every three days) and 99307-99310 every 30 days
along with services that are unrelated to Oncology.
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FINAL MPFS 2011
 Physician Extenders: They are sometimes known as NPs and
PAs. They can now perform certification and periodic recertification for SNF patients.
 Bone density payment: The proposal calls for these to be paid
70% of the 2006 RVUs at the 2006 conversion factor with this
year’s GPCIs for codes 77080-77082. This is retroactive to
January 1, 2010.
 Payment for Biosimilars: Here is the payment formula for drugs
that are ‘similar’ to today’s biologics. Down the road, we will see
lots of these in cancer treatment for sure…
 A biosimilar is a product approved under an abbreviated application for a
license of a biological product that relies on a license of another biologic.
 The payment for these biosimilar products will be the sum of all ASPs
assigned to a biosimilar products divided by all applicable units plus six
percent of the REFERENCE PRODUCT…how does that work?
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FINAL MPFS 2011
 Waiver of Cost Sharing for Preventive Services: The ACA requires that
CMS establish regulations that will waive the deductible and coinsurance
requirements for some preventive services, including the following (there
are others that would not be performed by most cancer practices):
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Annual wellness visits,
Initial preventive physician examination, depending upon CMS feed-back,
Screening mammography,
Pneumococcal, influenza, hepatitis B vaccinations,
PAPs/pelvics,
Prostate screening,
Colorectal screening, even if a screening exam becomes therapeutic (e.g. removal of
polyps),
Bone mass measurement,
And, smoking screening and cessation (asymptomatic) in the absence of disease or
treatment reasons to administer smoking cessation.
https://www.cms.gov/PhysicianFeeSched/PFSFRN/list.asp#TopOfPage
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FINAL MPFS 2011
 Primary Care Bonus Payments: Primary Care in certain
areas is getting a bonus under certain conditions. The ACA
(Health Reform) requires that CMS implement a 10% bonus
for providers designated as family medicine, internal
medicine, geriatrics, or pediatrics that furnish primary care
services effective January 1, 2010. The ACA limits the bonus
payments to practitioners whose allowed charges consist of
60% or more of primary care services (codes 99201-99215,
99304-99340, and 99341-99350). There is also a 10%
bonus for surgeons performing procedures in a HPSA area
2011-2016.
https://www.cms.gov/PhysicianFeeSched/PFSFRN/list.asp#TopOfPage
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FINAL MPFS 2011
 Self-Referral Disclosure Law: Effective for dates of service after January
1, 2011 for CAT, MRI, and PET:
 A list of FIVE (not ten) alternative ‘suppliers’ (not a hospital) within a 25mile radius of the physician’s office who provide the same imaging
services. If there are not five, you must list all.
 The list must include, name, address, phone number of other facilities. If
there is no one they can go to, tell the patient they can get these tests in
other facilities.
 The list is to be given to the patient at the time of referral. EACH time the
patient is referred it must be given.
 No signature or form retention is required. Make a note in the chart or
get a stamp for charts---but there should be a notation that it was given.
 Must be written in a way that patients can understand.
 Emergency situations are not an exception.
 Exceptions include patients who are not on Medicare at the time of the
referral.
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FINAL MPFS 2011

Drugs: This rule maintains the current average sales price (ASP) + 6% reimbursement for Part
B drugs; however, it includes proposed changes to ASP reporting, thresholds, and vial
amounts.
 Among other provisions, if the manufacturer is late with quarterly reporting, the CMS
proposes to update ASPs by carrying over the previously reported manufacturer ASP for
applicable national drug code(s) (NDC(s)). This is called the “carry over” methodology,
not to be confused with “the hang-over” methodology, which is when ASPs are calculated
after a night in Vegas. This method will not be implemented if there are not a significant
number of involved NDCs. But, manufacturers are still subject to Civil Monetary Penalties,
if they make a habit of not submitting ASPs.
 CMS also proposes to update the regulations to clearly state that Medicare will not pay for
amounts of “overfill”, i.e. product in excess of the amount reflected on the FDA-approved
label. The ASP plus 6% will be paid for FDA-approved amounts in the vial, but practices
may not bill for and/or pool their overfill.
 Partial quarter ASPs for new drugs were also discussed in the proposed rule. Singlesource drugs will be priced at WAC, plus 6% for that quarter and multisource and line
extension drugs will be added to the weighted average of applicable NDCs.
 CMS also proposes to maintain the applicable threshold percentage for price substitution of
WAMP or AMP for two consecutive quarters at 5%. CMS also finalizes the proposal to
maintain the applicable threshold percentage for price substitution at 5%, however did not
finalize a new proposal for price substitution at 103% of average manufacturer price (AMP)
in certain circumstances when the ASP exceeds the AMP.
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What is Overfill?
 An amount in the vial that is not indicated on the label.
 It is an amount not included in what you paid for in
terms of vial size.
 Under ‘incident to’, practices may not be reimbursed for
anything which does not represent an expense to them.
 Prior to the final rule, overfill was statutorily excluded
from payment. But, the FR reinforced this.
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FINAL MPFS 2011
 Signature on Requisition: CMS will require a physician’s or a non-
physician practitioner’s signature on requisitions for clinical
diagnostic laboratory tests paid under the Clinical Lab Fee Schedule.
This has gotten very negative comments in the past.
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CMS believes that signatures are already required on orders for clinical diagnostic
laboratory tests paid under the Clinical Lab Fee Schedule and there is confusion
about the difference between an order and a requisition.
The proposed policy will also be consistent with the requirement that orders for
diagnostic tests paid under the MPFS must be signed by a physician or appropriate
non-physician practitioner.
CMS has updated this policy to state that it will not be enforced First Quarter
2011.
 One-year filing for Part B claims: There has already been a transmittal
about this. But, starting January 1, 2010, there will be a one-year filing
deadline for claims.
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PQRI Goes Away
 CMS is changing the name of the Physician Quality Reporting
Initiative (PQRI) to the Physician Quality Reporting System
(PQRS).
 The PQRS as it will now be known will pay bonuses equal to 1% of
your Medicare PFS charges for 2011, and a 0.5% bonus for
reporting years in 2012 through 2014.
 In 2015, providers who don't participate in PQRS will suffer a
payment decrease. Beginning in 2015, EPs who do not
satisfactorily report Physician Quality Reporting System measures
will be subject to payment adjustments
 2015: -1.5% payment adjustment
 2016 and beyond: -2% payment adjustment
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FINAL Fee Schedule 2011

PQRI for 2011: This year, there are 194 measures in the rule. Like last year, there are 2
reporting periods: 6 months and 12 months. Other proposed changes to PQRI applicable
to office-based cancer practices include:
 Registries: CMS once again emphasized that Registries are the way to go for more accuracy in
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PQRI data submission. CMS wants to get away from claims submissions ASAP. New cancer
registry: [email protected].
Success Criteria: It is PROPOSED for claims ONLY that you report on at least 3 measures (if
applicable) AND you report on at least 50% of applicable patients, instead of 80%---which would
still be the rate for EMR/EHR or Registry submission.
Group Practices: Two types of group practices are proposed to report in 2011. First are practices
over 200 eligible providers called GPROI. Then there are groups 2-199 eligible providers called
GPROII. To report as a GPROII, you must self-nominate; be in the first 500 practices to do so
after the beginning of the year 2011; and, you must report at least one of GPROII groups, which
do not apply to many cancer practices. CMS is looking for specialty measures groups for
GPROII.
Deleted Measures: These measures used by cancer folks are leaving (maybe) in 2011:
 Measures 114 and 115 for Tobacco Use (more later about this);
 Measure 136 for Melanoma
Measures Reportable by Registry Only: These are the same as last year:
 137-138: Melanoma
 143-144: Pain In Cancer Measures
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GPRO II
 How to Participate in GPROII in 2011
 Potential participants must
 Meet group practice definition
 Have billed Medicare B between 1/1 – 10/29/10
 Self-nominate between 1/3 – 1/31/11
 Provide group practice’s TIN
 Agree to attend/participate in mandatory training sessions and
kick-off meeting
 Reporting requirements vary by size of group practice/# of
eligible professionals
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FINAL MPFS 2011
 PQRS 2011
 New Measures:
 #224 Melanoma: Overuse of Radiation in Stages 0-1A
 Mammography: Reminder System
 #226 Tobacco: Screening/ Cessation/ Interventions
 EHR Reporting: If you have a certified (by CMS) EHR/EMR that can
submit data to CMS for you, you can report using your EMR. Here
are some :
 Immunizations: Influenza and pneumonia
 Screening Mammography
 Therapy or screening for osteoporosis
 Colorectal screening
 EHR Use (duh—obvious if you are submitting by EHR)
 Tobacco use and cessation
 Advance care plan
 Alcohol screening (on the patients, not the staff)
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FINAL MPFS 2011
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PQRS 2011
 MOCP (Maintenance of Certification) Adjustment: Certain certifying agencies board-certify
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physicians and their facilities. If you meet these criteria. This is a health reform provision.
Beginning in 2011, provides an additional 0.5% PQRI bonus for 3 years (2011-2014) if
physicians and other eligible professionals report quality data to the PQRI through a
maintenance of certification (MOC) process, and after 2014, the Secretary could require
participation in an MOC as part of the physician cost/quality index under section 3007 of
ACA.
Public Reporting: the “Medicare Compare” web site was supposed to be up and running
1/1/2011 with all the PQRI and E-Rx success stats for providers. That deadline will now be
2012. Um, whoops…
Integration of PQRI and “Meaningful Use” ARRA incentive: It is proposed that, in 2012,
there will be measures that obviate use of EHR, plus quality of care. This reportedly is to
avoid duplication, as you will not be able to get ARRA incentives along with e-prescribing.
Appeals: For the first time in 2011, it is proposed that the determination of whether or not
EPs qualify for the incentive may be appealed through an ‘informal’ appeal through everpopular [email protected].
Interim Feedback: CMS proposes to provide feedback to participating providers in June
2011 about their PQRI incentive status. Maybe, they should have done this when the
incentive was 2%.
https://www.cms.gov/PhysicianFeeSched/PFSFRN/list.asp#TopOfPage
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FINAL E-Prescribing 2011
 E-Prescribing: E-prescribing will pay 1% of the
providers’ billed and allowed fee schedule services (all
services paid by RVUs) in 2011. 2011 is the last year
where you will not be penalized, if you do not
participate if you qualify. BUT, 2011 is the year that
those that should be penalized will be identified. The
penalty only exists for those who do not have at least
100 cases in the denominator codes (mostly E/M); who
do not report at least 10 encounters in 2012 or, do not
qualify as a physician or physician extender who has at
least 10% of fee schedule revenue in the denominator
codes.
https://www.cms.gov/PhysicianFeeSched/PFSFRN/list.asp#TopOfPage
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E-Rx Reporting
 For successful claims-based reporting in 2011,a single code
should be reported (numerator) G8553 – At least one prescription
created during the encounter was generated and transmitted
electronically using a qualified e-Rx system
 Must be on the same claim (denominator)–90801, 90802, 90804,
90805, 90806, 90807, 90808, 90809, 90862, 92002, 92004,
92012, 92014, 96150, 96151, 96152, 99201, 99202, 99203,
99204, 99205, 99211, 99212, 99213, 99214, 99215, 99304,
99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316,
99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336,
99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348,
99349, 99350, G0101, G0108, G0109
 Combination is reported on at least 25 encounters
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FINAL E-Prescribing
 If you participate in the HIT incentive, you may not receive the eprescribing incentive, but you must e-prescribe AND FOR NOW
YOU MUST REPORT!
 Incentive
 Reporting period: Calendar year, but data 1/1/2011-6/30/2011
will be used to identify those who should be penalized. So, you
must report at least 50% before 6/30/11.
 Reporting mechanisms: Registries, claims, or EHR (if you are
reporting PQRI this way), but half-year data must be submitted
on other deadlines.
 Hardship exceptions—there will be new G-codes for these:
 Rural practices with no high speed internet OR
 Providers near pharmacies that do not process e-rx.
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2009 PQRI Payments
Effective January 2010, CMS revised the manner in which incentive payment information is
communicated to eligible professionals receiving electronic remittance advices. CMS has
instructed Medicare contractors to use a new indicator of LE to indicate incentive payments
instead of LS. LE will appear on the electronic remit. In an effort to further clarify the type of
incentive payment issued (either PQRI or eRx incentive), CMS created a 4-digit code to indicate
the type of incentive and reporting year. For the 2009 PQRI incentive payments, the 4-digit code is
PQ09. This code will be displayed on the electronic remittance advice along with the LE indicator.
For example, eligible professionals will see LE to indicate an incentive payment, along with PQ09
to identify that payment as the 2009 PQRI incentive payment. Additionally, the paper remittance
advice will read, "This is a PQRI incentive payment." The year will not be included in the paper
remittance.
If you have questions about the status of your PQRI incentive payment (during the distribution
timeframe), please contact your Provider Contact Center. The Contact Center Directory is
available on the CMS website. The QualityNet Help Desk is available Monday through Friday
from 8:00 AM - 8:00 AM EST at 1-866-288-8912 or via [email protected] . They can also
assist with program and measure-specific questions.
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Imaging Reduction
 Transmittal 694, CR 6965, effective July 1 and
implemented July 6, 2019
 Implements Health Reform Provision
 Reduction of –TC increased from 25% to 50% for
additional procedures done in the same session on the
same day.
 Many experts thought this would not happen until 2011.
However, you will see more of this in 2011!
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Claims Filing
 Transmittal 697, CR 6960, effective January 1, 2010 and
implemented October 4, 2010
 Claims must be filed within one calendar year. Implementation will
be according to this schedule:
 1) claims with dates of service prior to October 1, 2009 will be
subject to pre-PPACA timely filing rules and associated edits;
 2) claims with dates of service October 1, 2009 through December
31, 2009 received after December 31, 2010 will be denied as
being past the timely filing statute and;
 3) claims with dates of service on or after January 1, 2010
received more than 1 calendar year beyond the date of service will
be denied as being past the timely filing statute (ex: claim DOS =
3/15/10, claim must be received by COB 3/15/11).
 One exception is a mistake by CMS or agents thereof.
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Signatures: Review Criteria
 Auditors: MACs, CERTs, and RACs, just to name a few. CMS
requires that orders for healthcare services and the services that
were provided be authenticated by the author using either a
handwritten or electronic signature. CMS has made it clear that
stamped signatures are not an acceptable form of authentication.
 The previous language in the CMS Program Integrity Manual
required a “legible identifier”. The recent CMS Transmittal 327 has
added additional clarification and signature assessment
requirements.
 Any auditor can use this rule, unless other laws or regulations
supersede this rule.
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SIGNATURES: CMS AUDITS

If the signature is missing from any other medical documentation, excluding the order, the
reviewer should accept a signature attestation from the author of the medical record entry.
Providers should not add late signatures to the medical record “beyond the short delay that occurs
during the transcription process” and should instead use the signature attestation process. Other
providers in the same group may not attest to the original author’s signature.

In addition, if the Medicare policy is “silent” on whether a signature must be dated, the reviewer
has been instructed to ensure that the rest of the documentation contains enough information to
determine the date when the service was ordered and/or performed. For example, the reviewer
finds that the first and third order on a page have a specific date; however, the second order on
the same page is not dated. It could be assumed that the second order occurred on the same
date.

All providers should be reviewing all documentation for dates and signatures in a timely
manner and prior to considering the medical record complete. Also, review all request letters
for any additional language the reviewer might add reminding you that a signature log or
attestation can be submitted with the copies as part of the Additional Documentation Request
(ADR).
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National Coverage Analyses
(NCAs)

Tobacco Cessation (8/25/2010)
 The Centers for Medicare and Medicaid Services (CMS) has determined that the evidence is adequate to

conclude that counseling to prevent tobacco use, which is recommended with a grade of A by the U.S.
Preventive Services Task Force (USPSTF) for all adults and pregnant women who use tobacco, is
reasonable and necessary for prevention of illness or disability and is appropriate for individuals entitled to
benefits under Part A or enrolled under Part B.
Therefore CMS will cover tobacco cessation counseling for outpatient and hospitalized Medicare
beneficiaries:
 Who use tobacco, regardless of whether the patient has signs or symptoms of tobacco-related disease;
 Who are competent and alert at the time that counseling is provided; and
 Whose counseling is furnished by a qualified physician or other Medicare-recognized practitioner.

CMS will cover two individual tobacco cessation counseling attempts per year. Each attempt may
include a maximum of four intermediate or intensive sessions, with the total annual benefit thus
covering up to eight sessions per Medicare beneficiary who uses tobacco. The practitioner and
patient have the flexibility to choose between intermediate (more than three minutes) or intensive
(more than ten minutes) cessation counseling sessions for each attempt.

This decision memorandum does not modify existing coverage for minimal individual cessation
counseling (three minutes or less), which is already covered as part of each Evaluation and
Management (E&M) visit and is not separately billable.
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The 5A’s of Tobacco
Cessation
 Ask about tobacco use
 Advise patient to quit
 Refer (1-800-QUIT-NOW or local program)
 Assess readiness to quit
 Assist in quit attempt
 Arrange follow-up
Cessation Counseling Attempt
 Cessation counseling attempt occurs when a qualified
physician or other Medicare-recognized practitioner
determines that a beneficiary meets the eligibility
requirements above and initiates treatment with a
cessation counseling attempt.
 A cessation counseling attempt includes up to 4
cessation counseling sessions (1 attempt = up to 4
sessions).
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Cessation Counseling Attempt
 Two cessation counseling attempts (or up to 8
cessation counseling sessions) are allowed every 12
months.
 In calculating the 12-month period, it is necessary for
at least 11 months to have passed following the
month in which the first Medicare-covered cessation
counseling attempt/session was performed.
 Per CR4104, providers may query the CWF to see how
many covered sessions a beneficiary has already received.
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Cessation Counseling
Session
 Face-to-face patient contact of either the intermediate
(>3 min and < 10 min) or intensive (>10 min) type
performed either by or “incident to” the services of a
qualified practitioner for the purpose of counseling the
beneficiary to quit smoking or tobacco use.
 During a 12-month period, the practitioner and the
beneficiary would have the flexibility to choose between
intermediate or intensive cessation strategies for each
session.
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Coding
 CPT codes
 99406 Smoking and tobacco-use cessation counseling visit; intermediate,

greater than 3 minutes up to 10 minutes
99407 Smoking and tobacco-use cessation visit; intensive, greater than 10
minutes
 These HCPCS codes became effective January 1, 2008
 Medically necessary E/M may also be reported with modifier 25.
 No CCI edits linking these codes with 00100-01999
 For patients where diagnosis and treatment is not impacted by
smoking, use:
 G0436: Long Descriptor: Smoking and tobacco cessation counseling visit

for the asymptomatic patient; intermediate, greater than 3 minutes, up to
10 minutes, Short Descriptor: Tobacco-use counsel 3-10 min;
G0437: Long Descriptor: Smoking and tobacco cessation counseling visit
for the asymptomatic patient; intensive, greater than 10 minutes, Short
Descriptor: Tobacco-use counsel >10 min.
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Coding
 ICD-9-CM for patients that qualify due to treatment or diagnosis
 Codes should reflect:
 The condition the patient has that is adversely affected by tobacco use, or
 The condition the patient is being treated for with a therapeutic agent whose
metabolism is affected by tobacco use.
 For others…
 1.Who use tobacco (regardless of whether they have signs or symptoms of
tobacco-related disease);
 2.Who are competent and alert at the time that counseling is provided;
and,
 3.Whose counseling is furnished by a qualified physician or other
Medicare- recognized practitioner.
 These diagnosis codes that should be reported for these individuals are:
 ICD-9 code 305.1 (non-dependent tobacco use disorder), or
 ICD-9 code V15.82 (history of tobacco use).
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Documentation
Medical record should support:
 The level of service provided,
 The time spent counseling and
 That the coverage criteria were met.
Services could be subject to post-payment review.
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Sources
 CMS Manual System
 Pub 100-03 Medicare National Coverage Determinations
Transmittal 36
 Pub 100-04 Medicare Claims Processing Transmittal 562
 Pub 100-04 Medicare Claims Processing Transmittal 726
 MLN Matters
 MLN Matters Number MM3834
 MLN Matters Number MM4104
42
Physician Quality Reporting
System (PQRS)
 Program from the Centers for Medicare and Medicaid
Services to provide financial incentives for
professionals who successfully report a designated set
of quality measures
 Double good for you- #226 (2011), Inquiry Regarding
Tobacco Use
43
Implementing the American
Reinvestment & Recovery Act of 2009
• American Reinvestment & Recovery Act – February
2009
• EHR Incentive NPRM on Display – December 30,
2009; published January 13, 2010
• NPRM Comment Period Closes – March 15, 2010
• Final Rule Published 7/13/2010
onPoint Oncology LLC
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Stage 1
2011*
Stage 2
2013*
1.
Capturing health information in
a coded format
1.
2.
Using the information to track
key clinical conditions
2.
3.
3.
Communicating captured
information for care
coordination purposes
4.
Reporting of clinical quality
measures and public health
information
Capture
information….
4.
5.
6.
7.
Disease management, clinical
decision support
Medication management
Support for patient access to
their health information
Transitions in care
Quality measurement
Research
Bi-directional communication
with public health agencies
Report information…
Stage 3
TBD*
1.
Achieving improvements in
quality, safety and efficiency
2.
Focusing on decision support
for national high priority
conditions
3.
Patient access to selfmanagement tools
4.
Access to comprehensive
patient data
5.
Improving population health
outcomes
Leverage information
to improve
outcomes…
*Indicates “payment year” in which each Stage is first introduced. Actual
compliance timeframe depends on an EP’s first payment year.

Eligible Professional (EP)
 defines those providers eligible for incentives

“Certified EHR”
 Based on set of standards, implementation specifications, and
certification criteria EHR vendors must meet---ONLY certified in
EMR in Oncology Altos’ OncoEMR

“Meaningful Use”
 A set of measures for using a certified EHR which EP’s must meet
 Continuous 90 day reporting period (first payment year)
 Reporting period = All year (each subsequent year)

Choose a program
 Medicare or Medicaid
 Must choose one (may switch programs once)
eligible professionals (EP’s)
Medicare
Medicaid
 Doctor of medicine or
 Physicians
osteopathy
 Doctor of dental surgery or
dental medicine
 Dentists
 Certified nurse midwives
 Doctor of podiatric medicine
 Nurse practitioners
 Doctor of optometry
 Physicians assistants (in
 Chiropractor
rural health clinic or FQHC
led by a physician assistant)
eligible professionals (EP’s)
 EP’s who see patients in multiple practices but do not
have a certified EHR at each practice are eligible if
more than 50% of encounters occur at an EHRenabled practice
 Starts in calendar year 2011
 EP’s may receive payments up to $44,000 over five years
 Incentive based on percentage of Medicare allowable
 Meaningful Use must be demonstrated for all patients (not just Medicare)
 Incentive payments end in 2015
 Penalties - reduction in Medicare reimbursements for EP’s not
demonstrating Meaningful Use starting in 2015
2011
2012
2013
2014
2015
2016
2017
TOTAL
Adopt
2011
$18,000
$12,000
$8,000
$4,000
$2,000
$0
$0
$44,000
Adopt
2012
----------
$18,000
$12,000
$8,000
$4,000
$2,000
$0
$44,000
Adopt
2013
----------
-----------
$15,000
$12,000
$8,000
$4,000
$0
$39,000
Adopt
2014
----------
-----------
-----------
$12,000
$8,000
$4,000
$0
$24,000
Adopt
2015
+
----------
-----------
-----------
----------
$0
$0
$0
$0
•
Maximum payments based upon 75% of Medicare Part B fee schedule payments up to the maximum
incentive amount per year.
•
e.g., Minimum of $24,000 per year to be eligible for maximum $18,000 bonus
First Payment Year
Reduction in Medicare Fee
Schedule for non-adoption
of certified EHR
2011
$0
2012
$0
2013
$0
2014
$0
2015
-1%
2016
-2%
2017 and thereafter
-3%
•
In 2015, reduction in Medicare reimbursement begins for physicians who
are not meaningful EHR users (1% per year, capped at a 3% reduction).
•
Statute allows for exceptions for “significant hardship” as determined by
the Secretary.
 Starts in calendar year 2011
 EP’s may receive payments up to $63,750 over six years
 Incentive based on up to 85% of state-calculated global
average costs for EHR
 1st yr cost no later than 2016
 No payments made after 2021 or more than 5 years
 No Medicaid penalty for failure to demonstrate Meaningful
Use
Payment
Component
Base Year
Maximum of 85% of
EHR Acquisition
and Implementation
Costs
Year 2
Year 3
Year 4
Year 5
Year 6
TOTAL
Physician
$21,250
$ 8,500
$ 8,500
$ 8,500
$ 8,500
$ 8,500
$63,750
Certified Nurse
Mid-Wife
$21,250
$ 8,500
$ 8,500
$ 8,500
$ 8,500
$ 8,500
$63,750
Dentist
$21,250
$ 8,500
$ 8,500
$ 8,500
$ 8,500
$ 8,500
$63,750
Nurse
Practitioner
$21,250
$ 8,500
$ 8,500
$ 8,500
$ 8,500
$ 8,500
$63,750
$21,250
$ 8,500
$ 8,500
$ 8,500
$ 8,500
$ 8,500
$63,750
Physician
Assistant
 Requires minimum 30% Medicaid patient
mix
 (20% for Pediatrics)
 Patient mix percentage based on EP-selected
90 day average within previous 12 months,
calculated by encounters or by patient panel
 Group practice claim volume can used to
calculate eligibility
 Encounters defined as “services rendered”
 Medicaid does not require M.U. in first year if
an EP can demonstrate that they are:
 Adopting
 Implementing
 Upgrading
…their Certified EHR technology
Medicare or Medicaid?
 If an eligible provider opts to receive incentives under
Medicare
 May collect PQRI and HITECH incentives
 May NOT collect e-Rx incentives
 If an eligible provider opts to receive incentives under
Medicaid
 May collect PQRI, HITECH, and e-Rx incentives
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 2011 – self-reporting (attestation) via CMS web
portal---was supposed to be registered in PECOS
but, for now, you don’t…
 2012 & beyond – if available, report information
directly from certified EHR using:
 Integrated web portal
 Local HIE
 Registries
… Specifics TBA
HOW:
A single, consolidated annual incentive payment
 Medicare: paid by CMS (not via claims Fiscal
Intermediary)
 Medicaid: paid by State Medicaid program, or their
designated intermediary
Payments will be made once an EP:
– Demonstrates Meaningful Use for the reporting period and
reaches the threshold for maximum payment, within 15-46
days after attestation
 EP’s can reassign their Medicare or Medicaid payment,
with guidelines
 Incentives are calculated individually per EP, group
affiliations are not considered in 2011
Records retention
 Evidence of qualification to receive incentive payments
must be retained for SIX years
Two Sides To The Story
 Health IT Vendors
 Design EHR technologies
that meet the standards and
certification criteria
 Submit EHR technologies to
an ONC-Authorized Testing
and Certification Body
(ONCATCB), which tests and
certifies EHR technologies
for use
onPoint Oncology LLC
 Health Care Providers
 Demonstrate meaningful use
of certified EHR technology
to qualify for the Medicare
and Medicaid EHR incentive
programs by using MU
technology in the operation
of the facility.
62
What Is Meaningful Use?
 Your facility must attest that:
 Are using certified EHR technology (with technology




specified so it can be checked)
Have met each of the 15 core meaningful use objectives;
and 5 of the 10 “menu” objectives
Have accurately and completely reported the associated
HIT functionality measures – one for each objective
Have accurately and completely reported 6 quality
measures using your EHR to generate values (electronic
reporting from EHR starting in 2012)
Reporting period is 90 days in first reporting year
onPoint Oncology LLC
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Core Set
Policy
Priority
Stage 1 Objectives
Use CPOE for medication orders
Improving
quality, safety,
efficiency and
reducing health
disparities
Measure
30%+ of
patients
Implement drug-drug & drug-allergy checks
Functionally
enabled
Generate and transmit permissible prescriptions
electronically (eRx)
40%+ of
eligible
prescriptions
Record selected demographics (preferred language,
gender, race, ethnicity, date of birth)
50%+ of
patients
Maintain an up-to-date problem list of current and active
diagnoses
80%+ of
patients
Maintain active medication list
80%+ of
patients
Policy
Priority
Stage 1 Objectives
Maintain active medication allergy list
Improving
quality,
safety,
efficiency
and
reducing
health
disparities
(cont.)
Measure
80%+ of
patients
Record and chart changes in selected vital signs (height,
weight, BP, BMI, growth charts (2-20 yrs.)
50%+
of patients
Record smoking status for patients 13 years old or older
50%+
of patients
Implement one clinical decision support rule along with the
ability to track compliance that rule
1 rule
Report ambulatory quality measures to CMS or the States
Aggregate
numerator/
denominator
Policy Priority
Engage patients
and families in
their healthcare
Improve Care
Coordination
Ensure adequate
security and
privacy
provisions for
personal health
information
Stage 1 Objectives
Measure
Provide patients with an electronic copy of their health
information (including diagnostic test results, problem list,
medication lists, and medication allergies) upon request,
within 3 days of request
50%+ of all
patients who
request
Provide clinical summaries to patients for each office visit
within 3 days of visit
50%+ of all
office visits
Capability to exchange key clinical information (for example
problem list, medication lists, medication allergies,
diagnostic test results) among providers of care and patient
authorized entities electronically
1 test of
capability
Protect electronic health information created or maintained
by certified EHR technology through the implementation of
appropriate technical capabilities.
Conduct or
review a
security risk
analysis
Menu Set
Policy
Priority
Improving
quality, safety,
efficiency and
reducing health
disparities
Stage 1 Objectives
Implement drug formulary
checks
Measure
Functionality
enabled
Incorporate clinical lab test results into certified
EHR technology as structured data
40%+ of all clinical
lab tests ordered
Generate lists of patients by specific conditions to
use for quality improvement, reduction of disparities,
research or outreach
At least 1 report of
patients with
condition
Send reminders to patients 65 years or older of 5 years
or younger per patient preference for preventive/
follow up care
20%+
of patients
Policy
Priority
Engage patients
and families in
their healthcare
Improve Care
Coordination
Stage 1 Objectives
Measure
Provide patients with timely electronic access to their
health information (including lab results, problem list,
medication lists, medication allergies) within four
business days of the information being available to
the EP
10%+ of
patients
Use certified EHR technology to identify patient-specific
education resources and provide those resources to the
patient if appropriate
10%+
of patients
Policy Priority
Improve care
coordination
Stage 1 Objectives
Measure
Perform Medication Reconciliation when the EP or eligible
hospital receives a patient from another setting of care or
provider of care
50%+ of care
transitions to EP
Provide summary of care record for each transition of a
patient to another setting of care or provider of care or
referral to another provider of care
50%+ of care
transitions from
EP
Capability to submit electronic data to immunization registries
or Immunization Information Systems and actual submission At least 1 test
in accordance with applicable law and practice
Improve
population health
Capability to submit electronic syndromic surveillance data to At least 1 test
public health agencies and actual submission in accordance
with applicable law and practice
 Some measures can be reported as inapplicable if the
EP has no applicable patients or an insufficient # of
actions that would allow calculation
EP’s must submit clinical data on 6 total measures – 3 Core
(using alternate if necessary) …
Core Measures
+
Alternate Core Measures
NQF 0013
Hypertension: Blood
Pressure Measurement
NQF0024
Weight Assessment and
Counseling for Children
and Adolescents
NQF 0028
Preventive Care and
Screening Measure Pair: a.
Tobacco Use Assessment
b. Tobacco Cessation
Intervention
NQF 0041
PQRI 110
Preventive Care and
Screening: Influenza
Immunization for Patients ≥
50 Years Old
NQF 0036
Childhood Immunization
Status
NQF 0421
PQRI 128
Adult weight screening and
follow up
- Measures are reported as numerator/denominator
- EP’s can report a denominator of ZERO if there are no
applicable cases
… and 3 “additional measures” (38 available)
A few examples:
NQF 0059
PQRI 1
Title: Diabetes: Hemoglobin A1c Poor Control
Description: Percentage of patients 18 - 75 years of age with diabetes (type 1 or
type 2) who had hemoglobin A1c > 9.0%.
NQF 0575
Title: Diabetes: Hemoglobin A1c Control (<8.0%)
Description: The percentage of patients 18-75 years of age with diabetes (type 1
or type 2) who had hemoglobin A1c <8.0%
NQF 0081
PQRI 5
Title: Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or
Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic
Dysfunction (LVSD)
Description: Percentage of patients aged 18 years and older with a diagnosis of
heart failure and LVSD (LVEF< 40%) who were prescribed ACE inhibitor or ARB
therapy.
Where Do I Sign Up?
 Registration begins in January 3, 2011 at the EHR
Incentive Program website
http://www.cms.gov/EHRIncentivePrograms/
 Requirements include






Name
NPI
Business address and phone
Taxpayer ID number for incentive payments
Medicare or Medicaid program selection
State selection for Medicaid providers
onPoint Oncology LLC
73
 Select your EHR partner WHO IS
CERTIFIED!
 Develop detailed implementation plan




Set goals & detailed timelines
Set expectations
Gain “buy in”
Plan for the unexpected
 Pick your program (Medicare or Medicaid
or E-Rx)
 Implement!
More Information
 For 3 MEDICARE tip sheets,
 go to http://www.cms.gov/EHRIncentivePrograms.
Select the “Medicare Eligible Professional” tab on
the left, and then scroll to “Downloads.”
 Medicaid EHR Incentive Payments for Eligible
Professionals
 Go to http://www.cms.gov/EHRIncentivePrograms.
Select the “Medicaid Eligible Professional” tab on
the left, and then scroll to “Downloads.”
 EHR Incentive Program Timeline
 Find it at http://www.cms.gov/EHRIncentivePrograms
in the “Downloads” section of the “Overview” tab.
75
Multiple Layers of Audits – Federal Medicare
RAC
MAC
Incorrectly
Billed
Claims
Processing
Errors
X
X
X
X
X
X
X
PSC/ZPIC
CERT
MAC Billing
Audits
Medical
Necessit
y
Incorrect
Payment
Amounts
Non-covered
Services
Incorrectl
y Coded
Services
Duplicate
Services
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Office of Audit
Services Audits
Annual Work Plan
Projects
X
X
Large $ Items
X
X
X
Don’t Be
Caught
Unaware……...
 Be
Prepared!
77
New ICD-9 Codes 10-1-2010
 New Hem-Onc Codes










Red blood cell disorders (275.0_)
Transfusion circulatory overload (276.61)
Post-transfusion purpura (287.41)
Other secondary thrombocytopenia (287.49)
Febrile non-hemolytic transfusion reaction (780.66)
Jaw pain (784.92)
Hemoptysis, unspecified (786.30)
Feces disorders (787.6_)
Transfusion reactions (999.6_-999.8_)
Do not resuscitate status (V49.86)
onPoint Oncology LLC
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Deleted ICD-9-CM Codes 10-1-2010
 Iron Disorders (275)
 Fluid disorders (276.6)
 Secondary thrombocytopenia (287.4)
 Hemoptysis (786.3)
 Incontinence of feces (787.6)
onPoint Oncology LLC
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CPT: 96445 To 96446
 Intra-peritoneal Chemo
 96445 has been deleted
 96446, Chemotherapy into the peritoneal cavity through
an indwelling catheter or port
 No peritoneocentesis necessary
 Reflects current practice…
onPoint Oncology LLC
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New HCPCS Codes 2011
onPoint Oncology LLC
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Changed and Deleted HCPCS
2011
Changed
Deleted
onPoint Oncology LLC
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Your To Do List Right Now
 Make sure you have received 2009 E-Rx and PQRI payments.
 Run your 2011 numbers using the new RVUs and allowables.
 Ascertain your vendor’s plan for Meaningful Use for implementation in 2011 or
2012.
 Select your incentive programs for 2011.
 Check to make sure you are NOT billing overfill in your facility.
 Update your Superbill---for a suggested one, see

http://communityoncology.info/category/library/
 Think about alternative revenue streams—oral drugs, trials, etc.
 Participate in the struggle—can you afford another cut or even a hold.
onPoint Oncology LLC
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 CAN Web Site
 The latest news
 Forms
 Regulations
 Newsletters
 Presentations
 http://communityoncology.info
onPoint Oncology LLC
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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
onPoint Oncology LLC
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THANK YOU FROM ONPOINT ONCOLOGY LLC!
onPoint Oncology LLC
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