Transcript Coding-for-2010-v5-12-10

ELIMINATION OF CONSULTATION CODES
IN THE ONCOLOGY/HEMATOLOGY
PRACTICE –
AND OTHER ISSUES
Presented by:
Roberta L. Buell, MBA, principal, onPoint Oncology LLC, Sausalito, Calif
Recorded on December 11, 2009
DISCLAIMER
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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.
2
SESSION OBJECTIVES

Discuss Proposed Fee Schedule for 2010

Discuss Coding/Options for PQRI 2009-2010
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Discuss Coding for E-Prescribing 2009-2010
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Discuss ICD-9-CM Codes 2010
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Discuss HCPCS Codes 2010
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Discuss the Status of RACs
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Know What You Need to Do Next
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HOLD IT!!!
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The Centers for Medicare & Medicaid Services (CMS) is working with Congress, health care providers, and the
beneficiary community to avoid disruption in the delivery of health care services and payment of claims for
physicians, non-physician practitioners, and other providers of services paid under the Medicare physician fee
schedule, beginning January 1, 2010. In this regard, CMS has instructed its contractors to hold claims for services
paid under the Medicare Physician Fee Schedule (MPFS) for up to the first 10 business days of January (January 1
through January 15) for 2010 dates of service. This should have minimum impact on provider cash flow because, by
law, clean electronic claims are not paid any sooner than 14 calendar days (29 days for paper claims) after the date
of receipt. Meanwhile, all claims for services delivered on or before December 31, 2009, will be processed and paid
under normal procedures.
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The holding of claims allows Medicare contractors time to receive the new, updated payment files and perform
necessary testing before paying claims at the new rates. CMS has instructed contractors to begin processing claims
at the new rates no later than January 19, 2010. Please note that most contractors are closed on the January 18
Martin Luther King Day holiday. Therefore, even absent a new update, most claims likely would not have been paid
any sooner than January 19, 2010, given the aforementioned statutory 14-day payment floor.
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CMS has extended the 2010 Annual Participation Enrollment Program end date from January 31, 2010, to March 17,
2010– therefore, the enrollment period now runs from November 13, 2009, through March 17, 2010.
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The effective date for any Participation status change during the extension, however, remains January 1, 2010, and
will be in force for the entire year.
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Contractors will accept and process any Participation elections or withdrawals, made during the extended enrollment
period that are received or post-marked on or before March 17, 2010.
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MEDICARE PHYSICIAN PAYMENT BASICS
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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.
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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 after 2/28/10.
 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 $28.3895 down from $36.0666 after the
2 month hold.
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IMPACT OF 2010 MPFS CHANGES
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OTHER FEE SCHEDULE CHANGES FOR 2010
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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:
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New consults in the office will be coded as New Patients
(99201-99205). This means that no one in practice of your
specialty has seen the patient at all for 36 months.
Established consults in the office will be coded as Established
Patients (99212-99215)…this is not an exact match with
consultation criteria.
Hospital consults will be coded as Admissions (99221-99223)
with a new modifier (“AI”) signifying who was the admitting
physician. There is no exact crosswalk of five levels to three.
TeleHealth consults are the exception. They have special Gcodes.
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THE GOOD NEWS IS….
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Your documentation only needs to match the
code you are using…no need for all the complex
consultation documentation!!!
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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 from Frank Cohen; 2010 NF RVUs; 2009 CF and GPCIs =1
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CPT RULE CHANGES 2010
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Concurrent Care
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“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.
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Transfer of Care
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“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…”
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CPT CONSULTATIONS 2010
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“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.”
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CPT CONSULTATIONS
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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.
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CPT CHANGES FOR CONSULTATIONS 2010
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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
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VALUE-BASED PURCHASING
AND PQRI
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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.
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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
MMSEA - Medicare, Medicaid, and SCHIP Extension Act of
2007

Authorized 2008 PQRI, 1.5% incentive, eliminated
cap Incentive
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Required alternative reporting periods and
alternative reporting criteria for 2008 and 2009
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Requires alternative reporting for measures
groups and for registry-based reporting
MIPPA - Medicare Improvements for Patients and Providers
Act
Section 131: 2009 PQRI
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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
Section 132: e-Prescribing Incentive Program
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Authorized separate 2% incentive payment to EPs who
successfully use a qualified eprescribing system
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eRx measure removed from 2009 PQRI --separately
posted measure specifications.
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The Secretary has the authority to update the codes
of the electronic prescribing measure in the future.
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FR requires names of eligible professionals who are
successful e-prescribers be posted on the CMS web
site
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PQRI :
ELIGIBLE PROFESSIONALS
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Physicians
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MD/DO
Podiatrist
Optometrist
Oral Surgeon
Dentist
Chiropractor
Therapists
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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
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2009-2010 PQRI QUALITY MEASURES
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153 PQRI quality measures for 2009
172 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
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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 is a new measure, “Cancer Stage
Documented”--Measure #194 for colon, breast,
and rectal cancer. Check it out!!!
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2010 PQRI MEASURES GROUPS
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7 measures groups:
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•
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.
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2010 PQRI REPORTING PERIODS
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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
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In 2010, 2 reporting periods apply to
claims, registries, and measures groups.
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2009-2010 PQRI SATISFACTORY
REPORTING OPTIONS
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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
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•
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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!
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NEW REPORTING OPTION 2010
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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.
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PQRI THINGS TO REMEMBER
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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.amaassn.org/ama/pub/category/17432.html
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Billing Parameters for PQRI
REPORTING MEASURES WITH CLAIMS
C
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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
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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.
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2009 SUCCESSFUL E-PRESCRIBERS
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“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
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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
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REPORTING SCENARIOS
E-PRESCRIBING: 2009 ONLY
A 70 year old male patient presents to the
clinician’s office for medical care.
Scenario 1:
The clinician discusses
current medications and
prescribes new
medication, updates
active medication list in
eRx system, transmits
prescription electronically
to pharmacy
Reports G8443
Scenario 2:
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
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CODING FOR E-PRESCRIBING 2009-2010
You must use a QUALIFIED E-prescribing system AND
 Have an encounter with one of these codes
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
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 was 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
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OFFICIAL 2010 REPORTING

Numerator: eRx Quality-Data Code for Successful Reporting:

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REPORTING DENOMINATOR: Any patient visit for which one (or more) of the
following denominator codes applies and is included on the claim

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Prescription(s) Generated and Transmitted via Qualified eRx System G8553: At least one
prescription created during the encounter was generated and transmitted electronically
using a qualified eRx system
Denominator Criteria (Eligible Cases): Patient visit during the reporting period (CPT or
HCPCS): 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
25 Encounters with G8553 per Eligible Provider
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FREE E-PRESCRIBING IN ONCOLOGY!
•
•
•
•
That’s right!
Just for cancer practices!
www.oncologyerx.com
For more information,
contact me!
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ICD-9-CM 2009-2010 (10-1-2009)
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New Codes for Cancer
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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
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ICD-9-CM CODING 2009-2010 (10-1-2009)
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ICD-9-CM CHANGES 2010 (10-1-2009)

New Codes to Describe
Oncology
Administrators, Coders,
Billers After Seeing
2010 Regs!!!
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

799.21 Nervousness
799.22 Irritability
799.24 Emotional lability
799.25 Demoralization
and apathy
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Redundancy of CMS Auditors
Roles of Medicare Improper Payment Review Entities
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Source: American Hospital Association
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Where Did RACs Find Overpayments?
Most overpayments were collected from inpatient
hospital services for medical necessity and coding
SNF 2%
Doc/Ambulance/
Lab/DME/Other 4%
Inpatient
Hospital 85%
95% from
Hospitals
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RAC Appeals Experience to Date
RAC DEMO FINDINGS
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RAC Jurisdictions
A
D
B
March 1, 2009
March 1, 2009
August 1, 2009
C
3
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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
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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.connellyhealthcare.com/RAC
 Region D (Midwest, West Coast, Southwest states)
HealthDataInsights
www.healthdatainsights.com/RAC.aspx

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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

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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
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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 RAC 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?
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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

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.?
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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
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?
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




MACs/ Carriers per their
own internal screens
CERT Auditors
Medical Integrity
Contractors
Bundling and Medically
Unlikely Edits
Private Insurance
Companies on behalf of
MA or themselves.
WHO ELSE CAN ASK FOR/ DENY/REVIEW STUFF
49
NEW HCPCS CODES 2010
50
OTHER HCPCS CHANGES
J9170 for Docetaxel 20 mg has been deleted
for dates of service after 12/31/09
 Notice that the Atropine code has changed.
 -AI (A-Eye) is for Principal Physician of Record,
use this on hospital records.

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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!
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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 Emails or FAX to 650-618-8621
 Go to our website:
http://www.onpointoncology.com

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THANK YOU FROM ONPOINT ONCOLOGY LLC!
54