Transcript Medicare 2010-2011

MOASC
Webinar
July 21, 2010
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What’s Going On Right Now
What Might Happen In 2011: MPFS Proposed
PQRI and E-Prescribing 2010-2011
Meaningful Use Final Rule 7-13-2010
ICD-9-CM for 2010-2011
Follow Up Items For Practices
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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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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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http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/medicare/the-medicare-physician-paymentschedule.shtml
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We have had 4 different conversion factors
this year!
◦ 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
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We have a new fee schedule starting July
1…yikes!
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Procedure
96365
96367
96372
96411
96413
96415
96417
99204
99205
99213
99214
2010 $
$67.48
$32.82
$21.76
$61.58
$143.07
$30.97
$70.80
$155.23
$194.69
$66.74
$99.93
Procedure
2009 RVUs
2010 RVUs
96365
1.91
1.83
96367
0.96
0.89
96372
0.58
0.59
96411
1.77
1.67
96413
4.09
3.88
96415
0.93
0.84
96417
2.04
1.92
99204
3.93
4.21
99205
4.96
5.28
99213
1.70
1.81
99214
2.56
2.71
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To assist providers in their quest to get physicians enrolled in PECOS, the Part
B MACs will be sending revalidation letters to all physicians who have not
updated their Medicare enrollment in over 6 years. (Medicare contractors
first began updating the PECOS database with physician enrollments in
November of 2003; therefore, physicians enrolled prior to this date will not be
in the database.). The letter will instruct the physician to submit either an
updated paper enrollment form or to enroll online via PECOS.
Need to update any changes within 30 days
◦ Address, phone, suite
◦ New members in group
◦ Other changes
If no claims to Medicare in one year—physician is disenrolled in Medicare
REFERRING PHYSICIAN WITH NO NPI REGISTERED THROUGH PECOS CAN BE
REJECTED!
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◦ Claims ordered / referred must:
 NPI of ordering provider
 Name in PECOS or MAC system
 Specialty as listed
◦ Grace Period (??)
 Phase 1: 10/5/09 to 7/6/10 warning message on
remittance
 Phase 2: 7/6/10 and after: claim rejected if referring
individual not in Pecos or MAC list
 JULY 1, 2010: CMS SAID THEY WOULD HOLD OFF ON
REJECTING CLAIMS.
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Transmittal 762, Change Request 6711,
effective July 30, 2010
◦ Use of –JW still optional at discretion of Carrier
◦ Depends upon J-code. Let’s say J-code is 1 mg.
You use 9 mg and waste 1 mg. You would bill 2
lines
 9 units on one line
 1 unit with –JW on another line
◦ But, if the J-code is 10 mg, you would just bill the
one line.
◦ Must document waste in either case.
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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.
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Many experts thought this would not happen
until 2011.
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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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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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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. If a signature is not
legible or is missing, the providers should take the appropriate steps to comply with the
requirement in advance to prevent delays regarding the outcome of the review.
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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Retro changes in fee schedule means that patient
portions will need to be changed or secondaries
need to be re-billed.
◦ Routine waiver of patient portions implicated AntiKickback statute.
◦ Patient portions in this instance may be waived under
these conditions:
 If they fall within the Retroactive period of claims
adjustment.
 Once the actual adjusted fee schedules is paying, beneficiary
portions must be collected as usual.
 Waivers must be made without regard to beneficiary, item or
service, AND there is no advertising or solicitation to
patients.
 Waivers are not conditional in any way.
http://www.oig.hhs.gov/fraud/docs/alertsandbulletins/Retroactive_Beneficiary_Cost-Sharing_Liability.pdf
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ESAs in Chronic and End-Stage Renal Disease
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CMS received a formal request for a national coverage determination (NCD) for
recombinant human erythropoietin (ESAs) for treatment of chronic kidney disease
(CKD) and dialysis-related anemia.
Medicare has historically made payment for ESAs for particular indications with
specific conditions. Erythropoiesis Stimulating Agents (ESAs) are drugs or biologic
agents which interact with the erythropoietin receptor or its pathway.
Anemia, which has multiple causes, is not uncommon in some patient
populations, such as those with chronic renal disease. Emerging data have
suggested that ESA use may be associated with decreased survival and increased
morbidity in both renal and non-renal patient populations.
ESAs have FDA approved labeling that includes boxed warnings citing greater risks
for death, serious cardiovascular events, and stroke in some chronic renal failure
populations. The requestor points to recent clinical studies that have shown
significant ESA-related adverse safety signals and asks CMS to establish coverage
limitations for ESA use in both pre-dialysis and dialysis renal disease patient
populations.
Some parties have suggested that prior ESA use may predict the long term success
of subsequent kidney transplantation in patients with chronic kidney disease. We
are commissioning a technology assessment from an outside entity.
Comment Period 6/16/10-7/16/10
http://www.cms.gov/mcd/viewtrackingsheet.asp?id=245
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CMS received informal inquiries for a national coverage determination (NCD) for
autologous cellular immunotherapy treatment of prostate cancer. This interest
arose upon the recent FDA approval of the Sipuleucel T treatment regimen,
marketed as Provenge®.
As described on the FDA website at
http://www.fda.gov/BiologicsBloodVaccines/CellularGeneTherapyProducts/Approv
edProducts/ucm213559.htm, "PROVENGE® (Sipuleucel T, APC8015) is an
autologous cellular immunotherapy product consisting of peripheral blood
mononuclear cells (PBMCs) obtained from patients by leukapheresis and activated
in vitro with a recombinant fusion protein (prostatic acid phosphatase fused with
GM-CSF)…FDA will require the sponsor to complete a post marketing study to
evaluate the risk of stroke in patients who receive sipuleucel-T."
Provenge® has FDA approved labeling for the treatment of asymptomatic or
minimally symptomatic metastatic castrate resistant (hormone refractory) prostate
cancer.
We are opening this national coverage analysis to determine whether or not
autologous cellular immunotherapy is reasonable and necessary under sections
1862(a)(1)(A) and/or 1862(a)(1)(E) of the Social Security Act.
Comment Period: 6/30/10-7/30/10, with decision due by 3/30/11
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The new statute clarifies that the term “other services related to the admission”
includes “all services that are not diagnostic services (other than ambulance and
maintenance renal dialysis services) for which payment may be made by” Medicare
that are provided by a hospital to a patient: (1) on the date of the patient’s
inpatient admission, or (2) during the 3 days (or in the case of a hospital that is
not a subsection (d) hospital, during the 1 day) immediately preceding the date of
admission unless “the hospital demonstrates (in a form and manner, and at a time,
specified by the Secretary) that such services are not related to such admission.”
The statute makes no changes to the billing of diagnostic services.
The provision is effective for services furnished on or after June 25, 2010, the date
of enactment of the Preservation of Access to Care for Medicare Beneficiaries and
Pension Relief Act of 2010. The provision also prohibits Medicare from reopening,
adjusting or making payments when hospitals submit new claims or adjustment
claims for services that were provided prior to the date of enactment in order to
separately bill outpatient non-diagnostic services.
Will this ever cross over to Part B??
http://www.hfma.org/templates/blogpost.aspx?blogid=258
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June 25, 2010
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On June 25, 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. CMS will
publish this information in the July 13, 2010
Federal Register.
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 the PROPOSED RULE.
Remember that this is a proposal, not the law.
https://www.cms.gov/PhysicianFeeSched/PFSFRN/list.asp#TopOfPage
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SGR: The current conversion factor is $36.8729 with the
recent 2.2% increase, effective June 1. The Medicare law
includes the standard statutory formula that will require
(absent Congressional intervention) CMS to implement a
minus 6.1 percent update in payment rates for physicianrelated services. This cut will be on top of the 2010 -21.3
percent reduction, now delayed until December 1, 2010.
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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The Medicare Economic Index: You may ask
yourself why this is being discussed.
Because, if you just look at the RVUs, you’d
think we’re getting a big, huge increase in
almost all of our services. But, in order to rebase this silly update factor called the MEI:
◦ CMS added a factor of 1.168 to ALL practice
expense RVUs and a factor of 1.413 to all
malpractice RVUs.
◦ CMS rebased the conversion factor using .921,
yielding a -1% change for hematology-oncology.
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Impact of the MEI
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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 was codified in the proposed rule,
but it is happening THIS WEEK.
GPCIs: For several years, including 2010, there was a 1.00 ‘floor’ on
GPCIs in places where the work GPCI fell further than that. Upholding
1.00 was a really cool for some folks. It will not be upheld next year
with the following exceptions. Alaska will have a GPCI floor of 1.5. The
“frontier states” will have a practice expense GPCI floor of 1.00 as well as
a work GPCI of 1.00. Frontier states include: Montana, Wyoming, North
Dakota, Nevada, South Dakota. Additionally, Medicare used housing
data to change everybody’s GPCIs.
Telehealth Services: To perform telehealth services, there must be twoway 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.
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Physician Extenders: They are sometimes known as NPs and
PAs. It is proposed that they can now perform certification
and periodic re-certification 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.
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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):
◦ Annual wellness visits,
◦ Initial preventive physician examination, depending upon CMS feedback,
◦ 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, maybe, smoking screening and cessation, if this gets good
comments.
https://www.cms.gov/PhysicianFeeSched/PFSFRN/list.asp#TopOfPage
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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). Providers may
get this bonus in addition to a HPSA bonus, which we
call the “Boonie Bonus”. 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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Self-Referral Disclosure Law: The good news is that, while the law said it was retro to
January 1, this is not effective right now, and so you can stop doing it. The Affordable
Care Act (ACA) amends the in-office ancillary services exception to the self-referral law
as applied to magnetic resonance imaging, computed tomography, and positron
emission tomography, to require a physician to disclose to a patient in writing at the
time of the referral a list of other suppliers who perform the same services in the area in
which the patient resides. Here’s the bad news: CMS is proposing to require that the
referring physician follow the following guidelines:
◦ A list of ten alternative ‘suppliers’ (not a hospital) within a 25-mile radius of the
physician’s office who provide the same imaging services. The list must include no
less than 10 suppliers.
◦ The list must include, name, address, phone number and distance from the
physician’s office at the time of the referral. 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.
◦ A signature on the disclosure is required and must be maintained in the medical
record. CMS is currently not proposing to expand the list of procedures affected by
this policy.
◦ Emergency situations are not an exception.
◦ Exceptions include patients who are not on Medicare at the time of the referral.
Equipment Utilization Rate: Medicare law requires CMS to implement a 75 percent
equipment utilization rate assumption to expensive diagnostic imaging equipment in a
non-budget neutral manner for CY 2011, and the changes to PE RVUs will not be
transitioned over a period of years. All other codes will remain at the 50 percent
equipment assumption rate. In general, the codes affected by the 75 percent utilization
rate are PET, CT and MRI codes.
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Drugs: The proposed 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 actual vial contents.
◦ 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%, and outlines a new
proposal for price substitution at 103% of average manufacturer price (AMP) in certain
circumstances when the ASP exceeds the AMP by 5% or more. WAMP will not be used
in price substitution, according to the proposal. Any ASP substitutions would have to
be reviewed on a quarterly basis.
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Signature on Requisition: CMS proposes to 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.
◦ 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 nonphysician practitioner.
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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 for 2011: This year, there are 198 proposed measures. 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:
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Registries: CMS once again emphasized that Registries are the way to go for more accuracy in 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.
Measures Groups: There are still no Measures Groups in cancer. There are some that apply if you perform
screening procedures or if you are multi-specialty. You must report consecutive Medicare patients in 2011,
not all patients. There is no EHR submission for Measures Groups.
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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PQRI 2011
◦ New Measures: Remember that more can be added in the final
rule!
 Melanoma: Overuse of Radiation in Stages 0-1A
 Mammography: Reminder System
 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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PQRI Proposed 2011
◦ MOCP (Maintenance of Certification) Adjustment: Certain certifying agencies boardcertify 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 eprescribing.
◦ 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 ever-popular [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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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. 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.
◦ Measures: Exactly the same as in 2010, unless you are reporting under GPROI
or GPROII, i.e. as a group practice. Then, the number depends entirely upon
your group’s size.
◦ 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)
◦ 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.
https://www.cms.gov/PhysicianFeeSched/PFSFRN/list.asp#TopOfPage
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Implementing the American
Reinvestment & Recovery Act of 2009
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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
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Definition
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Process of defining
◦ To be determined by Secretary
◦ Must include quality reporting, electronic
prescribing, information exchange
NCVHS Hearings
HIT Policy Committee recommendations
Listening Sessions with providers/organizations
Public Comments on the HIT Policy Committee
recommendations
◦ NPRM comments received from the Department and
OMB
◦
◦
◦
◦
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Data
capture and
sharing
Advanced
clinical
processes
Improved
outcomes
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•
Meaningful Use will be defined in 3 stages
through rulemaking
◦ Stage 1 – 2011
◦ Stage 2 – 2013*
◦ Stage 3 – 2015*
*Stages 2 and 3 will be defined in future CMS rulemaking.
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Medicare
Medicaid
Feds will implement (will be an option
nationally)
Voluntary for States to implement (may not be
an option in every State)
Fee schedule reductions begin in 2015 for
providers that are not Meaningful Users
No Medicaid fee schedule reductions
Must be a meaningful user in Year 1
Adopt/Implement/Upgrade option for 1st
participation year
Maximum incentive is $44,000 for EPs
Maximum incentive is $63,750 for EPs
MU definition will be common for Medicare
States can adopt a more rigorous definition
(based on common definition)
Medicare Advantage EPs have special eligibility
accommodations
Medicaid managed care providers must meet
regular eligibility requirements
Last year an EP may initiate program is 2014;
Last payment in program is 2016. Payment
adjustments begin in 2015
Last year an EP may initiate program is 2016;
Last payment in program is 2021
Only physicians, subsection (d) hospitals and
CAHs
5 types of EPs, 3 types of hospitals
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Year
Incentives
Penalties for Non-Compliance
2011
$18,000, $12,000, $8,000,
$4,000, $2,000
$0
2012
$18,000, $12,000, $8,000,
$4,000, $2,000
$0
2013
$15,000, $12,000, $8,000, $4,000
$0
2014
$12,000, $8,000, $4,000
$0
2015
$0
-1% in Medicare Fee Schedule
2016
$0
-2% in Medicare Fee Schedule
2017 & beyond
$0
-3% in Medicare Fee Schedule
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

Incentives will start in 2011 for adoption,
implementation, upgrade, maintenance, and operation
of a certified EHR
◦ Up to $63,750



No Medicaid payment reductions if a provider does not
adopt certified EHR technology
To be eligible for Medicaid providers are
required to waive Medicare EHR incentive
payments
Incentives for up to 85% of costs for EHR
◦ Caps: 1st year payment at $25,000
◦ Caps: following years at $10,000/year
 1st yr cost no later than 2016
 No payments made after 2021 or more than 5 years
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Providers
Medicaid Patient Volume
Non-hospital based providers
≥ 30%
Non-hospital based pediatrician
≥ 20%
Physician who practices in federally qualified
health center or rural health clinic
≥ 30% attributable to needy individuals
Children’s hospitals
No requirement needed
Acute-Care hospitals
≥ 10%





Only physicians, D.O.’s etc. can participate;
no NPPs
Incentives are the same
Requires 90 days of continuous meaningful
use
Attestation of meaningful use will be
reporting mechanism
Reporting begins 1/11; payment reportedly
to begin 4/11
The “core” criteria for ambulatory settings are as follows:
1. Record patient demographics (including gender, race and ethnicity, date of birth,
preferred language) at least 50% of the time
2. Record vital signs (height, weight, blood pressure, body mass index, and growth charts
for children) at least 50% of the time
3. Maintain up-to-date problem lists at least 80% of the time
4. Maintain active medication lists at least 80% of the time
5. Maintain active medication allergy lists at least 80% of the time
6. Record smoking status for patients >13 years of age at least 50% of the time
7. Provide patients with a clinical summary for each office visit within 3 business days, at
least 50% of the time
8. On request, provide patients with an electronic copy of their health information
(including test results, problem lists, meds lists, allergies) within 3 business days, at least
50% of the time
9. Generate electronic prescriptions at least 40% of the time
10. Use Computerized Physician Order Entry (CPOE) for medication orders at least 30% of
the time. (note: CPOE for lab ordering, imaging ordering, and referrals are not addressed
here – only medications)
11. Implement drug-drug and drug-allergy interaction checks at least 40% of the time
12. Be able to exchange key clinical information among providers by performing at least
one test of the EHR’s ability to do this.
13. Implement one clinical decision support rule, and ability to track compliance with the
rule (this is reduced from the previous 5 rules to the final 1 rule)
14. Implement systems that protect privacy and security of patient data in the EHR, by
conducting or reviewing a security risk analysis, and taking corrective step if needed
15. Report clinical quality measures to CMS or states – for 2011 provide aggregate
numerator and denominator through attestation; for 2012, electronically submit measures
(this refers to PQRI measures)
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
In addition to the 15 “required” elements noted above, a physician must also
demonstrate at least 5 of the following 10 items:
1. Implement drug-formulary checking
2. Incorporate lab test data into the EHR as structured data
3. Generate lists of patients by specific conditions (to use for quality improvement,
reduce disparities, research, or outreach)
4. Use EHR technology to identify patient-specific education resources, and
provide those to the patient as appropriate – and do this at least 10% of the time
5. Provide medication reconciliation between care settings, at least 50% of the
time
6. Provide summary of care record for patients transferred to another provider or
setting, at least 50% of the time
7. Submit electronic immunization data to local registries (performing at least one
test of data submission, where registries can accept them)
8. Submit electronic syndromic surveillance to public health agencies (perform at
least one test, where local agencies can accept them)
9. Send reminders to patients (per patient preference) for preventive and followup care, at least 20% of the time, or for over-65 year-olds or under-5 year-olds)
10. Provide patients with timely electronic access to their health information, at
least 10% of the time.
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
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)
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




Iron Disorders (275)
Fluid disorders (276.6)
Secondary thrombocytopenia (287.4)
Hemoptysis (786.3)
Incontinence of feces (787.6)
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





Make sure you are being paid correctly by your
Medicare Carrier.
Understand Medicare fee schedule impact on
private insurance company contracts.
Ascertain your vendor’s plan for Meaningful Use
in 2010 for implementation in 2011.
Start planning for PQRI and E-Rx or ARRA in
2011.
Think about alternative revenue streams—oral
drugs, trials, etc.
Participate in the struggle—2011 is a false
positive.
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
CAN Web Site
◦
◦
◦
◦
◦
◦
The latest news
Forms
Regulations
Newsletters
Presentations
http://communityoncology.info
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
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
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