Changes to Oncology Coding 2009 Bobbi Buell Version 9. 0 April. 2009
Disclaimer Payers differ on their guidelines. Please verify coding for each payer and claim. This is not legal or payment advice. This content is abbreviated for Medical Oncology. It does not substitute for a thorough review of code books, regulations, and Carrier guidance. This information is good for the date of the information and may contain typographical errors. CPT is the trademark for the American Medical Association. All Rights Reserved. All denial data from Remit. DATA. Copyrighted to them and all rights reserved.
Session Objectives Discuss the Stimulus Package Provisions Discuss Fee Schedule for 2009 Discuss CPT Changes for 2009 Discuss Drug Administration Coding for 2009 Discuss Anti-Emetic Policies from NGS Discuss Coding/Options for PQRI 2009 Discuss Coding for E-Prescribing 2009 Discuss the Status of RACs and Other Audits Discuss What You Need to Do Next
Stimulus Package (AMA) COBRA Sixty-five percent temporary COBRA premium subsidy for workers who have been involuntarily terminated between Sept. 1, 2008, and Dec. 31, 2009. Subsidy available for up to 9 months. Subsidy would not be considered income for purposes of other federal/state program eligibility. To be eligible for the subsidy, an individual must have a modified adjusted gross income below $145, 000 (or $290, 000 for joint filers); if the taxpayer’s income exceeds this threshold, then the premium subsidy must be repaid. For taxpayers with AGI between $125, 000 and $145, 000 ($250, 000 and $290, 000 for joint filers), the amount of the premium subsidy that must be repaid is reduced proportionately. http: //www. ama-assn. org/ama/pub/legislation-advocacy/current-topics-advocacy/hr 1 -stimulus-summary. shtml
Stimulus Package (AMA) • Medicaid ▫ $87 billion in additional federal matching funds is provided (from Oct. 1, 2008 -Dec. 31, 2010). Increases FMAP (Federal Medical Assistances Programs) for all states by 6. 2%. Holds states harmless against a drop in their FMAPs for FYs 2009, 2010, and first quarter of FY 2011 (e. g. , if 2008 FMAP is higher than 2009, the state gets the higher 2008 rate). ▫ States with large increases in unemployment would receive an additional FMAP increase. It is estimated that the conference agreement would provide about 65% of its spending via the hold harmless agreement and across-the-board increases, and about 35% via the unemployment-related increase. States must comply with current Medicaid prompt pay requirements in order to receive FMAP increase. Extends through June 30, 2009, the current moratorium on 4 Medicaid regulations relating to provider taxes, targeted case management services, school-based services, and outpatient hospital services; states the sense of the Congress that the HHS Secretary should not promulgate as final the proposed regulations relating to cost limits on public providers, GME payments, and rehabilitative services. ▫ Provides for a temporary increase in state DSH allotments for FY 2009 and 2010. http: //www. ama-assn. org/ama/pub/legislation-advocacy/current-topics-advocacy/hr 1 -stimulus-summary. shtml
Stimulus Package (AMA) Health Information Technology Provides approximately $19 billion for Medicare and Medicaid HIT incentives over five years. Officially establishes the Office of the National Coordinator for Health Information Technology (ONCHIT) within HHS to promote the development of a nationwide interoperable HIT infrastructure; President Bush already created ONCHIT by Executive Order in 2004. Establishes HIT Policy and Standards Committees that are comprised of public and private stakeholders (e. g. , physicians HHS would adopt through the rule-making process an initial set of standards, implementation specifications, and certification criteria by December 31, 2009. ONCHIT would be authorized to make available an HIT system to providers for a nominal fee. http: //www. ama-assn. org/ama/pub/legislation-advocacy/current-topics-advocacy/hr 1 -stimulus-summary. shtml
Stimulus Package (AMA) Health Information Technology Incentives Provides financial incentives through the Medicare program to encourage physicians and hospitals to adopt HIT. Medicare incentive payments would be based on an amount equal to 75% of the Secretary’s estimate of allowable charges, up to $15, 000 for the first payment year. Incentive payments would be reduced in subsequent years: $12, 000, $8, 000, $4, 000, and $2000, after 2015. Physicians who report using an EHR that is also capable of eprescribing would be eligible for EHR incentives only. Early adopters, whose first payment year is 2011 or 2012, would be eligible for an initial incentive payment up to $18, 000. In 2014, the payment limit would equal $12, 000. Adopters, whose first payment year is 2015, would receive $0 payment for 2015 and any subsequent year. Physicians who do not adopt/use a certified HIT system would face reduction in their Medicare fee schedule of -1% in 2015, -2% in 2016, and 3% in 2017 and beyond. E-prescribing penalties would sunset after 2014. For eligible professionals in a rural health professional shortage area, the incentive payment amounts would be increased by 10 percent. Incentives under the Medicaid program are also available for physicians, hospitals, federally-qualified health centers, rural health clinics, and other providers; however, physicians cannot take advantage of the incentive payment programs under both the Medicare and Medicaid programs. Eligible pediatricians (non-hospital based), with at least 20 percent Medicaid patient volume, could receive up to $42, 500, and other physicians (non-hospital based), with at least 30 percent Medicaid patient volume, could receive up to $63, 750, over a six-year period. Allows HHS to increase penalties beginning in 2019, but penalties cannot exceed -5%. Exceptions would be made on a case-by-case basis for significant hardships (e. g. , rural areas without sufficient Internet access). http: //www. ama-assn. org/ama/pub/legislation-advocacy/current-topics-advocacy/hr 1 -stimulus-summary. shtml
Stimulus Package (AMA) • More HIPAA ▫ ▫ ▫ ▫ Federal privacy/security laws (HIPAA) are expanded to protect patient health information. HIPAA privacy and security laws would apply directly to business associates of covered entities. Defines actions that constitute a breach of patient health information (including inadvertent disclosures) and requires notification to patients if their health information is breached. Allows patients to pay out of pocket for a health care item or service in full and to request that the claim not be submitted to the health plan. Requires physicians to provide patients, upon request, an accounting of disclosures of health information made through the use of an EHR. Prohibits the sale of a patient’s health information without the patient’s written authorization, except in limited circumstances involving research or public health activities. Requires personal health record (PHR) vendors to notify individuals of a breach of patient health information. Non-covered HIPAA entities such as Health Information Exchanges, Regional Health Information Organizations, e-Prescribing Gateways, and PHR vendors are required to have business associate agreements with covered entities for the electronic exchange of patient health information. Authorizes increased civil monetary penalties for HIPAA violations. Grants enforcement authority to state attorneys general to enforce HIPAA. http: //www. ama-assn. org/ama/pub/legislation-advocacy/current-topics-advocacy/hr 1 -stimulus-summary. shtml
Stimulus Package (AMA) • Comparative Effectiveness Research (“CER”) ▫ The government will increase funding for CER by $1. 1 billion. Both the Report on the Conference Agreement and that actual ARRA language provide that the FCC-CER will not mandate coverage, reimbursement, or other policies of public or private payers. CER will not include national clinical guidelines or coverage determinations as ARRA incorporates by reference the provisions in the Medicare Modernization Act of 2003 that explicitly preclude this. Establishes the Federal Coordinating Council for Comparative Effectiveness Research (FCC-CER), an advisory board that will be comprised of up to 15 representatives of federal agencies—at least half will be physicians or other experts with clinical expertise. The FCC-CER will coordinate CER to reduce duplication of efforts and encourage coordinated and complementary uses of resources, coordinate related health services research, and make recommendations to the President and Congress on CER infrastructure needs. The Agency for Healthcare Research and Quality (AHRQ) will receive $700 million for CER; AHRQ must transfer $400 million to NIH to conduct or support CER http: //www. ama-assn. org/ama/pub/legislation-advocacy/current-topics-advocacy/hr 1 -stimulus-summary. shtml
Medicare Physician Payment Basics Payments are based on RVUs for each code The pool of RVUs is fixed – any changes must be budget neutral--we had one of the few exceptions in 2004 -2005. The Medicare conversion factor determines the overall level of Medicare payments A formula spelled out in the Medicare statute determines the annual update to the conversion factor and that has been a disaster.
What Happened to the Conversion Factor? • Section 131 of the MIPPA substitutes a positive update to payment rates under the MPFS of 1. 1 percent for the negative update that would have resulted from the application of the statutory formula that includes the sustainable growth rate. Section 133(b) of the MIPPA also requires CMS to make a technical change in how a statutorily required budget-neutrality adjustment is applied. Section 133(b) of the MIPPA requires that the budget-neutrality adjustment be applied instead to the conversion factor…so, we end up at $36. 0666 from $38. 0870. THIS HELPS PROCEDURAL SPECIALTIES $38. 0870 AND HURTS US.
Impact of 2009 PFS Changes
Impact of PFS Changes for 2009
Other Proposed Medicare FS Changes 2009 Non-payment for preventable conditions is now part of inpatient payment. CMS discusses the possibility of it in physician payment and is still looking for comments. Nurse Practitioners who enrolled in the Medicare Program on or after 1/1/2003 must have a Masters’ Degree or DNP. Reinstates the ability to use electronic facsimile transmission of prescription until January 1, 2012. But, this is unrelated to getting the incentive in 2009. G 0332 is out!
Change in the Enrollment Methodology Establishment of an Effective Billing Date for Physicians and Non- Physician Practitioners: The final rule establishes the effective date of billing for physicians and non-physician practitioners as the later of: (1) the date of filing of a Medicare enrollment application that was subsequently approved by a Medicare contractor; or (2) the date an enrolled physician or non-physician practitioner first started furnishing services at a new practice location. In addition, physicians and non-physician practitioners who meet all program requirements may bill retrospectively: For services furnished up to 30 days prior to the effective date, rather than the 23 months allowed under current regulations; and For services furnished up to 90 days prior to the effective date if the President has declared an emergency under the Robert T. Stafford Disaster Relief and Emergency Assistance Act
Enrollment in Medicare Billing for 30 days prior to that date is permitted in certain circumstances When the enrolling physician or NPP met all program requirements including state licensure requirements, The services were furnished at the enrolled practice location, And circumstances prevented enrollment prior to providing services to Medicare beneficiaries
PECOS • Starting January 1, enrollment for physicians or other providers in a new location will be much more strict in terms of what you can bill-now it's 23 months; next year, it will be 30 days. The Internet-based Provider Enrollment, Chain and Ownership System (PECOS) will allow physicians and non-physician practitioners to enroll, make a change in their Medicare enrollment, view their Medicare enrollment information on file with Medicare, and check on the status of a Medicare enrollment application via the Internet. • Is supposed to reduce enrollment time. • Physicians and non-physician practitioners in the District of Columbia and the States shown above who wish to access Internet-based PECOS may go to this place to check it out: https: //pecos. cms. hhs. gov/pecos/login. do
PECOS Physician or NPP cannot use PECOS in order to: Change his/her name or social security number Change an existing business structure To sole proprietorship from Professional Association, Professional Corporation or LLC, or vice versa Reassign benefits to another supplier if that supplier does not have a current Medicare enrollment record in PECOS For more information http: //www. cms. hhs. gov/Medicare. Provider. Sup. Enroll
After Revocation of Billing Privileges The final rule provides that a physician or non-physician practitioner is not allowed to bill for services furnished after certain reportable events, including: A Federal exclusion or debarment, or felony conviction; A State license suspension or revocation; or A practice location is determined to be not operational by CMS or its contractor. For all other revocation actions, individual practitioners will be required to submit all outstanding claims within 60 days of the effective date of revocation.
Provider Reporting of Certain Events Revised Reporting Responsibilities for Physicians and Non- Physician Practitioners: The rule requires physicians and nonphysician practitioners and physician and non-physician practitioner organizations to notify their Medicare contractor of a change of ownership, final adverse action, or change of location within 30 days of the reportable event. Failure to notify the designated contractor of a change related to a final adverse action or a change of location may result in an overpayment from the date of the reportable event.
Lab Services Technical Component of Pathology Services for Hospital Patients - Section 136 of the MIPPA allows independent laboratories to bill Medicare directly for the technical component of physician pathology services furnished to hospital inpatient and outpatients until December 31, 2009, rather than requiring that it be bundled into the payment to the hospital. Clinical Laboratory Fee Schedule Update - Section 145 of the MIPPA sets the clinical laboratory fee schedule update at the Consumer Price Index for all Urban Consumers (CPI-U) minus 0. 5 percentage points for each of the calendar years 2009 through 2013, but repeals a competitive bidding demonstration program for clinical laboratory services that had been required under the MMA. Must maintain ordering and referring information for 7 years.
Fee Schedule: Carry-over • Anti-Markup Provisions (Delayed until 1/1/2009) ▫ CMS proposes to prohibit the markup of purchased diagnostic services for both the technical and professional components performed by outside suppliers. ▫ Two approaches this year: Physicians “who do not share the practice” will be subject to the anti- markup. This includes contractors who serve several physicians. This means they must be in the practice ≥ 75% of the time. Physicians who do not share the building will be subject to antimarkup. If the physician who provides the professional component, or supervises the technical component, is an owner, employee, or independent contractor of the billing physician and provides or supervises the service in a building in which the ordering physician provides the full range of services that the ordering physician generally provides.
Telehealth Services The Final telehealth delivery of follow up inpatient consultations. The new codes will enable practitioners to bill for follow-up inpatient consultations delivered via telehealth. This provision effectively restores follow-up inpatient consultations to the list of Medicare covered telehealth services. They had been included prior to 2006, but ceased to be on the list of Medicare telehealth services, when the CPT Editorial Panel of the American Medical Association (AMA) deleted the specific codes for followup inpatient consultations and advised practitioners to report follow-up inpatient consultation using more general codes (i. e. codes describing subsequent hospital care) CMS did not add these more general codes to the list of Medicare telehealth services because, in addition to follow-up inpatient consultation, the subsequent hospital care codes could be used to report services involving the on-going (day to day) management of a hospital inpatient, which CMS believed would not be appropriately furnished via telehealth. The new codes are G 0406 -G 0408 (with -GT modifier).
CPT Changes 2009 CPT decided to ‘go green this year and changed the numbering for the Hydration and Therapeutic codes so they are in the same section as the Chemo codes. All Hydration and Therapeutic codes will be “ 963” codes instead of “ 907” codes. 90761 = 96361 90767 = 96367 90772 = 96372 ETC. Source: CPT 2009 Crosswalk available at http: //www. asco. org
CPT Changes 2009 The Chemotherapy Section name has changed to “Chemotherapy or Highly Complex Drug or Highly Complex Biologic Agent” Administration The word “highly complex” used with frequency Will payers change admin codes on some drugs? CMS leaves this up to the MACs and Carriers. Other payers may be more strict with drug administration, but let’s wait and see what the AMA says. Descriptor Source: CPT 2009
Drug Admin Coding 2005 Drug Administration Coding in REVIEW General Principals that live to this day One INITIAL code per day is the one that best describes the service that the patient is having that day, unless you are in a hospital. Before/after infusions and pushes must always be categorized as SEQUENTIAL or concurrent to sequential. They must be a different substance to merit a separate code. Hours following EACH infusion’s initial hour must be over 30 minutes. Any infusion of 15 minutes or less is coded as a push. One concurrent code per day regardless of substances or hours. Hydration coding differs from non-chemo and chemo administration. Port flushes are billable IF they are the only service of the day!
Common Coding Errors & Omissions Using more than one initial code per date of service Billing port flush with evaluation and management and/or administration codes Assorted administration code omissions
Billing Port Flush with Administration and/or E&M Service “ Pay for 96523, irrigation of implanted venous access device for drug delivery systems, if it is the only service provided that day. If there is a visit or other drug administration service provided on the same day, payment for 96523 is included in the payment for the other service. ”
Routes of Drug Administration from NGS Not only does the indication for the use of the drug need to meet medical necessity requirements, but the route of administration is also subject to medical necessity criteria. Contractors must continue to apply the policy that not only the drug is medically reasonable and necessary for any individual claim, but also that the route of administration is medically reasonable and necessary. That is, if a drug is available in both oral and injectable forms, the injectable form of the drug must be medically reasonable and necessary as compared to using the oral form. ( Pub 100 -02, Chapter 15, Sect 50. 2 - Determining Self. Administration of Drug or Biological (Rev. 91; Issued: 06 -20 -08; Effective/Implementation Date: 07 -21 -08)). Medication given by injection (parenterally) is not covered if standard medical practice indicates that the administration of the medication by mouth (orally) is effective and is an accepted or preferred method of administration. (Pub 100 -02, Chapter 15, Section 50. 4. 3)
Oral Anti-emetics For anti-emetic medication, CMS states: It is recognized that a limited number of patients will fail on oral anti-emetic drugs. Intravenous anti-emetics may be covered (subject to the rules of medical necessity) when furnished to patients who fail on oral anti-emetic therapy. (Pub 100 -02, Chapter 15, Section 50. 5. 4)
HCPCS Changes: New Chemo Codes J 8705 TOPOTECAN, ORAL, 0. 25 MG J 9033 INJECTION, BENDAMUSTINE HCL, 1 MG J 9207 INJECTION, IXABEPILONE, 1 MG J 9330 INJECTION, TEMSIROLIMUS, 1 MG
HCPCS Changes J 1572 INJECTION, IMMUNE GLOBULIN, (FLEBOGAMMA/FLEBOGAMMA DIF), INTRAVENOUS, J 2788 INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, MINIDOSE, 50 MICROGRAMS (250 I. U. ) J 2790 INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, FULL DOSE, 300 MICROGRAMS (1500 I. U. )
HCPCS Deleted Codes Q 4097 INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NONLYOPHILIZED (E. G. Q 4098 INJECTION, IRON DEXTRAN, 50 MG J 9182 Etoposide 100 mg • BACK IN ACTION J 1750 INJECTION, IRON DEXTRAN, 50 MG
MIPPA Legislation - PQRI The Medicare Improvements for Patients and Providers Act (MIPPA), passed in July 2008, contained several new authorities and requirements for quality reporting and PQRI for 2009 and beyond. Section 131 directly impacts PQRI Section 132 contains the new electronic prescribing incentive provisions.
Source of PQRI/ E-Prescribing Slides From Slides of Sylvia W. Publ, MBA, RHIA, Consortium for Quality Improvement and S&C Operations, CQISCO, CMS December 17, 2008 Subject to Disclaimers
Value-Based Purchasing and PQRI Key mechanism for transforming Medicare from passive payer to active purchaser. Current Medicare Physician Fee Schedule is based on quantity and resources consumed, NOT quality or value of services. Value = Quality / Cost Incentives can encourage higher quality and avoidance of unnecessary costs to enhance the value of care.
PQRI Legislative Background TRHCA – Tax Relief & Health Care Act, 2006 Established 2007 PQRI, 7/1 -12/31/07, authorized 1. 5% incentive subject to a cap, claims-based reporting by eligible professionals (EPs) of up to 3 individual applicable measures for 80% of eligible cases MIPPA - Medicare Improvements for Patients and Providers Act Section 131: 2009 PQRI Authorized PQRI 2009 raised incentive to 2%, adds qualified audiologists as eligible professionals, no effect on 2007 or 2008 incentive payments Requires CMS to post on our web site names of EPs who satisfactorily report quality measures for 2009 PQRI MMSEA - Medicare, Medicaid, and SCHIP Extension Act of 2007 Authorized 2008 PQRI, 1. 5% incentive, eliminated cap Incentive Section 132: e-Prescribing Incentive Program Required alternative reporting periods and alternative reporting criteria for 2008 and 2009 Requires alternative reporting for measures groups and for registry-based reporting Authorized separate 2% incentive payment to EPs who successfully use a qualified eprescribing system e. Rx measure removed from 2009 PQRI --separately posted measure specifications. The Secretary has the authority to update the codes of the electronic prescribing measure in the future. Requires names of eligible professionals who are successful e-prescribers be posted on the CMS web site
PQRI : Eligible Professionals Physicians MD/DO Podiatrist Optometrist Oral Surgeon Dentist Chiropractor Practitioners Physician Assistant Nurse Practitioner Clinical Nurse Specialist Certified Registered Nurse Anesthetist Certified Nurse Midwife Clinical Social Worker Therapists Clinical Psychologist Physical Therapist Registered Dietician Occupational Therapist Nutrition Professional Qualified Speech Audiologist Language Pathologist
2009 PQRI Quality Measures 153 PQRI quality measures for 2009 Includes 101 measures from the 2008 PQRI and 52 new measures E-prescribing measure (Measure #125) removed, as required by MIPPA as a separate program 18 measures reportable only through registries By December 31, 2008, measure specifications will be available at: http: //www. cms. hhs. gov/pqri
2009 PQRI Measures Groups 7 measures groups: Diabetes Mellitus Chronic Kidney Disease Preventive Care Coronary Artery Bypass Graft (CABG) (new) Rheumatoid Arthritis (new) Perioperative Care (new) Back Pain* (new) * Measures in this measures groups are reportable only as a measures group, not as individual measures • ESRD measure group removed for 2009
2009 PQRI Reporting Periods Reporting period: January 1, 2009 – December 31, 2009 2 reporting periods for reporting measures groups and registry-based reporting: January 1, 2009 – December 31, 2009 July 1, 2009 – December 31, 2009
2009 PQRI Satisfactory Reporting Options Criteria for claims-based submission of individual measures (1 option): Reporting period: January 1, 2009 – December 31, 2009 3 PQRI measures or 1 -2 measures if < 3 apply* 80% of applicable Medicare Part B FFS patient claims for 1 -3 measures * If < 3 measures, measures are subject to measure applicability validation (MAV)
2009 PQRI Satisfactory Reporting Options (ctd. ) Criteria for registry-based reporting of individual measures (2 options): Reporting period: January 1, 2009 – December 31, 2009 ≥ 3 PQRI measures 80% of applicable Medicare Part B FFS patient claims for ≥ 3 measures Reporting period: July 1, 2009 – December 31, 2009 ≥ 3 PQRI measures 80% of applicable Medicare Part B FFS patient claims for ≥ 3 measures
2009 PQRI Satisfactory Reporting Options (ctd. ) Criteria for measures groups (6 options: 3 for claims-based submission and 3 for registry-based reporting): Reporting period: January 1, 2009 – December 31, 2009 30 consecutive patients for 1 measures group OR 80% of applicable Medicare Part B FFS patient claims for 1 measures group, with a minimum of 30 applicable patients Reporting period: July 1, 2009 – December 31, 2009 80% of applicable Medicare Part B FFS patient claims for 1 measures group, with a minimum of 15 applicable patients Criteria for claims-based submission of measures groups identical to criteria for registry-based reporting of measures groups except only Medicare Part B FFS patients can be included in consecutive patient sample for claims-based submission of measures groups
PQRI Process Visit Documented in the Medical Record Critical Step Encounter Form Coding & Billing N-365 NCH Analysis Contractor Confidential Report National Claims History File Carrier/MAC Incentive Payment
The Medicare Incentive Schedule and Penalties 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.
2009 Successful E-Prescribers “Successful E-Prescriber” is defined as an EP who reports the e-prescribing measure established for PQRI (i. e. , Measure #125) for at least 50% of applicable Medicare Part B FFS patients using a qualified system E-prescribing measure is reportable only through claims Limitation to applicability of incentive payment Denominator codes for the e-prescribing measure must comprise at least 10% of an EP’s total allowed charges for all covered services furnished by the EP during the reporting period
2009 E-Prescribing Process Critical Step PBM Visit Documented in Rx Trans. Medical Record & Rx mitted to Generated Pharmacy Encounter Form Coding & Billing N-365 NCH Analysis Contractor Confidential Report National Claims History File Carrier/MAC Incentive Payment
Reporting Scenarios E-Prescribing A 70 year old male patient presents to the clinician’s office for medical care. Scenario 1: Scenario 2: Scenario 3: The clinician discusses current medications and prescribes new medication, updates active medication list in e. Rx system, transmits prescription electronically to pharmacy The clinician documents there is no change in meds, no prescription generated. Pt has mail order pharmacy that cannot accept e. Rx & asks for hard copy. Physician updates meds in e. Rx system, e. Rx system provides hard copy of prescription to patient. Reports G 8445 Reports G 8446 Reports G 8443 All of these scenarios represent successful 2009 reporting
What is Not E-Prescribing IV Drugs in the office Calling in a prescription for NH patient Patient seen in ED and is sent home with a prescription Faxing a prescription to a pharmacy Sending a prescription via PDA (exception: depends on software used – must meet e-prescribing system qualifications) Knowingly sending a computer-generated fax initiated at the doctor’s office to a pharmacy (exception: if sent via qualified e prescribing system and pharmacy system generates message as a fax, it is e-prescribing) Office visits provided as part of a global surgical package Medicare Advantage patients (exception: some private fee-for-service plans - can e-prescribe, but this does not count toward incentive payment calculation)
Billing Parameters for PQRI Reporting Measures with Claims C
PQRI Tools: Where to Begin Gather information and educational materials from the PQRI web page: www. cms. hhs. gov/mcd/view on the CMS website (e. g. , Measures/Codes, Educational Resources, Tool Kit web pages). Gather information from other sources, such as your professional association, specialty society or the American Medical Association.
PQRI Measure #71 Changes for 2009 Coding Changes Different instructions Deleted: 3302 F, 3303 F, 3305 F, 3306 F, 3307 F, 3309 F, 3310 F, 3311 F, 3312 F Added: 3370 F = AJCC Breast Cancer Stage 0 documented 3372 F = AJCC Breast Cancer Stage I: T 1 mic, T 1 a, or T 1 b documented 3374 F = AJCC Breast Cancer Stage I: TIC, Tumor Size >1 cm- 2 cm 3376 F = AJCC Breast Cancer Stage II documented 3378 F = AJCC Breast Cancer Stage III documented 3380 F = AJCC Breast Cancer Stage IV documented http: //www. cms. hhs. gov/PQRI/15_Measures. Codes. asp
PQRI Coding 2009 • Coding Example--Measure #71 Hormonal Therapy for Stage IC-III. ER/PR + Breast CA ▫ ▫ Report once per reporting period for all females 18 and over having breast cancer seen during the reporting period. Numerator Coding for patients receiving tamoxifen and AIs and have Stage 1 C-III, ER/PR+; coding now depends upon the submission of one to three numerator codes in some cases. Tamoxifen/AI Prescribed (Three CPT II Codes [4179 F & 3374 F or 3376 F or 3378 F & 3315 F] ▫ are required to report) Tamoxifen/ AI Not Prescribed for Medical, Patient, or System Reasons (Three CPT II Codes [4179 F-1 -3 P & 33 xx. F & 3315 F ] Tamoxifen/ AI Not Prescribed due to Stage or ER/PR Negative [3370 F or 3372 F or 3380 F or 3316 F]--ONE CODE ONLY Tamoxifen/ AI Not Prescribed; Reason Not Specified (Three CPT II Codes [4179 F-8 P & 33 xx. F & 3315 F] are required to report) No documentation of cancer stage or ER/PR status [3370 F-8 P or 3316 F-8 P ONLY] Denominator Coding Patient is 18 years old or older Breast Cancer Dx Codes (174. 0 -174. 6, 174. 8, 174. 9) E/M codes (99201 -99205, 99212 -99215) http: //www. cms. hhs. gov/PQRI/15_Measures. Codes. asp
PQRI Errors • Errors from 2007 ▫ 1, 711, 975 (12. 15%) of QDC submission attempts had a missing ▫ ▫ • NPI. 2, 662, 023 (18. 89%) of QDC submission attempts occurred with an incorrect HCPCS code. 1, 963, 196 (13. 93%) of QDC submission attempts occurred with an incorrect Dx code. 1, 019, 422 (7. 24%) of QDC submissions had an incorrect HCPCS and Dx code. 700, 201 (4. 97%) had only the QDC code and no other line items were billed. “Physician Quality Reporting Initiative 2007 Reporting Experience” available at http: //www. cms. hhs. gov/pqri/
Oncology-Specific Errors % OK HCPCS Wrong Dx Wrong QDC Only NPI Problem #71 Breast Cancer 83. 70% with drug tx 5. 61% 4. 04% 5. 87% 13. 38% #73 Plan of Chemotherapy 25. 16% 52. 70% 12. 40% Measure 5. 68% #72 Stage III Colon Cancer 56. 25% 7. 38% 12. 00% 4. 68% 9. 31% “Physician Quality Reporting Initiative 2007 Reporting Experience” available at http: //www. cms. hhs. gov/pqri/
Hem-Onc Specific Errors Measure % OK HCPCS Wrong Dx Wrong QDC Only NPI Problem #70 Baseline Flow in CLL 77. 31% 7. 13% 10. 35% 3. 28% 12. 50% #67 MDS Baseline Cytogenetic Testing 66. 63% 9. 05% 9. 47% 3. 67% 10. 31% #69 Multiple Myeloma Tx With Biphosphonates 73. 02% 12. 21% 8. 28% 4. 46% 12. 40% #74 RT Recommended Breast Ca 15. 45% 58. 15% 1. 03% 7. 47% 7. 31% “Physician Quality Reporting Initiative 2007 Reporting Experience” available at http: //www. cms. hhs. gov/pqri/
PQRI Things to Remember • Patient must have the proper age, diagnosis and that must be linked to the PQRI codes. • Codes must be arrayed per measure specifications. • Patient must meet the age requirement. • Codes must be reported with the denominator CPT or HCPCS codes. • Claims must have an NPI. • 80% is calculated by NPI. • Get forms at http: //www. ama- assn. org/ama/pub/category/17432. html
Coding for E-Prescribing 2009 You must use a QUALIFIED E-prescribing system AND Have an encounter with one of these codes 90801, 90802, 90803, 90804, 90805, 90806, 90807, 90808, 90809, 92002, 92004, 92012, 92014, 96150, 96151, 96152, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99241, 99242, 99243, 99244, 99245, G 101, G 0108, G 0109. Notice some from original guidelines were removed.
Coding for E-prescribing 2009 Report on all eligible patients: G 8443 --All prescriptions created during the encounter were generated using an e-prescribing system. G 8445 --No prescriptions were generated during the encounter. Provider does have access to a qualified e-prescribing system. G 8446 --Provider does have access to a qualified e-prescribing system. Some or all prescriptions generated were printed or phoned in as required by state regulation, patient request, or pharmacy being able to receive electronic transmission.
Free E-Prescribing in Oncology! • That’s right! • Just for cancer practices! • www. eexpertpartners. co m/payperview. html • For more information, contact me!
Part D Information The Secretary has the authority to change the requirements for successful E-Prescribing in the future. The MIPPA legislation allows for future use of Part D data in lieu of claims-based reporting by eligible professionals.
Redundancy of CMS Auditors Roles of Medicare Improper Payment Review Entities
Source: American Hospital Association
Where Did RACs Find Overpayments? Most overpayments were collected from inpatient hospital services for medical necessity and coding Incorrectly Coded 35% Other 17% Outpatient 4% No/Insufficient Documentation 8% SNF 2% Doc/Ambulance/ Lab/DME/Other 4% Inpatient Hospital 85% Rehab 6% Medically Unnecessary 40% 95% from Hospitals 65 Source: CMS, The Medicare Recovery Audit Contractor Program: An Evaluation of the 3 -Year Demonstration, June 2008
RAC Appeals Experience to Date RAC Demo Findings 66
Recovery Audit Contractors (RACS) The Centers for Medicare & Medicaid Services (CMS) has updated its Medicare recovery audit contractor (RAC) expansion schedule map. According to the updated map, CMS intends to now implement the permanent RAC program in 2 phases. The first phase will begin on March 1, 2009 and involve about half the country. The second phase will begin on August 1, 2009 or later. On February 6, 2009, CMS announced that the bid protests to the permanent RAC program have been settled. Prior to the bid protests, the CMS expansion schedule included 3 phases (with the first phase beginning on October 1, 2008). However, implementation was delayed due to the bid protests.
RAC Expansion
RAC Jurisdictions A D B March 1, 2009 August 1, 2009 C 69 3
What is a RAC? RAC Program Mission The RACs will detect and correct past improper payments so that CMS and the Carriers/FIs/MACs can implement actions that will prevent future improper payments Providers can avoid submitting claims that don’t comply with Medicare rules CMS can lower its error rate Taxpayers and future Medicare beneficiaries are protected 70 2
Overview of the RAC Initiative Section 306 of the Medicare Modernization Act directed CMS to investigate Medicare claims payments using RACs under a three year demonstration project whereby RACs would be paid on a contingency basis. MSP RAC Claim RAC California, Florida and New York were chosen for the demonstration project focusing on services provided from October 1, 2001 - September 31, 2005.
Overview of the RAC Initiative CMS and its 6 Recovery Audit Contractors (RACs)
Overview of the RAC Initiative CMS Payments to RACs Contingency basis for all accurately identified overpayments Percentage basis for all underpayments identified and recovered
Overview of the RAC Initiative Selection of Claims for Review Must “target” claims through data analysis Cannot randomly select claims Cannot just focus on high payment claims
Overview of the RAC Initiative Claim Review Period Per Section 302 of the Tax Relief and Health Care Act of 2006, “retrospectively (for a period of not more than 4 years prior to such fiscal year)” Draft – SOW for RAC fiscal “shall not attempt to identify any overpayment or underpayment more than 3 years past the date of the initial determination made on the claim”
Overview of the RAC Initiative Types of RAC “Targeted” Reviews Automated – No medical records involved in the review, certainty that overpayment exists based on data review Complex – Medical records are involved in the review, high probability (but not certainty) that the service is not covered
Overview of the RAC Initiative Responding to a RAC Record Requests Providers must respond to request for records within 45 CALENDAR days Providers may request an extension at any time prior to the 45 th day by contacting the RAC Appealing Denials Standard CMS appeal processing timelines All non-IP services handled through standard appeal processes
Overview of the RAC Initiative Services excluded from RAC Review Claims paid within the prior 12 month period (i. e. on June 1, 2007, RAC may not review claims with a claim processed/paid date between June 1, 2006 and May 31, 2007) Services provided under a program other than Medicare FFS (i. e. , Medicare Managed Care, Medicare Drug card or drug benefit programs)
Overview of the RAC Initiative Services excluded from RAC Review Cost report settlement issues (i. e. , IME or GME) Part B Carrier Evaluation and Management (E&M) services incorrectly coded (99201 -99499), except*: E&M services that are not reasonable and necessary, but can notify providers about doing level of service in the future. Appeals from ASCO and others on consults Violations of Medicare global surgical billing and payment rules
Overview of the RAC Initiative Services excluded from RAC Review Services previously evaluated by an “Affiliated Contractor (AC)” (QIO, FI, Pt B or DME Carrier) Services being investigated as part of potential fraud cases by Benefit Integrity Program Safeguard Contractors “Benefit Integrity Contractor (BIC)” or law enforcement agency
Overview of the RAC Initiative Coordination of Contractor Reviews through the “RAC Data Warehouse” Claims information entered by RAC, and BIC Claims not available for review by RAC AC has ongoing post-pay review on the claim AC has previously made a prior authorization AC has requested the medical record AC has previously issue a full or partial denial on the claim.
Overview of the RAC Initiative Requirements for Permanent RACs that did not exist under the demonstration project Medical Director required (no requirement previously) Clinicians and coding experts required (clinicians were required but not coding experts) AC Validation Process (was optional before) Standardized medical record request letters (not previously addressed)
Mechanics of the RAC Process Steps in the Process Initial Communication from RAC Receiving RAC Requests Responding to RAC Requests Notification of Outcome Appeal Processes
Mechanics of the RAC Process Initial Communication from the RAC Letter to designee introducing you to your RAC Request to designate a RAC Liaison Roles and Responsibilities of RAC Liaison
Mechanics of the RAC Process Receiving RAC Requests Typically sent to RAC Liaison/HIM Director Specificity of request Singular vs. volume of claim requests Series of claims for an individual
Mechanics of the RAC Process Responding to RAC Requests Timeliness Questions when preparing response Previously evaluated claims Amount of detail to submit
Mechanics of the RAC Process Notification of Outcome of RAC Review Length of time to receive notification of outcome Who receives the denial Reasons for denial, including regulatory citations Rights of appeal Contact information Payment refund procedures
Mechanics of the RAC Process Appeal Processes Timeline for appealing denials Phone vs. paper appeal Resubmission of records
MACs/ Carriers per their own internal screens CERT Auditors Who Else Can Ask For/ Deny/Review Stuff Medical Integrity Contractors Bundling and Medically Unlikely Edits Private Insurance Companies on behalf of MA or themselves.
Preparing for Review 1. Try to figure out what they are looking for…what do charts requested have in common—drugs, procedures, visits… 2. Get personally involved with seeing that charts are put together correctly. 3. Call the requestor, if you have questions… 4. Copy ALL records involved in the request—office, hospital, lab. 5. Check for legibility and continuity of charts. Find unfiled documentation, if that is an issue 6. When in doubt, send more rather than less---but do not send unrelated material.
Preparing for Review 6. Check for correct provider names, dates, authentication. 7. For major audits, have a physician and nurse reviewer. 8. Write addenda as necessary. 9. Send to the correct contractor. 10. Make sure documentation gets there when it is due. Send by traceable mail (Express, Fedex, etc) 11. Keep a record of records checked out, why request was made, and to whom.
Strategies for Success Cash is king, queen, jack, and ace…bring in as much as you can… Know where your MAC is at as far as anti-emetics. NGS is an aberration so far. Look at HOW your individual payers are going to adopt the new CPT codes. Analyze the reasons for rejected, denied, or delayed claims and fix it. Put together policies and procedures for the RAC coming to your area. Make sure clinicians are involved. Really consider doing PQRI and e-prescribing---4% is nothing to sneeze at. Enforce payments with private payers. They have been proven wrong!! Look at your billing profiles from 10 -1 -07. Give $$ back before the RACs collect it for you! Participate in the struggle!
Contact Info Contact bbuell@covad. net bobbibuell 1@yahoo. com 800 -795 -2633 Newsletter is free! E-prescribing is free! Go to our website: http: //www. onpointoncology. com
Thank You from on. Point Oncology LLC!
Скачать презентацию Changes to Oncology Coding 2009 Bobbi Buell Version
e9b02625e20396deb1c7946e33883ca5.ppt