Reimbursement 2012 Bobbi Buell MBA 800 -795 -2633
Agenda What’s Going On Right Now Medicare PFS Final Rule 11 -1 -2011 PQRS and E-Prescribing 2012 Meaningful Use/ HIT 2012 Hospital Outpatient Prospective Payment System Final Rule Coding 2012 ICD-10 -CM Planning 2 on. Point Oncology LLC
Disclaimer 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 for 2012 is still being evaluated. 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. ICD-9 -CM information is abbreviated and coders are urged to check the tabular lists of code books for correct coding. 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. on. Point Oncology LLC 3
A Little History… Year Medicare Acts Conversion 1 st Hour $ Drugs Other 1991 Proposed MPFS $30. 00 $58. 78 85% of AWP Drugs now paid at 2 -3 times AWP 1993 Final MPFS $31. 00 N/A 100% of AWP 99213 = $31. 00 1994 Cancer Coverage $33. 72 and Improvement Act $32. 90 N/A 100% of AWP Off-label use approved; oral cancer drugs Part B 1996 HIPAA passed $35. 42 and $34. 63 N/A 100% of AWP False Claims Act for Medicare 1997 BBA of 1997 $36. 69 N/A 95% of AWP Oral antiemetics passed 4 (c) on. Point Oncology LLC
A Little History Year Medicare Acts Conversion 1 st Hour $ Drugs Other 1998 None of Note $36. 69 N/A 95% of AWP or inherent reasonableness LCA for LUPRON 1999 None of Note $34. 73 N/A 95% of AWP 26 states have off label laws 2000 None of Note $36. 61 $61. 90 95% of AWP Drug pricing investigated 2001 None of Note $38. 26 $62. 00 95% of AWP Aredia goes generic 2002 Single Drug Pricer $36. 20 N/A 95% of AWP under SDP Taxol goes generic 5 (c) on. Point Oncology LLC
A Little History Year Medicare Acts 2003 1 st Hour $ Drugs Other Passed MMA $36. 79 for 2004 $59. 22 95% of AWP RACs approved 2004 MMA $37. 34 $217. 35 85% of AWP for some drugs 99211 denied with drugs 2005 Demo Project $37. 90 $177. 61 ASP, plus 6% $130 per visit for demo 2006 Demo Project $37. 90 $172. 81 ASP, plus 6% $26 per visit for demo 2007 PQRI $37. 90 $165. 99 ASP, plus 6% IVIG in shortage 2008 ESAs limited $38. 09 $161. 49 ASP, plus 6% 40% denial rate on ESAs beginning of the year 6 (c) on. Point Oncology LLC Conversion
A Little History Year Medicare Acts Conversion 1 st Hour $ Drugs 2009 ARRA, MIPPA $36. 07 $147. 51 (32. 1% since 2004) ASP, plus 6% 2010 None of Note Many $140. 72 ASP, plus 6% PQRS/ ERx = 4% incentive 2011 None of Note $33. 98 $146. 44 ASP, plus 6% MUEs, Drug Shortages 7 (c) on. Point Oncology LLC Other
Medicare Physician Fee Schedule PFS Final Rule 2012 11/1/2011
Congress Continually Passes Temporary Fixes to Prevent the Negative Update in Medicare Physician Payments Year Legislation CF with CMS CY Congressional Difference Final CF Changes 2006 The Deficit Reduction Act of 2005 (DRA) $36. 1770 $37. 8975 $1. 7205 2007 Medicare Improvements and Extension Act, the Tax Relief and Health Care Act of 2006 (MIEA-TRHCA) $35. 9848 $37. 8975 $1. 9127 $38. 0870 $4. 0188 $36. 0666 $5. 9156 Department of Defense Appropriations Act, 2010 (Jan-Feb) $36. 0846 $7. 6785 Temporary Extension Act of 2010 (Mar) $36. 0846 $7. 6785 Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010 (Jun-Nov) $36. 8729 $8. 4667 Physician Payment and Therapy Relief Act of 2010 (Dec) $36. 8729 $8. 4667 $25. 5217 $33. 9764 $8. 4547 $24. 6712 $34. 0376 $9. 3664 2008 2009 2010 Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA) (Jan-Jun) The Medicare Improvements for Patients and Providers Act (MIPPA) (Jul-Dec) MIPPA Continuing Extension Act of 2010 (Mar-May) 2011 The Medicare and Medicaid Extenders Act (Jan-Dec) 2012 Temporary Payroll Tax Cut Continuation Act of 2011 (Jan-Feb) Source: CMS. Calendar Year (CY) 2006 -12 Medicare Physician Fee Schedule Final Rule $34. 0682 $30. 1510 $28. 4061
Recent “Doc Fix” Bill—One more Band-aid On February 17, 2012, Congress passed the ‘‘Middle Class Tax Relief and Job Creation Act of 2012’’. Key highlights of the bill include: Physician Payment - freezes physician payments at their current level through December 31, 2012 Physician Work Geographic Adjustment - extends the floor on the adjustment to the work portion of payments for physician services that accounts for the geographic area where a physician practices. This provision increases payments to physicians in the 54 of the 89 Medicare geographic areas that would otherwise have an adjustment value below the floor. Relevant Offsets : Resetting Clinical Laboratory Payment Rates - reduces payment rates for clinical laboratory services by two percent in 2013. As the two percent reduction is applied after the update is calculated, the resulting 2013 update amount becomes the new reset base on which the 2014 update will be applied Legislation mandates that the HHS Secretary study options for bundle or episode of care payments for physician services currently paid under the fee schedule for cancer or other prevalent chronic conditions. The report is due to Congress by January 1, 2013. Source: H. R. 3630. “Middle Class Tax Relief and Job Creation Act of 2012” as passed by Congress on February 17, 2012.
MPFS 2012 On November 1, 2011, the Centers for Medicare & Medicaid Services (CMS) posted a final notice for Medicare payments in the physician fee schedule for calendar year (CY) 2012. Here are the highlights of Rule which became effective for dates of service on or after 1 -1 -2012. The 27. 2% reduction did not happen. But, as you know, the SGR was not fixed. We’re looking at 32% next year. https: //www. cms. gov/Physician. Fee. Sched/PFSFRN/list. asp#Top. Of. Page 11 on. Point Oncology LLC
Multiple Procedure Payment Reduction (MPPR) Expansion to Include Physician Interpretation CMS finalized its proposal to expand the MPPR, which reduces payment by 25 percent for each second and subsequent advanced imaging service furnished during the same session to the “PC” of advanced imaging services, which represents the physician interpretation of the image Applies to CT, MR, and ultrasound CMS currently applies the MPPR to the TC of the same services CMS will consider the following MPPR policies in CY 2013 and beyond: Apply the MPPR to the TC and PC of all imaging services (e. g. , PET) Apply the MPPR to the TC of all diagnostic tests CPT 71250 72192 Total Modifier Description Global TC 26 Ct thorax w/o dye Ct pelvis w/o dye Physician Work RVUs 1. 02 0. 00 1. 02 1. 09 0. 00 1. 09 CY 2012 Total Transitional Malpractice NF RVUs NF PE RVUs 5. 84 0. 06 6. 92 5. 44 0. 01 5. 45 0. 40 0. 05 1. 47 5. 54 0. 06 6. 69 5. 13 0. 01 5. 14 0. 41 0. 05 1. 55 CF 1 $24. 6712 NF Payment $170. 72 $134. 46 $36. 27 $165. 05 $126. 81 $38. 24 $322. 55 Current payment Methodology Final Payment Methodology 1 x $134. 46 1 x $36. 27 0. 5 x $126. 81 1 x $38. 24 $272. 38 0. 5 x $126. 81 0. 75 x $38. 24 $262. 82 Source: Centers for Medicare & Medicaid Services (CMS). Calendar Year 2012 Medicare Physician Fee Schedule Final Rule (CMS-1524 -FC). Released November 1, 2011. 1 CF = The final CY 2012 CF is $24. 6712 PC = Professional Component TC = Technical Component
MPFS 2012 Practice Expense: CMS continues for the third year (at a 50/50 blend), the four-year phase-in of 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. Net year, this process of 5 -year review will end and CMS will focus on mis-valued codes. These include 96413, 96367, and 96365. This should be watched carefully. https: //www. cms. gov/Physician. Fee. Sched/PFSFRN/list. asp#Top. Of. Page 13 on. Point Oncology LLC
MPFS 2012 Drugs Average Manufacturers’ Price will be price substitution for drugs where AMP is 5% or more below ASP for 2 consecutive quarters prior to the current quarter or for 3 out of the preceding 4 quarters. This match-up will apply to BIOSIMILARS once they are approved. CMS emphasized that 103% of AMP will be the price substitute if the threshold is exceeded per the guidelines. Before implementation, 103% of AMP and 106% of ASP will be compared. The spreadsheet used by Manufacturers will change in 2012. https: //www. cms. gov/Physician. Fee. Sched/PFSFRN/list. asp#Top. Of. Page 14 on. Point Oncology LLC
MPFS 2012 The 72 -Hour Rule (7/1/2012) One of the most horrible parts of hospital reimbursement is that all “related” services within 72 hours before are bundled into the hospital per discharge payment (MS-DRG). CMS now proposes that, for any physician practice that is totally owned by the hospital or wholly-operated by the hospital, their diagnostic procedures or related therapeutic procedures will be impacted by the 72 hour rule. Professional components will be paid at the facility (not non-facility) rate. –TC will be denied. All other codes will be paid at the facility rate. Practices are responsible for billing with a – PD Modifier, when the patient is admitted, but this is not final until 7/1/2012. Hospitals must notify the practice, 15 on. Point Oncology LLC
Medicare Physician Fee Schedule PQRS and E-Prescribing 2012
PQRS 2012 The PQRS will pay bonuses equal to a 0. 5% bonus for reporting years in 2012 through 2014. This is for all fee schedule services, excludes drugs, labs, and DME. In 2015, providers who don't participate in PQRS will suffer a payment decrease. Beginning in 2015, EPs who do not satisfactorily report Physician Quality Reporting System measures will be subject to payment adjustments 2015: -1. 5% payment adjustment 2016 and beyond: -2% payment adjustment 17 on. Point Oncology LLC
MPFS 2012 PQRS Changes (Proposed) CMS is making an effort to consolidate PQRS reporting with ARRA HIT incentives for Quality Indicator Reporting. Time frame—a six month reporting period (7/1/201212/31/2012) will only be available for Measures Groups through a Registry. All other reporting must be for the full twelve-month period. Consolidates current Group Practice options to one Group Practice Reporting Option (GPRO) that is defined as 25 or more eligible professionals. 18 measures may be reported under this option. CMS will ‘suggest’ appropriate beneficiaries for reporting. Practices must go through a self-nomination process. 18 on. Point Oncology LLC
PQRS Changes 2012 Measures 26 additional new measures, including 6 for cancer 44 CQM measures that are now reportable to get the ARRA HIT incentive (“Meaningful Use”) 10 measures groups for reporting, none of which are related to cancer Reporting/HIT EHR submission of PQRS data either through a submission vendor or through a qualified EHR system. These must be certified by PQRS. . Can report your CQMs for MU either by attestation or by EHR through a portal or direct from your EHR. 19 on. Point Oncology LLC
New Cancer Measures 2012 New Individual Measures for 2012 PQRS Measure Developer Consensus Status Reporting Mechanism CAP N/A Claims, Registry Image Confirmation of Successful Excision of Image –Localized Breast Lesion ASBS N/A Claims, Registry Preoperative Diagnosis of Breast Cancer ASBS N/A Claims, Registry Sentinel Lymph Node Biopsy for Invasive Breast Cancer ASBS N/A Registry AAD N/A Registry Measure Title Immunohistochemical (IHC) Evaluation of HER 2 for Breast Cancer Patients Biopsy Follow-up Source: Centers for Medicare & Medicaid Services (CMS). Calendar Year 2012 Medicare Physician Fee Schedule Final Rule (CMS-1524 -FC). Released November 1, 2011. PQRS = Physician Quality Reporting System CAP = College of American Pathologists ASBS= American Society of Breast Surgeons AAD= American Academy of Dermatology
Why Participate? Performance will be the basis for payment in the near future Physician Compare beginning in 2013 http: //www. medicare. gov/find-a-doctor/provider- search. aspx 21 on. Point Oncology LLC
Physician Compare Website “Physician Compare for 2011 includes information about physicians and other professionals who participated in the Physician Quality Reporting System. It does not yet contain physician and eligible professional performance information. We expect to have performance information on Physician Compare starting in 2013. This will be for services those providers furnished to Medicare beneficiaries during 2012. ” In other words you will lose control over how beneficiaries perceive you!! 22 on. Point Oncology LLC
Physician Compare Website 23 on. Point Oncology LLC
PQRS Resources See on CMS Web Site Frequently Asked Questions Supplemental education materials National Provider Calls Special Open Door Forums Quality. Net Help Desk http: //www. cms. hhs. gov/PQRI/36_Help. Desk. Support. asp#Top. Of. Page 7: 00 a. m. - 7: 00 p. m. CST at 866 -288 -8912 or qnetsupport@sdps. org 24 on. Point Oncology LLC
E-Prescribing – Penalties 2012 – 1% reduction 2013 – 1. 5% reduction 2014 – 2% reduction 2011 Individual EPs must have : report at least 10 electronic prescriptions to avoid penalty for 2012. Reporting period 1/1/11 – 6/30/11 (processed by 7/31); report at least 25 electronic prescriptions to avoid penalty for 2013. Reporting period 1/1/11 – 12/31/11. 25
E-Prescribing 2012 Reporting Year Report 10 Encounters Report 25 Encounters 2011 No penalty in 2012 No penalty in 2013 No penalty in 2014 No penalty in 2015 https: //www. cms. gov/Physician. Fee. Sched/PFSFRN/list. asp#Top. Of. Page 26 on. Point Oncology LLC
E-Rx Reporting For successful claims-based reporting in 2012, a single code should be reported (numerator) G 8553 – At least one prescription created during the encounter was generated and transmitted electronically using a qualified e-Rx system To avoid the penalty in 2012, this does not need to be matched to the codes below. Must be on the same claim (denominator)– 90801, 90802, 90804, 90805, 90806, 90807, 90808, 90809, 90862, 92002, 92004, 92012, 92014, 96150, 96151, 96152, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G 0101, G 0108, G 0109 27 on. Point Oncology LLC
e. Rx Incentive Payment e. Rx incentive is percentage of all Medicare fee schedule charges (not including drugs) based on EP’s TIN/NPI. 2011, 2012 – 1% 2013 – 0. 5% EPs have until February 28, 2012 to submit CY 2011 claims to show they qualify. 28
e. Rx Incentive Payment May report through: Claims submissions. Qualified Registry – (Some registries qualify for both PQRS and e. Rx). Check CMS website for list of registries. Currently 2010 list available: http: //www. cms. gov/PQRI/Downloads/Qualified_Registries_Ph ase 4_e. Rx. PQRI_06282010_FINAL. pdf Qualified EHR – Check CMS website for list. http: //www. cms. gov/PQRI/Downloads/Qualified. EHRVendorsfo rthe 2011 Physician. Quality. Reportingande. Rx 121310. pdf 29
e. Rx – Penalties Penalty Exceptions: Individual EPs EP who is not a physician, NP or PA as of June 30, 2012 EP who does not have 100 cases in applicable codes through 6/30/2012 Physician is unable to electronically prescribe due to local, state, or federal law or regulation (e. g. , state law prohibits e-Prescribing of controlled substances) Hardship Exception: Hardship Exception Codes: Use G 8642 (practice in rural area without high speed internet access) or G 8643 (practice in area without available pharmacies for eprescribing). Groups Third and fourth exceptions above also apply to GPRO Must go to the CMS web site to register exceptions by 6/30/2012 30
EHR and e. Rx: Integration & Penalties If an EP gets an EHR incentive in 2011 and 2012, can still get e. Rx 2012 penalty E-prescribing measures are different E-prescribing system requirements are different But, can e-prescribe through a qualified EHT this year. If an EP gets an e. Rx incentive in 2011 and 2012, can still get e. Rx penalty Reporting periods for incentive and penalty are different For individual EPs (not groups) reporting requirements are different. 31
E-Prescribing MPFS 2012 Changes include: Use same coding requirements for the incentive in 2012. It is a bit different to avoid the penalty. Establish GPRO reporting requirements to be the same as PQRS— 25 or more eligible professionals. Modifies the requirements of the program to allow usage of either a qualified e-prescribing system or using a certified EHR system to prescribe. Reporting choices—only one per year-- include: EHR (2 submissions per year) Registry (2 submissions per year) Claims 32 on. Point Oncology LLC
Medicare & Medicaid EHR Incentive Programs
How Much Are the Incentives? • Medicare Incentive Payments Detail Columns = first calendar year EP receives a payment • Rows = Amount of payment each year if continue to meet requirements • CY 2011 CY 2012 CY 2013 CY 2014 CY 2015 and later CY 2011 $18, 000 CY 2012 $12, 000 $18, 000 CY 2013 $8, 000 $12, 000 $15, 000 CY 2014 $4, 000 $8, 000 $12, 000 CY 2015 $2, 000 $4, 000 $8, 000 $0 $2, 000 $4, 000 $0 $44, 000 $39, 000 $24, 000 $0 CY 2016 TOTAL 34 $44, 000 on. Point Oncology LLC
How Much Are the Incentives? • Medicaid Incentive Payments Detail • • Columns = first calendar year EP receives a payment Rows = Amount of payment each year if continue to meet requirements CY 2011 CY 2012 CY 2013 CY 2014 CY 2015 CY 2016 CY 2011 $21, 250 CY 2012 $8, 500 $21, 250 CY 2013 $8, 500 $21, 250 CY 2014 $8, 500 $21, 250 CY 2015 $8, 500 $21, 250 CY 2016 $8, 500 $8, 500 $21, 250 $8, 500 $8, 500 $8, 500 $8, 500 CY 2017 CY 2018 CY 2019 CY 2020 CY 2021 TOTAL 35 $8, 500 $63, 750 on. Point Oncology LLC $63, 750 $63, 750
A Conceptual Approach to Meaningful Use Improved outcomes Advanced clinical processes Data capture and sharing 36 on. Point Oncology LLC
What You Need to Participate • All providers must: • Register via the EHR Incentive Program website---you need to do this to be exempt from E-prescribing penalties, if the EP did not report. • Be enrolled in Medicare FFS, MA, or Medicaid (FFS or managed care) • Have a National Provider Identifier (NPI) • Use certified EHR technology http: //healthit. hhs. gov/certification • Medicaid providers may adopt, implement, or upgrade in their first year • All Medicare providers and Medicaid eligible hospitals must be enrolled in PECOS, when this is required. 37 on. Point Oncology LLC
Websites • Get information, tip sheets and more at CMS’ official website for the EHR incentive programs: http: //www. cms. gov/EHRIncentive. Programs • Eligibility • Meaningful Use • Medicaid State Information • Educational Materials • National CMS Listserv: http: //www. cms. gov/EHRIncentive. Programs/65_CMS_EHR_Listserv. asp • Frequently Asked Questions: http: //www. cms. gov/EHRIncentive. Programs/95_FAQ. asp • Registration for the EHR Incentive Programs: http: //www. cms. gov/EHRIncentive. Programs/20_Registrationand. Atte station. asp 38 on. Point Oncology LLC
Educational Materials www. cms. gov/EHRIncentive. Programs/55_Educational. Materials. asp Resources Available: Meaningful Use Calculator, Incentive Program Timelines, Webinars, Eligibility Flow Chart and Interactive Tool, CMS List. Serve, and more 39 on. Point Oncology LLC
Fee Schedule Changes to MU Incentive For 2012 Reporting of Clinical Quality Measures (CQMs): Attestation as it is today Overlap PQRS with HIT Incentives o Can delay your HIT incentive o You may submit two ways: • Through a portal • Directly from an approved (by PQRS) EHR 40 on. Point Oncology LLC
2012 Medicare Hospital Outpatient Prospective Payment System (OPPS): Final Rule
Increase in Threshold to Determine Whether Drugs are Paid Separately Medicare uses two methods to pay for drugs and biologicals in the hospital outpatient setting: Bundled: Payment for products with a per dose cost under a specified threshold are included in payment for administration or associated services Separately Paid: Payment for products with a per dose cost above the specified threshold are paid separately CMS increased the packaging threshold for CY 2012 from $70 to $75 Products with estimated per day costs at or below the threshold are bundled, while those with estimated costs above threshold are separately paid This is less than the $80 threshold CMS proposed The packaging threshold for CY 2012 is $75 per day (an increase of $5 per day from the CY 2011 threshold) Source: Centers for Medicare & Medicaid Services (CMS). Calendar Year 2012 Outpatient Prospective Payment System Final Rule (CMS 1525 FC). Released November 1, 2011.
Payment for Most Drugs and Biologics at ASP + 4, a Decrease from ASP + 5 For CY 2012, CMS will reimburse drugs and biologics as follows: • Drugs and biologics eligible for pass-through* payment: ASP + 6 percent • Non-pass-through specified covered outpatient drugs (SCOD): ASP + 4 percent * Pass-through status is assigned to new products with costs that are “not insignificant” and stays in effect for at least 2 years but no more than 3 years Source: Centers for Medicare & Medicaid Services (CMS). Calendar Year 2012 Outpatient Prospective Payment System Final Rule (CMS-1525 FC). Released November 1, 2011. ASP = Average Sales Price
Payment Increase for Qualifying Cancer Hospitals Cancer hospitals receive: The full difference for covered outpatient services under the OPPS and the pre-BBA amount – in other words, they are “held harmless” A transitional outpatient payment (TOP) to ensure that their payment under the OPPS is not less than it was prior to BBA implementation Per ACA, CMS will increase in payments to the 11 qualifying cancer hospitals in CY 2012 CMS will examine each cancer hospital’s data at cost report settlement to determine its payment-to-cost ratio (PCR) and, if it is below the weighted average PCR for other OPPS hospitals (target PCR; 0. 91 for CY 2012), it will receive a payment adjustment to make the hospital’s PCR equal the target PCR Most cancer hospitals will no longer qualify for Transitional Outpatient Payments (TOPs) as a result of the increased payments received under the proposed cancer hospital payment adjustment CMS estimates an overall 9. 5 percent increase in payments for these hospitals as a result of these changes Source: Centers for Medicare & Medicaid Services (CMS). Calendar Year 2012 Outpatient Prospective Payment System Final Rule (CMS-1525 FC). Released November 1, 2011. ACA = Affordable Care Act
Key Highlights of CY 2012 Quality Measures CMS did not add any new measures to the Hospital Outpatient Quality Data Reporting Program (HOP QDRP) program for CY 2012 Providers that do not satisfactorily report quality data during CY 2012 will continue to incur a two percent reduction in their annual payment update for CY 2013: Reduced conversion factor $68. 62 Full, proposed conversion factor $70. 02 The agency will continue its established process of adding measures to the HOP QDRP program for three years of payment determinations, rather than one In 2013, CMS will retain the 15 existing HOP QDRP measures from CY 2012 In 2014 , CMS will retain all measures from CY 2013 and finalized three of the nine proposed measures for CY 2014 Additional oncology-specific measures are being considered for 2015 and subsequent years: Cancer Care (hormonal therapy, biopsies) Chemotherapy Colonoscopy and endoscopy Source: Centers for Medicare & Medicaid Services (CMS). Calendar Year 2012 Outpatient Prospective Payment System Final Rule (CMS-1525 FC). Released November 1, 2011.
Pharmacy billing for drugs provided “incident to” a physician service MM 7397, revised 12/16/11 “Pharmacies, suppliers and providers may not bill Medicare Part B for drugs dispensed directly to a beneficiary for administration “incident to” a physician service…. These claims will be denied. ” "Pharmacies may not bill Medicare Part B for drugs furnished to a physician for administration to a Medicare beneficiary. When these drugs are administered in the physician's office to a beneficiary, the only way these drugs can be billed to Medicare is if the physician purchases the drugs from the pharmacy. ”
Pharmacy billing for drugs provided “incident to” a physician service Effective and implementation dates have been changed from January 1, 2012 to January 1, 2013 http: //www. cms. gov/Transmittals/downloads/R 2368 CP. pdf
ACA: The Proposed Rule for Overpayments The Centers for Medicare & Medicaid Services recently issued a proposed rule implementing a Patient Protection and Affordable Care Act requirement that health care providers and suppliers report and return self-identified overpayments by the later of 60 days after the date the overpayment was identified, or the date any corresponding cost report is due, if applicable. Retention of the overpayment beyond the deadline may result in False Claims Act liability. Examples of overpayments could include errors and non-reimbursable expenditures in cost reports; Medicare payments for non-covered services or in excess of the allowable amount for a covered service; duplicate payments; and receipt of Medicare payments when another payer had primary responsibility. The proposed rule was published in the Feb. 16 Federal Register with comments accepted for 60 days. http: //www. natlawreview. com/article/cms-publishes-proposed-rule-return-medicare-andmedicaid-overpayments 48 on. Point Oncology LLC
Coding and Billing 2012
ICD-9 -CM 10/1/2011 For more see…http: //www. cdc. gov/nchs/icd 9 cm_addenda_guidelines. htm This for Cancer Practices and Clinics only 50 on. Point Oncology LLC
ICD-9 -CM New Codes 10/1/2011 154. 2 Malignant neoplasm of anal canal 173. 10 Unspecified malignant neoplasm of the skin of the lip 173. 01 Basal cell carcinoma of the skin of the lip 173. 02 Squamous cell carcinoma of skin of the lip 173. 09 Other specified malignant neoplasm of the skin of the lip 51 on. Point Oncology LLC
ICD-9 -CM New Codes 10/1/2011 173. 10 Unspecified malignant neoplasm of the eyelid, including the canthus 173. 11 Basal cell carcinoma of the eyelid, including the canthus 173. 12 Squamous cell carcinoma of skin of the eyelid, including the canthus 173. 19 Other specified malignant neoplasm of the eyelid, including the canthus 52 on. Point Oncology LLC
ICD-9 -CM New Codes 10/1/2011 173. 20 Unspecified malignant neoplasm of the skin of the ear and the external auditory canal 173. 21 Basal cell carcinoma of the skin of the ear and the external auditory canal 173. 22 Squamous cell carcinoma of skin of the ear and the external auditory canal 173. 29 Other specified malignant neoplasm of the skin of the ear and the external auditory canal 53 on. Point Oncology LLC
ICD-9 -CM New Codes 10/1/2011 173. 30 Unspecified malignant neoplasm of the skin of other and other unspecified parts of the face 173. 31 Basal cell carcinoma of the skin of other and other unspecified parts of the face 173. 32 Squamous cell carcinoma of skin of other and other unspecified parts of the face 173. 39 Other specified malignant neoplasm of other and other unspecified parts of the face 54 on. Point Oncology LLC
ICD-9 -CM New Codes 10/1/2011 173. 40 Unspecified malignant neoplasm of the scalp and skin of neck 173. 41 Basal cell carcinoma of the skin of the scalp and skin of neck 173. 42 Squamous cell carcinoma of skin of the scalp and skin of neck 173. 49 Other specified malignant neoplasm of the scalp and skin of neck 55 on. Point Oncology LLC
ICD-9 -CM New Codes 10/1/2011 173. 50 Unspecified malignant neoplasm of skin of trunk, except scrotum 173. 51 Basal cell carcinoma of skin of trunk, except scrotum 173. 52 Squamous cell carcinoma of skin of trunk, except scrotum 173. 59 Other specified malignant neoplasm of skin of trunk, except scrotum 56 on. Point Oncology LLC
ICD-9 -CM New Codes 10/1/2011 173. 60 Unspecified malignant neoplasm of skin of the upper limb, including shoulder 173. 61 Basal cell carcinoma of skin of the upper limb, including shoulder 173. 62 Squamous cell carcinoma of skin of the upper limb, including shoulder 173. 69 Other specified malignant neoplasm skin of the upper limb, including shoulder 57 on. Point Oncology LLC
ICD-9 -CM New Codes 10/1/2011 173. 70 Unspecified malignant neoplasm of skin of lower limb, including hip 173. 71 Basal cell carcinoma of skin of lower limb, including hip 173. 72 Squamous cell carcinoma of skin of lower limb, including hip 173. 79 Other specified malignant neoplasm skin of lower limb, including hip 58 on. Point Oncology LLC
ICD-9 -CM New Codes 10/1/2011 173. 80 Unspecified malignant neoplasm of other specified sites of the skin 173. 81 Basal cell carcinoma of other specified sites of the skin 173. 82 Squamous cell carcinoma of other specified sites of the skin 173. 89 Other specified malignant neoplasm of other specified sites of the skin 59 on. Point Oncology LLC
ICD-9 -CM New Codes 10/1/2011 173. 90 Unspecified malignant neoplasm of unspecified sites of the skin Malignant neoplasm of the skin, NOS 173. 91 Basal cell carcinoma of skin, site unspecified 173. 92 Squamous cell carcinoma of skin, site unspecified 173. 99 Other specified malignant neoplasm of skin, site unspecified 60 on. Point Oncology LLC
ICD-9 -CM New Codes 10/1/2011 284. 11 Antineoplastic chemotherapy induced pancytopenia 284. 12 Other drug induced pancytopenia 284. 19 Other pancytopenia 286. 52 Acquired hemophilia 286. 53 Antiphospholipid antibody with hemorrhagic disorder 286. 59 Other hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors Antithrombinemia Antithromboplatinemia Etc. 61 on. Point Oncology LLC
ICD-9 -CM New Codes 10/1/2011 996. 88 Complications of stem cell transplant 999. 32 Bloodstream infection due to Central Venous Catheter 999. 33 Local infection due to Central Venous Catheter 999. 34 Acute infection following transfusion, infusion, or injection of blood and blood products 62 on. Point Oncology LLC
ICD-9 -CM New Codes 10/1/2011 999. 41 Anaphylactic reaction due to 63 administration of blood and blood products 999. 42 Anaphylactic reaction due to vaccination 999. 49 Anaphylactic reaction due to other serum 999. 51 Other serum reaction due to administration of blood and blood products 999. 52 Other serum reaction due to vaccination 999. 59 Other serum reaction due to other serum V 58. 68 Long-term (current) use of biphosphonates on. Point Oncology LLC
CPT Changes 2012 Changes to Observation Codes (99218 -99220) for time. 38232: Bone marrow harvesting for transplantation: autologous 77424 -77425: Intra-operative radiation treatments 64 on. Point Oncology LLC
CPT Changes—Infusion Coding Changes to Preamble—not much of it is new, but just further explained in detail. 96360 -96379, 96401 -96402, 96409 -96425, 96521 - 96523 are not to be reported by a PHYSICIAN in a facility (offices are not facilities) setting. EM should be appended with -25 with 96360 -96549, if separately identifiable office or other outpatient EM is performed. 65 on. Point Oncology LLC
CPT Changes-Infusion Coding INITIAL INFUSION Do not report an initial infusion due to a re-start of an intravenous line, an IV rate requiring 2 lines for implementation, or for accessing the port of a multiple lumen catheter. The difference in time and effort in providing this second IV is using an initial code with -59. Example 96365, 96365 -59, but these must be two totally separate and medically necessary lines. 66 on. Point Oncology LLC
CPT Changes—Infusion Coding SEQUENTIAL INFUSIONS All sequential infusions need to those of a new substance/drug. The one exception is that facilities (HOSPITALS) may report sequential infusions of the same drug using 96376, if infusions are more than 30 minutes apart. CONCURRENT INFUSIONS Clarified better that 96368 is not time-based and can only be reported once per day. Clarified that it is the infusion of a NEW substance/ drug. 67 on. Point Oncology LLC
CPT Changes—Infusion Coding Multiple Infusions of the SAME DRUG Must be over 30 minutes into the next hour for the add- on code as has been true since 2006 (2005 for Medicare) The sequential or subsequent infusions of the SAME drug should be reported based on the time of the infusion using the applicable add-on code. Example—A hospital patient is given a one-hour infusion every eight hours in 24 hours. 96365 is used for the initial infusion with 96366 is reported twice for the second and third infusions. HYDRATION codes should not be used in a ‘keep open’ situation or as a free flowing IV during a chemotherapeutic or therapeutic infusion. 68 on. Point Oncology LLC
CPT Changes-New Patient More clarification of what a new patient is A new patient is one who has not received professional services from the reporting physician OR the same EXACT specialty and subspecialty in the same group practice in the last three years. The subspecialty part has not been implemented by Medicare. Professional services are face-to-face services. 69 on. Point Oncology LLC
HCPCS 2012 --Added Plus, HCPCS Code. J 0897 – Injection, denosumab, 1 mg 70 on. Point Oncology LLC
HCPCS 2012 -Changes 71 on. Point Oncology LLC
HCPCS 2012 --Changes S 0353 Cancer treatment plan initial TREATMENT PLANNING AND CARE COORDINATION MANAGEMENT FOR CANCER INITIAL TREATMENT ADD I S 0354 Cancer treatment plan change TREATMENT PLANNING AND CARE COORDINATION MANAGEMENT FOR CANCER ESTABLISHED PATIENT WITH A CHANGE OF REGIMEN ADD I S-codes are Not paid by Medicare Usually used by the Blues Check with your payer before using 72 on. Point Oncology LLC 4/1/12
Other Important Deadlines HIPAA 5010 1/1/2012 Advanced Imaging Accreditation 1/1/2012 ICD-10 -CM will be postponed, but is a 3 -month postponement or 3 years? You still need to plan for it…. 73 on. Point Oncology LLC
Practice Implementation Planning—ICD-10 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 74 Organize Implementation Effort Establish Communication Plan Conduct Impact Analysis Contact System Vendors Estimate Budget Implementation Planning Develop Training Plan Analyze Business Processes Education and Training Policy Change Development Deployment of Code Implementation
Organize Implementation Effort Enlist staff person (coder, biller, manager) to oversee effort who will be key point person ―Prepare information to share with other providers and staff ―Identify work and scope for implementation Should be a team effort involving all medical practice staff and the staff needs to believe that this will actually happen. 75
Organize Implementation Effort Examine the level of coding you have in your practice—who is certified? Who has experienced a change before, e. g. E/M, admin codes? Who is equipped to deal with this? Look at all areas that will impact practice and identify each one that will be affected ― Practice management system ― Electronic Medical Record (EMR), if applicable ― Superbills ― Clinical areas and pharmacy Schedule regular meeting to share information with physicians and discuss progress and barriers of implementation. 76
Establish Communication Plan How will point person communicate with all staff? Most practices communicate via meetings or memos Ø No need to change method of communications Ø Develop regular schedule for ICD-10 progress efforts Monthly until 6 months prior to implementation Bi-weekly thereafter Ø Include information, publications, and articles Ø Document all meetings and what was discussed herein and make sure you are tracking with your plan. 77
Conduct Impact Analysis • Take this step prior to development of budget • In depth look at resources required for implementation • Maybe check for a little process improvement • Helps determine what costs might be involved as well as work processes • What systems will be affected? • • • Practice management Coding look up programs (if applicable)/CDMs/Superbills EMR Remittance systems Hardware space • What are the potential costs involved? 78
Conduct Impact Analysis Develop reasonable timeline that can be accomplished in your practice ―Map out a project plan on a simple Excel spreadsheet with benchmarks and status of completion Managers and/or coders should get physician approval for the project plan and its impact on the practice. Make sure you show and tell them the level of work it will take. 79
Conduct Impact Analysis Coding and documentation go hand in hand ICD-10 is based on complete and accurate documentation, even where it comes to right and left or episode of care. ICD-10 should impact documentation as physicians are required to support medical necessity using appropriate diagnosis code—this is not an easy situation, so physicians need to know from the outset that they need training. Will not change the way a physician practices medicine Complete and accurate documentation will continue to be important in 2013 (or whenever) as it is today 80
Contact System Vendors • Will they be able to accommodate the need to • • 81 move to ICD-10? Really? Were they ready for 5010? What plans do they have in place for implementation? Will they have new tools in place to help you with ICD-10? Will these have a cost? Will they create savings? When will they have software available for testing? Will we need new hardware or is current hardware sufficient?
Estimate Budget considerations should include Hardware costs Software costs and licensing Training Physician Query Productivity losses Jeopardy to cash flow Some notable budget estimates follow this slide… 82
ICD-10 Implementation $: AMA 83 (c) on. Point Oncology LLC
ICD-10 Implementation $$: MGMA 84 (c) on. Point Oncology LLC
Implementation Planning Begin Steps 1 -5 (reviewed up until this point) in 2012, but save others until 2013 or whenever. Break down planning into stages Training for a small practice does not need to begin until 6 months prior to implementation Review superbills and remove rarely used codes Crosswalk common codes from ICD-9 -CM to ICD-10 - CM Look up codes in ICD-10 -CM book and use GEMs, if necessary, but this is a very general and not necessarily accurate way of coding. 85
Crosswalk Example Iron Deficiency Anemia ICD-9 -CM ICD-10 -CM 280 Iron deficiency anemia 280. 0 Secondary to blood loss D 50. 0 Secondary to blood Loss 280. 1 Secondary to inadequate dietary intake D 50. 8 Other iron deficiency anemias 280. 8 Other specified iron deficiency anemias D 50. 1 Sideropenic dysphagia D 50. 8 Other iron deficiency anemias 280. 9 Iron deficiency anemia, unspecified 86 D 50 Iron deficiency anemia D 50. 9 Iron deficiency anemia unspecified
Develop Training Plan Who needs training? Physicians Coders Billing staff Administrative staff Nurses, MAs, Pharmacy Required number of hours depends on their role and coding interface What resources are available in your area? 87
Develop Training Plan Many organizations will have several mechanisms for training Distance learning Workshops Conferences Audio Conferences Webinars Books Establish training schedule or just “Train the Trainer”, but this must be a trusted coding person who also can communicate necessary information to clinicians. 88
Develop Training Plan Determine if temporary staff or overtime will be necessary during training period What materials will the office need for ongoing support after training? Books Software (code look up programs) Other 89
Analyze Business Processes Identify all systems and processes that currently use ICD-9 -CM Review existing medical policies related to ICD-9 -CM Which contracts tied to reimbursement are tied to a particular diagnosis? Which payers have policies for cancer drugs that are tied to ICD-9? How will this be impacted? Modify any contract agreements with health plans 90
Education and Training • Education should begin approximately 6 • • 91 months prior to implementation Large practices may need to begin earlier to accommodate all staff who need training Use various methods of training: on-line, distance, “Boot Camps” Training time depends on their role Physicians and coders/billers will need more training time than administrative staff
Policy Change/ Payment Impact After health plans complete and change medical policy for procedures and services a specialty provides Review new payment policies Identify opportunities to improve coding processes Communicate policy changes to applicable staff 92
Deployment of Code Should receive all updated software no later than 7/31/2013 for implementation of your charge documents. Vendor delivers software update with ICD-10 CM, but you should also know how long ICD-9 will be on-line. Vendors should Test system Integrate software into your systems Make internal customizations Test systems with clearinghouses, payers, electronic claims transmission (end to end) Ensure that the vendor will maintain updates to code during transition period 93
Implementation Make sure that your system accommodates both coding systems for a time. Have credit line established for claims rejections. Be prepared for re-dictation. Staff accordingly. 94 on. Point Oncology LLC
Other Considerations Consider use of electronic tools to facilitate coding process – Could reduce costs and claims rejections – Could increase productivity and coding accuracy Don’t convert superbills/charge documents too early – Currently, ICD-10 -CM is still updated annually – 6 – 12 months prior to implementation or after code set has been “frozen” – Assign ICD-10 -CM codes directly, not by applying ICD-9 -CM to ICD-10 -CM map—it’s good practice’!! 95
CDC’s Web Resources (FREE) General ICD-10 information http: //www. cdc. gov/nchs/about/major/dvs/ic d 10 des. htm ICD-10 -CM files, information, and General Equivalence Mappings (GEM) between ICD-10 CM and ICD-9 -CM http: //www. cdc. gov/nchs/about/otheract/icd 9/icd 10 cm. htm 96
CAN Web Site The latest news Forms Regulations Newsletters Presentations http: //can. communityoncology. org 97 on. Point Oncology LLC
CONTACT INFO Contact bbuell@covad. net bobbibuell 1@yahoo. com 800 -795 -2633 Newsletter is free! Go to our website: http: //www. onpointoncology. com on. Point Oncology LLC 98
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