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2007: What’s New? Bobbi Buell Version 1.0 January, 2007 Disclaimer (from CMS) “ This presentation was current at the time it was printed or downloaded. This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services. The Centers for Medicare & Medicaid Services (CMS) employees, agents, and staff make no representation, warranty, or guarantee that this compilation of information is error-free and will bear no responsibility or liability for the results or consequences of the use of this presentation. This publication is a general summary that explains certain aspects..implementation, but is not a legal document. This presentation was current at the time it was printed or downloaded. This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services. The Centers for Medicare & Medicaid Services (CMS) employees, agents, and staff make no representation, warranty, or guarantee that this compilation of information is error-free and will bear no responsibility or liability for the results or consequences of the use of this presentation. “ From the CMS NPI Power Point That goes ditto for me! I Session Objectives Provide update on changes in Medicare physician payment for 2007 Show impact of new reimbursement changes Explain all applicable coding changes Update information about Evaluation & Management Services Discuss optimal strategies for 2007. Medicare – the big picture $336 billion spent in 2005 2.7% of GDP in 2005 7.3% of GDP by 2035 Medicare Part B Physician services, outpatient hospital, DME, some drugs, physical therapy. Paid for by general revenue and beneficiary premiums Premiums are set to cover 25% of projected cost---this means patients will be paying more and more. Beneficiary out of pocket costs and premiums will grow faster than income. Expenditure growth will exceed GDP growth by at least 6% over the next decade Part B Patient Costs 2007 Part B・Deductible: $131 / year Standard Premium: $93.50 / month from $88.50 Income-Adjusted for wealthier beneficiaries Income-related monthly adjustment amounts Single = Less than or equal to $80,000 = $0.00 = $93.50 Joint Return= Less than or equal to $160,000 =$0.00 = $93.50 Single =Greater than $80,000 and less than or equal to $100,000 = $12.50 = $106.00 Joint =Greater than $160,000 and less than or equal to $200,000 = $12.50 = $106.00 Single =Greater than $100,000 and less than or equal to $150,000 = $31.20 = $124.70 Joint = Greater than $200,000 and less than or equal to $300,000 = $31.20 = $124.70 Single= Greater than $150,000 and less than or equal to $200,000 = $49.90= $143.40 Joint = Greater than $300,000 and less than or equal to $400,000 = $49.90= $143.40 Single = Greater than $200,00 = $68.60 = $162.10 Joint = Greater than $400,000 = $68.60 = $162.10 Part C Medicare managed care plans (Medicare Advantage) Paid for by Part A and B funding streams. Expected that more people will join over the next decade, but estimates were not reached when Part D kicked in. Part C Eligibility Medicare Advantage Eligibility Must be enrolled in Medicare Parts A & B; enrollees are still in the Medicare program, Must continue to pay the Part B premium ($93.50 / month in 2007), Must live in the plan’s service area, Must not have end-stage renal disease (ESRD) at time of enrollment Medicare Part D Prescription drug coverage Paid for by general revenue and beneficiary premiums More out of pocket costs for beneficiaries More coverage for cancer More unpaid work for practices, but most practices are not bogged down. 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. How RVUs Are Used 3 inputs go into the total RVUs Work = Face-to-face physician time, plus intensity of work Practice expense = practice expense relative to other procedures (with no intensity of expense) Malpractice insurance costs (< 5%) = malpractice risk Equation is ((W*WGPCI)+(PE*PEGPCI)+(M*MGPCI)) times the conversion factor = Fee Schedule Allowable for all codes except labs and drugs This year there is a budget neutrality withhold that changes the equation. Just This Year…Medicare ONLY There is a budget neutrality factor of 10.1%… Steps to calculate your payment: ((WRVU*0.8994(ROUND))*WGPCI)+(PE*PEGPCI)…. etc. 1. Work RVU X 0.8994 2. Round this result to two places using the EXCEL formula 3. Apply this as the WORK RVU in the formula on the preceding page. How does CMS determine the update? A formula spelled out in the Medicare statute determines the annual change Known as the Sustainable Growth Rate or SGR system or Medicare Boomerang There are three components Sustainable growth rate (SGR) Medicare Economic Index (MEI) Annual update adjustment factor (UAF) SGR Put in place to control growth in spending on physician services Link changes in spending to factors affecting the cost of providing services to Medicare beneficiaries and to economic growth SGR used to set an annual target for spending on physician services SGR formula SGR is the product of four factors Change in physician fees Change in Medicare fee for service enrollment Change in real per capita GDP Change in law and regulation affecting spending on physician services Calculating the annual fee schedule update Annual update to the conversion factor is the product of: Medicare Economic Index (MEI) Update Adjustment Factor Update Adjustment Factor Formula .75 × Target spending06 – Actual spending06 Actual spending06 + .33 × Target spending 96 – 06 – Actual spending96 – 06 Actual spending05 × SGR06 Annual update Statute defines a floor and ceiling for the UAF UAF can’t be more than MEI +3% or less than MEI -7% Final 2007 update = MEI – 7% Flaws with UAF Setting of target – SGR and all its flaws Calculation of actual expenditures Cumulative aspect of formula Sources of spending growth Increasing volume and intensity of office visits Minor procedures Imaging services Laboratory tests Physician-administered drugs Here’s the deal… SGR system is fatally flawed Cannot account for technological advances and expansion of medical knowledge Inappropriately linked to GDP Including the cost of Part B drugs overstates spending that is under physician control Cumulative nature of system means the problem can only get worse without a permanent fix…that’s why we have Band-Aids like this year and last year. Alternatives to SGR Annual update linked to MEI? Pay for performance? 2007 PVRP is a start for this! New formula to calculate the target? Separate targets by region, type of service Watch for a discussion this Spring when MedPac goes to Congress with recommendations! This Year’s SGR Fix The fix is in! A freeze next year of the Conversion Factor (stays at $37.8975)---but allowables are NOT frozen. A 1.5% reporting sweetener after July 1 for reporting PVRP quality measures, if you report for = or > 80% of reportable services. But, you will see no payment until 2008. A PVRP measure for Oncology will be the revised disease status codes from 2006. GPCI floor will be reinstated to support rural areas. Establishes a fund to promote payment ‘stability’ in 2008. Increases payment for ESRD of 1.6%. This Year’s SGR Fix Extends the treatment of certain physician pathology services for technical component. Extends MMA rate for brachytherapy. Allows brachytherapy to be paid at hospital costs for another year. Clarifies the payment process under CAP--post-payment review process. Requires reporting of hemoglobin and hematocrit as ‘quality indicators’ for cancer anti-anemia drugs in 2008. Providers will be paid for administration of Part D vaccines in their offices in 2007. Extends the Recovery Audit Contractor Audits beyond test states. 2007 Physician payment changes Five year review of RBRVS New practice expense methodology DRA cut to in-office imaging Five year review of RBRVS CMS proposed large increases for many evaluation and management (EM) services For example, 99214 payment will increase from $83 to $90 E&M Is Better? Code 2006 Code 2007 Descriptor 99211 99211 Office/outpatient visit, est 99212 99212 Office/outpatient visit, est 99213 99213 Office/outpatient visit, est 99214 99214 Office/outpatient visit, est 99215 99215 Office/outpatient visit, est 99241 99241 Office consultation 99242 99242 Office consultation 99243 99243 Office consultation 99244 99244 Office consultation 99245 99245 Office consultation 2007 $ 2006 $ Difference $20.09 $21.60 -7% $36.76 $38.66 -5% $59.50 $52.68 13% $90.20 $82.62 9% $122.03 $120.14 2% $48.51 $50.40 -4% $89.44 $92.09 -3% $122.41 $122.79 0% $179.63 $173.19 4% $222.84 $223.97 -1% Five year review of RBRVS Budget neutrality requirement CMS instituted 10% reduction to be applied to all work RVUs as we saw previously. Alternative was 5% reduction in conversion factor Impact of budget neutrality options varies by service due to weight of the work RVUs, but 70% of all physician services are reduced in 2007. Practice expense New method will cut Medicare payments to Oncology by an estimated 5-7% over five years depending upon what codes you use PE RVUS for drug administration, imaging and other technical component procedures decrease PE RVUs for EM increase New practice expense formula Calculate direct practice expense portion of RVUs with a “bottom-up” approach instead of former “top-down” method Eliminate non-physician work pool (NPWP) Use supplemental practice expense data from specialties. Include clinical labor in indirect cost formula 2007 Drug Administration Code 2006 Code 2007 Descriptor 2007 $ 2006 $ Difference 90760 90760 Hydration iv infusion, init $61.39 $63.29 -3% 90761 90761 Hydrate iv infusion, add-on $18.95 $20.09 -6% 90765 90765 Ther/proph/diag iv inf, init $75.04 $77.31 -3% 90766 90766 Ther/proph/dg iv inf, add-on $24.25 $25.77 -6% 90767 90767 Tx/proph/dg addl seq iv inf $39.79 $42.45 -6% 90768 90768 Ther/diag concurrent inf $22.74 $24.63 -8% 90772 90772 Ther/proph/diag inj, sc/im $19.33 $18.57 4% 90773 90773 Ther/proph/diag inj, ia $18.19 $18.95 -4% 90774 90774 Ther/proph/diag inj, iv push $57.23 $57.60 -1% 90775 90775 Ther/proph/diag inj add-on $26.15 $26.91 -3% 96401 96401 Chemo, anti-neopl, sq/im $58.36 $52.68 11% 96402 96402 Chemo hormon antineopl sq/im $42.45 $45.86 -7% 96405 96405 Chemo intralesional, up to 7 $121.65 $113.31 7% 96406 96406 Chemo intralesional over 7 $145.15 $145.91 -1% 96409 96409 Chemo, iv push, sngl drug $119.76 $122.41 -2% 96411 96411 Chemo, iv push, addl drug $68.97 $70.87 -3% 96413 96413 Chemo, iv infusion, 1 hr $165.99 $172.81 -4% 96415 96415 Chemo, iv infusion, addl hr $37.14 $39.03 -5% 96416 96416 Chemo prolong infuse w/pump $179.63 $185.70 -3% 96417 96417 Chemo iv infus each addl seq $81.48 $84.51 -4% 96420 96420 Chemo, ia, push tecnique $109.90 $110.66 -1% 96422 96422 Chemo ia infusion up to 1 hr $181.91 $192.90 -6% 96423 96423 Chemo ia infuse each addl hr $78.07 $78.83 -1% 96425 96425 Chemotherapy,infusion method $178.50 $179.26 0% 96440 96440 Chemotherapy, intracavitary $370.64 $405.12 -9% 96445 96445 Chemotherapy, intracavitary $360.03 $393.76 -9% 96450 96450 Chemotherapy, into CNS $300.15 $325.54 -8% 96521 96521 Refill/maint, portable pump $145.91 $153.11 -5% 96522 96522 Refill/maint pump/resvr syst $110.28 $110.66 0% 96523 96523 Irrig drug delivery device $27.67 $28.04 -1% 96542 96542 Chemotherapy injection $182.29 $192.52 -5% MEDICARE 2007 PART B Other components Multiple imaging codes-TC component reduced by 50% was proposed for multiple imaging in related families--will be a reduction of 25% 2007 in -TC These codes must fall into the same “family” MRI, MRA, CT, CTA, Ultrasound Hard on physicians that own their own equipment/free-standing imaging DRA Reduction: certain imaging codes’-TC will be compared with imaging APCs and will be reduced to the HOPD level Multiple imaging reduction taken first; then the DRA Reduction Huge reductions seen estimated by some Oncology practices (35-40%). 2007 Medicare Payments for OfficeAdministered Drugs Payments for drugs based on 106% of manufacturer’s average sales price (ASP + 6%) Manufacturers report the ASPs for their drugs to the Centers for Medicare & Medicaid Services (CMS) within 30 days after the end of each calendar quarter Payment amounts for multiple-source drugs are determined by weighting each drug’s ASP by its sales volume for each NDC within the category. 2007 Medicare Payments for OfficeAdministered Drugs Payments are adjusted quarterly with 2-quarter lag For example, payment amounts for July-September quarter are based on ASPs for January-March quarter. This hurts if any sizable price increase is taken by a manufacturer. New drugs are paid at 106% of wholesale acquisition cost (WAC) until ASP data are collected, usually 2-3 quarters. Principal Problems with ASP $ “Underwater” drugs Some drugs are not available to some physicians at the Medicare payment amount No way to account for it in a cost outlier system. Price increases not reflected for 2-3 quarters which may cause payment amount to be less than the current drug price other costs are not covered, e.g. supplies, handling, sales tax, etc. Prompt Pay Discount given to wholesalers taken out of ASP. Drug admin payment and coding rules do not cushion the blow as was projected. RBRVS And Private Payers Need to examine every aspect and component of RBRVS Year of Fee Schedule RVUs Use of GPCIs Conversion Factor Use of Budget Update Drug Payment Additional Fees Protocol Picture Off-label Laws In Your State Oncology Quality Demonstration Projects (2005-2007) 2005 Demonstration Project 2006 Demonstration Project Paid with intravenous chemotherapy Measures level of nausea/vomiting/ fatigue pain $130.00/day Paid with office visits (99212-99215) Question about where in treatment; whether treatment is on NCCN/ASCO guidelines; and stage of disease. $23.00/day 2007 No Demonstration Project Code changes released 11/1/2006 G-code Changes 1/1/2007 Codes for the focus of the visit (G9050-G9055) were reclassified to coverage code “I”: This means that, as of 1/1/2007, these codes are not covered by Medicare. Codes for adherence to clinical guidelines (G9056-G9062) were re-classified to coverage code “I”: Again, it seems that Medicare as of January 1, 2007 will not cover these codes. Codes for disease status (G9063-G9130) had a pricing change to price “00” meaning they will not be paid in 2007. Several long descriptors for disease status were changed or swapped, along with some additions. These codes will be used in the PVRP starting in July. Hospital Outpatient Prospective Payment (APCs) Elements of the payment system Unit of payment – the individual service Can bill for multiple services on same day Classification system – ambulatory payment classification (APC) groups Relative weights Single value for each APC that reflects relative costliness of that service compared to others, based on median costs Exception: New technology APCs Conversion factor – transforms relative weight into payment Hospital Outpatient Prospective Payment Base payments Base payment covers the hospital’s costs of providing the service (physician paid separately) Base payment built on total cost-based paymentincluding coinsurance-in 1996 60 percent of payment is adjusted by the hospital wage index Updated annually using hospital market basket Hospital Outpatient Payment For Medical Oncology Drug payments are weird Pass-through for 2-3 years paid at ASP plus 6% Drugs over $50 after pass-through are paid at ASP plus 6% (until 1/1/2007) and then $55 is the threshold. Many drugs bundled in with no payment Spending on drugs is about 8% of HOPPS expenditures (according to MedPac) Drug administration has traditionally been paid at a PER VISIT (not per hour) rate, which will change in 2007 Hospital-based Medical oncologists get paid at a reduced professional fee for Evaluation & Management based on a site of service differential BUT Hospitals OPDs Are Different Structurally Hospital OPDs are well-diversified portfolios of servicessurgery, nuclear medicine, radiation, physical therapy, etc Hospital OPDs are part of an inpatient facility where revenues may come from the inpatient side Hospital OPDs are often part of large purchasing organizations which may decrease losses on unpaid drugs and supplies Hospital OPDs Are Different Medicare Co-payments are a larger piece of the revenue stream and are not just 20%, which is not frequent in Oncology. Outlier payments for high loss cases 340B price breaks for Disproportionate Share Hospitals Exemption for cancer hospitals Hospital OPDs Are Different Private Payers Better negotiating leverage based on community profile and size Better negotiating leverage based on higher headcount of professional managers Many payers still pay on charge-based systems with drugs at AWP Hospitals have not allowed Medicare to become the standard of payment for outpatients. Medicare Outpatient PPS 2007 Drugs Separately paid drug threshold would rise from $50 to $55. This does not include anti-emetics. Separately paid drugs would be paid at ASP plus 6%, not ASP plus 5% as proposed. Pass through drugs would be paid the rate established by the Competitive Acquisition Program, generally ASP plus 6% Medicare Outpatient PPS 2007 Drug Administration Second and subsequent hours will be paid. Payments for services by the hour rather than by the visit. New APCs with new rates. CPT codes will be used instead of C-codes. But, hospitals will receive a boost in all APCs with a 3.4% increase in the inflation rate rate for all APCs Medicare OPPS 2007 Evaluation & Management Codes for Clinic Visits Five levels using CPT codes, not G-codes. Refining these levels. Imaging will not have second and following procedures reduced. Future increases tied to Quality Measures reporting starting in 2009. HOPD Drug Admin 2007 CPT/ HCPCS 90760 90761 90765 90766 90767 90768 90772 90773 90774 90775 90779 96401 96402 96405 96406 96409 96411 96413 96415 96416 96417 96440 96445 96450 96521 96522 96523 Description Hydration iv infusion, init Hydrate iv infusion, add-on Ther/proph/diag iv inf, init Ther/proph/dg iv inf, add-on Tx/proph/dg addl seq iv inf Ther/diag concurrent inf Ther/proph/diag inj, sc/im Ther/proph/diag inj, ia Ther/proph/diag inj, iv push Ther/proph/diag inj add-on Ther/prop/diag inj/inf proc Chemo, anti-neopl, sq/im Chemo hormon antineopl sq/im Chemo intralesional, up to 7 Chemo intralesional over 7 Chemo, iv push, sngl drug Chemo, iv push, addl drug Chemo, iv infusion, 1 hr Chemo, iv infusion, addl hr Chemo prolong infuse w/pump Chemo iv infus each addl seq Chemotherapy, intracavitary Chemotherapy, intracavitary Chemotherapy, into CNS Refill/maint, portable pump Refill/maint pump/resvr syst Irrig drug delivery device Source: CMS-1506P 8/8/2006 APC 0440 0437 0440 0437 0437 0437 0438 0438 0438 0436 0438 0438 0438 0438 0439 0439 0441 0438 0441 0438 0441 0441 0441 0440 0440 0624 Relative weight 1.8090 0.3945 1.8090 0.3945 0.3945 0.3945 0.7942 0.7942 0.7942 0.1809 0.7942 0.7942 0.7942 0.7942 1.5848 1.5848 2.4851 0.7942 2.4851 0.7942 2.4851 2.4851 2.4851 1.8090 1.8090 0.5145 National Minimum unadjuste unadjuste d d Payment copaymen copaymen rate t t 111.20 22.24 24.25 4.85 111.20 22.24 24.25 4.85 24.25 4.85 24.25 48.82 48.82 48.82 11.12 48.82 48.82 48.82 48.82 97.41 97.41 152.75 48.82 152.75 48.82 152.75 152.75 152.75 111.20 111.20 31.63 12.65 4.85 9.76 9.76 9.76 2.22 9.76 9.76 9.76 9.76 19.48 19.48 30.55 9.76 30.55 9.76 30.55 30.55 30.55 22.24 22.24 6.33 Coverage with Evidence Development CMS moving towards more coverage with their own trials… Coverage with Evidence Development (CED) policies: Coverage of drugs, devices, and other technologies when provision of the service is accompanied by data reporting or collection that benefits CMS. Examples include FDG-PET Registry and coverage of colorectal cancer drugs in off-label uses when provided as part of an approved clinical trial. CMS states intent to use data to inform permanent coverage decisions in cases where the current trial structure does not provide enough information about beneficiaries or beneficiary access. Off-Label Drug Coverage By statute, Medicare must cover off-label uses of drugs used in anticancer chemotherapy regimens if the uses are supported by citations in: U.S. Pharmacopoeia – Drug Information (“USPDI”) American Hospital Formulary Service AMA Drug Evaluations (Defunct) CMS may also change the list of approved compendia as appropriate for identifying medically accepted indications And, they should! Off-Label Uses Not in the Compendia The Medicare statute authorizes the carriers to cover off-label uses of cancer drugs that are not in the compendia based on studies in peerreviewed publications specified by CMS CMS’s current list of 15 journals has not been updated since legislation was passed in 1993 and it has always looked like a partial list! Additional Journals Recommended by ASCO Annals of Oncology Biology of Blood and Marrow Transplantation Breast Cancer Research and Treatment International Journal of Radiation Oncology, Biology, Physics Gynecologic Oncology Journal of the National Comprehensive Cancer Network Journal of Thoracic Oncology Clinical Cancer Research Medicare Coverage of Clinical Trials In 2000, CMS issued a National Coverage Decision (NCD) announcing coverage for routine costs of clinical trials. Since then, they have waffled on the coding a few times--except for the -QV. Investigational devices, items, or drugs are not covered, nor are costs of qualifying for the trial. In July 2006, CMS announced it will be reconsidering current policy to address issues that have surfaced since implementation, particularly coding and links to Evidence Development. Medicare Contractor Reform Carriers (Part B) and fiscal intermediaries (Part A) will be merged into one entity called Medicare Administrative Contractor (MAC) 15 primary Part A/B MACs 4 specialty MACs (home health and hospice) 4 specialty MACs (durable medical equipment); first bid awarded to CIGNA; protested by Palmetto. Primary A/B MACs will serve newly defined geographical regions Issue of medical directors in each state unresolved Transition from existing contractor to MAC: 6-13 months Total transition between now and 2010. Coding Changes 2006-2007 New Hem-Onc Codes 10/1/2006 Changes/New Codes in Hem-Onc Malignant stromal tumor of the stomach added to malignant connective tissue tumors (171.5) and benign connective tissue tumors (215.5) MDS codes (238.7x) Constitutional aplastic anemia (284.0x) Pancytopenias / Myelophthisis /Other (284.x) Anemia of other chronic illnesses (285.29)-Revised Neutropenia (288.0x- new fifth digits) Hemophagocytic syndromes (288.4) Decreased white cell count (288.5x) Elevated white cell count (288.6x) Neutropenic splenomegaly (289.53) Myelofibrosis (289.83) New Codes 10/1/2006 Neoplasm-related pain (338.3) Mucositis due to anti-neoplastic therapy (528.01) Abnormal tumor markers (795.8x) Unspecified adverse effect of drug, medicinal, or biological substance (995.2x) Colonic polyps (V18.51) Estrogen receptor status, positive or negative (ER+/-) (V86.0-V86.1) See your code book for more changes! 8 Codes Per Claim Medicare to allow up to 8 diagnosis codes per claim-- You may have to wait until next July but Medicare will permit you to report up to eight diagnosis codes on a single claim. Expanding the number of ICD-9-CM codes available on the CMS-1500 form was mandated by HIPAA. CMS plans to update Medicare claims processing systems in three phases so all carriers are ready to accommodate this change by July 2007. The only exception to the current policy is for clinical lab services. Clinical lab claims with more than four ICD-9 codes are manually reviewed, but "this process has not always worked effectively," CMS says in Transmittal 1095, an update to the Medicare Claims Processing Manual. This is very good news for Medical Oncology and profiling our performance by patient. CPT 2007 Changes to consultation codes To reflect 2006 changes Clarification (?) of who can request a consult. New codes for warfarin management (we’ll get into that) Ventilator Assist and Management 94002-94005 Medical Genetics Counseling by a genetics counselor, each 30 minutes = 96040 Additional hours of hydration, therapeutic, chemotherapy infusions no longer have the eight hour time limit Warfarin Management 99363--Anticoagulant Management for an outpatient taking warfarin, physician review and interpretation of INR testing, patient instructions, dosage adjustment, and ordering of additional tests; first 90 days of therapy, minimum of 8 INRs. 99364-- Each additional 90 days of therapy, minimum 3 INRs. “B” status by Medicare--hard edit and will not be paid. Warfarin Management May be any outpatient setting--but not inpatient. May not be used for periods less than 60 days (CPT) for the subsequent code. Use 99211, if less than 60 days. May only be used with E&M, IF the E&M does not include anything having to do with warfarin therapy. Use -25 on the E&M if this is the case. If started in the hospital, the subsequent code must be used as the initiation of therapy did not start as an outpatient. HCPCS Highlights (Many More Drug Changes) A9568 New code for TC-99M arcitumomab; A9549 deleted. G0377 Administration of Part D Vaccine in Your Office ($19.33) J0394 Apomorphine Hcl J1562 Immune globulin 100 mg sc J0894 Decitabine 1 mg J8650 Nabilone oral, 1 mg J9261 Nelarbine 50 mg injection Review of Concurrent Infusions Non-chemo infusions In one bag Under or equal to 15 minutes Over 15 minutes Piggy-back Chemo infusions In one bag??? Piggy-back Consultations Transmittal 788, CR #4215 No shared visits for consultations in either office or hospital. Either the NPP or MD should charge for the consult. This is an area of dispute. 3 R’s have been more formalized and one has been added… REQUEST from another physician must be clearly documented in BOTH the receiving and referring physician charts. Referring MDs must have it in their plan of care, but there is no need for you to check every record. The REASON for the consult must be clearly documented. Opinion RENDERED by the consultant. REPORT goes back to the referring physician. 99211 may not be used for a consult. Only ONE consultation may be billed per inpatient stay. No shared or split visits. Consultations Consultations (Cont’d) Consultations may be billed based on time for counseling/coordination of care, but an opinion must be rendered. If care for a diagnosis is transferred prior to the encounter, the encounter is not a consult. This is a highly-debated issue. Also, if care is continuous before the consult for the same/original problem, an additional consult may not be billed. E/M Medical Necessity (Trailblazer) 1. The guiding principle of Medicare is whether an item or service was “medically necessary”. For E&M, this means Frequency of service/ intensity of service. Separate from whether criteria was met, does the H&P meet the patient’s actual needs at the time of service? E/M Medical Necessity (Trailblazer) 2. Information used by Medicare is contained within the medical record documentation of the history, physical, and medical decision-making. Medical necessity is based on these attributes: Number, acuity, and severity of problems addressed in the E&M criteria. The context of the service in terms of other services previously rendered for the same problem. Complexity of documented co-morbidities that influence physician work. Physical scope encompassed by the problems, i.e. number of physical systems affected by the problem. E/M Medical Necessity Tips (Trailblazer) Identify presenting complaints and/or reasons for the visit. Demonstrate the history, physical and MDM associated with each. Demonstrate how physician work was affected by comorbidities or chronic problems noted. Ensure that the nature of the presenting problem is consistent with the level billed (99213 = low to moderate severity). Become familiar with the clinical examples in CPT Appendix C. Empire Medicare: Wastage Recent reviews by Medicare contractors indicate that providers are not adequately documenting, in their medical records, the provision and administration of drugs in the office setting. Empire Medicare Services expects that providers adhere to the following guidelines: Physicians and non-physician providers should enter the drug ordered in their plan of care for the encounter The dose and route should be included along with the name of the drug The encounter should be dated and signed in the medical record (or electronically if using EMR). The person actually administering the drug should enter into the record that he/she administered the drug, include the dose, route, and site of administration, and sign/date that entry It is recommended that providers include the drug lot number when documenting the administration of the drug. If the drug was administered by the ordering provider, it would be sufficient for that person to enter given next to the order in the plan of care (and also include the site of administration and lot number). A provider may indicate that the drug will be administered over a number of dates in the future, in a single plan of care. However, each subsequent administration of the drug must be separately documented as noted above. Signatures should be legible (you may want to print your name under the signature, if necessary). If the full amount of a single-use vial is not administered, the provider or staff administering the drug should enter a note in the patient’s medical record indicating the amount not administered (discarded) as wastage.These guidelines are intended to document the provision and administration of drugs that are covered under the Medicare incident to benefit (the drug is administered by the physician/non-physician provider or staff in the office). Use of these documentation guidelines will not extend Medicare coverage to any drug not otherwise covered (e.g., drugs that are usually self-administered, drugs that are not Food and Drug Administration (FDA) approved, drugs provided for indications that are not considered medically necessary, etc.). Drugs provided in the physician office may not be billed to Medicare unless they are also administered by or incident to the same physician/group. Furthermore, providers should not bill Medicare for visits (Evaluation & Management (E&M) services) when the purpose of the encounter was for the administration of the drug. Providers should retain drug invoice records to document the purchase of the drug, if requested by a Medicare contractor. Posted: 10/24/2006 Best Practices Negotiate private contracts with an iron fist--the train has left the station for Medicare.. Understand your RBRVS and how the payer is using it. Know whether EVERY payer is paying you correctly---electronically compare your paid rates to contracted rates using an EOB analyzer. Figure out their bundling rules and whether or not they meet coding standards. Understand the ASP/ AWP relationship for each payer. Ascertain the balance billing terms for each patient’s plan. Never give up asking for a facility fee to make up for unpaid costs in RBRVS, if you are paid at an equivalent rate to Medicare. Have a lawyer review every contract. Do not give up the idea of being out-of-network for small, but odious contracts. Successful Best Practices Collections! Collections! Collections! Cash! Cash! Cash! Do not give up money for denied claims--appeal and learn from the experience. Audit chemo prospectively; peer review E&M. Prepare for chaos around the NPI. Make sure you have everything settled in your practice 60 days before the deadline (5/23/07). Use the highest quality care guidelines and detailed ICD9 coding in the future--you will be rewarded for it down the road. Automate everything you can that will help with understanding your data and benchmarking. Get together with local hospital outpatient clinics and figure out ways as a group to take care of patients. Participate in the struggle! Use Our Web Site Often! Go to http://www.p4pbis.com