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Changes to Oncology Coding 2009 Bobbi Buell Version 8.0 February-March 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 RemitDATA. Copyrighted to them and all rights reserved. Session Objectives Discuss Fee Schedule for 2009 Discuss CPT Changes for 2009 Discuss Drug Administration Coding for 2009 Discuss Anti-Emetic Policies from NGS Discuss ESA Coding Now 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 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 AND HURTS US. Impact of 2009 PFS Changes Code Number Descriptor 96360 Hydration initial 96361 Hydration Add-on 96365 Therapeutic initial 96366 Therapeutic Add-on 96367 Therapeutic Sequential 96368 Therapeutic Concurrent 96372 Therapeutic Injection 96374 Therapeutic Push initial 96375 Therapeutic Push seq 96401 Chemo injection non-h 96402 Chemo injection horm 96409 Chemo Push initial 96411 Chemo Push Sequent 96413 Chemo infusion initial 96415 Chemo infusion add-on 96416 Chemo infusion long 96417 Chemo infusion seql 96523 Irrigate implanted dev Work PE 0.17 0.09 0.21 0.18 0.19 0.17 0.17 0.18 0.1 0.21 0.19 0.24 0.2 0.28 0.19 0.21 0.21 0.04 Mal 1.33 0.33 1.63 0.39 0.73 0.36 0.4 1.29 0.52 1.65 0.82 2.8 1.51 3.73 0.67 4.17 1.76 0.65 0.07 0.04 0.07 0.04 0.04 0.04 0.01 0.04 0.04 0.01 0.01 0.06 0.06 0.08 0.07 0.08 0.07 0.01 Total RVUs 2009Total RVUs 2008 RVU change 2008 $ 1.57 1.61 -0.04 $ 60.56 0.46 0.49 -0.03 $ 18.28 1.91 1.97 -0.06 $ 73.89 0.61 0.64 -0.03 $ 23.61 0.96 0.97 -0.01 $ 38.09 0.57 0.6 -0.03 $ 22.09 0.58 0.56 0.02 $ 20.57 1.51 1.54 -0.03 $ 57.89 0.66 0.68 -0.02 $ 25.52 1.87 1.73 0.14 $ 64.75 1.02 1.09 -0.07 $ 40.75 3.1 3.16 -0.06 $ 119.21 1.77 1.81 -0.04 $ 68.18 4.09 4.27 -0.18 $ 161.49 0.93 0.97 -0.04 $ 36.18 4.46 4.63 -0.17 $ 175.20 2.04 2.12 -0.08 $ 79.60 0.7 0.72 -0.02 $ 27.42 2009 $ $ 56.62 $ 16.59 $ 68.89 $ 22.00 $ 34.62 $ 20.56 $ 20.92 $ 54.46 $ 23.80 $ 67.45 $ 36.79 $ 111.81 $ 63.84 $ 147.51 $ 33.54 $ 160.86 $ 73.58 $ 25.25 Change $ (3.94) $ (1.69) $ (5.00) $ (1.61) $ (3.47) $ (1.53) $ 0.35 $ (3.43) $ (1.72) $ 2.70 $ (3.96) $ (7.40) $ (4.34) $ (13.98) $ (2.64) $ (14.34) $ (6.02) $ (2.17) Change w/4% $ (1.67) $ (1.03) $ (2.25) $ (0.73) $ (2.08) $ (0.71) $ 1.19 $ (1.25) $ (0.76) $ 5.39 $ (2.49) $ (2.93) $ (1.79) $ (8.08) $ (1.30) $ (7.91) $ (3.08) $ (1.16) Impact of PFS Changes for 2009 Code Number Descriptor 99211 Office visit, established 99212 Office visit, established 99213 Office visit, established 99214 Office visit, established 99215 Office visit, established 99241 Office Consultation 99242 Office Consultation 99243 Office Consultation 99244 Office Consultation 99245 Office Consultation Work PE 0.17 0.45 0.92 1.42 2 0.64 1.34 1.88 3.02 3.77 Mal 0.34 0.55 0.75 1.09 1.38 0.66 1.08 1.45 1.93 2.3 0.01 0.03 0.03 0.05 0.08 0.05 0.1 0.13 0.16 0.21 Total RVUs 2009Total RVUs 2008 RVU change 2008 $ 0.52 0.54 -0.02 $ 19.81 1.03 1.03 0 $ 37.33 1.7 1.68 0.02 $ 59.80 2.56 2.53 0.03 $ 89.89 3.46 3.43 0.03 $ 121.50 1.35 1.34 0.01 $ 47.99 2.52 2.5 0.02 $ 89.12 3.46 3.43 0.03 $ 122.26 5.11 5.06 0.05 $ 179.01 6.28 6.25 0.03 $ 220.90 2009 $ $ 18.75 $ 37.15 $ 61.31 $ 92.33 $ 124.79 $ 48.69 $ 90.89 $ 124.79 $ 184.30 $ 226.50 Change Change w 4% $ (1.06) $ (0.30) $ (0.18) $ 1.30 $ 1.51 $ 3.97 $ 2.44 $ 6.13 $ 3.29 $ 8.28 $ 0.70 $ 2.65 $ 1.77 $ 5.40 $ 2.53 $ 7.52 $ 5.29 $ 12.66 $ 5.60 $ 14.66 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. G0332 is out! Change in the Enrollment Methodology Establishment of an Effective Billing Date for Physicians and NonPhysician 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 Internetbased PECOS may go to this place to check it out: https://pecos.cms.hhs.gov/pecos/login.do PECOS Physician or NPP may not 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/MedicareProviderSupEnroll 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 NonPhysician Practitioners: The rule requires physicians and non-physician 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 rule incorporates the requirement in section 149 of the MIPPA that, effective for services furnished on or after January 1, 2009, CMS add three new facility types to the list of authorized telehealth originating sites: a hospital-based or CAH-based renal dialysis center (including satellites), a skilled nursing facility (SNF), and a community mental health center (CMHC). The final rule also adopts the proposal to add new HCPCS codes specific to the 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 followup 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 G0406-G0408 (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 Initial 2009 Administration Codes 96360 Hydration IV infusion, 1st h 96365 Therapeutic IV infusion, 1st h 96374 Therapeutic IV injection 96409 Chemo IV push 96413 Chemo IV infusion, 1st h 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.” Port Flush Billing Procedures 96523 is payable with lab. Do not use 96374-96375 for port access--this is erroneous at best. Do not change practice patterns to accommodate a port flush… 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) Chapter 15, Section 50.2 Policy about determining whether or not a drug USUALLY is self-administered. For the purposes of applying this exclusion, the term “usually” means more than 50 percent of the time for all Medicare beneficiaries who use the drug. Therefore, if a drug is self-administered by more than 50 percent of Medicare beneficiaries, the drug is excluded from coverage and the [Part B] contractor may not make any Medicare payment for it. In arriving at a single determination as to whether a drug is usually self-administered, contractors should make a separate determination for each indication for a drug as to whether that drug is usually selfadministered Chapter 15, Section 50.2 Reasonable and Necessary “Contractors will make the determination of reasonable and necessary with respect to the medical appropriateness of a drug to treat the patient’s condition. Contractors will continue to make the determination of whether the intravenous or injection form of a drug is appropriate as opposed to the oral form.” Chapter 15, Section 50.2 Conditions under which a drug is self-administered “For the purposes of determining whether a drug is usually self-administered, an acute condition means a condition that begins over a short time period, is likely to be of short duration and/or the expected course of treatment is for a short, finite interval. A course of treatment consisting of scheduled injections lasting less than 2 weeks, regardless of frequency or route of administration, is considered acute. Evidence to support this may include Food and Drug administration (FDA) approval language, package inserts, drug compendia, and other information.” Chapter 15, Section 50.4.3 “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. For example, the accepted standard of medical practice for the treatment of certain diseases is to initiate therapy with parenteral penicillin and to complete therapy with oral penicillin. Carriers exclude the entire charge for penicillin injections given after the initiation of therapy if oral penicillin is indicated unless there are special medical circumstances that justify additional injections..” Chapter 15, Section 15.5.4 Last time this policy was revised was 2003 Effective January 1, 1998, Medicare also covers self-administered antiemetics, which are necessary for the administration and absorption of the anti-neoplastic chemotherapeutic agents when a high likelihood of vomiting exists….Self-administered anti-emetics to reduce the side effects of nausea and vomiting brought on by the primary drug are not included beyond the administration necessary to achieve drug absorption. Section 1861(s)(2) of the Act extends coverage to oral anti-emetic drugs that are used as full replacement for intravenous dosage forms of a cancer regimen under the following conditions: Coverage is provided only for oral drugs approved by the Food and Drug Administration (FDA) for use as anti-emetics; The oral anti-emetic must either be administered by the treating physician or in accordance with a written order from the physician as part of a cancer chemotherapy regimen; Oral anti-emetic drugs administered with a particular chemotherapy treatment must be initiated within two hours of the administration of the chemotherapeutic agent and may be continued for a period not to exceed 48 hours from that time; Transmittal 91, Change Request 5988 Subject: Self-Administered Drug Exclusion Lists Updates the requirement for contractors AND MACs to update the self-administered drug lists each year. Says nothing new at all specifically about anti-emetics or oral forms of drugs. But, interesting is it did uphold the following policy in Chapter 15, Section 50.2 Chapter 15, Section 50.2 “Fiscal intermediaries, carriers and Medicare Administrative Contractors (MACs) are instructed to follow the instructions below when applying the exclusion for drugs that are usually self-administered by the patient. Each individual contractor must make its own individual determination on each drug. 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. “ HCPCS Changes 2009 (1/1/2009) New Codes: J0641 J1267 J1453 J1459 INJECTION, LEVOLEUCOVORIN CALCIUM, 0.5 MG INJECTION, DORIPENEM, 10 MG INJECTION, FOSAPREPITANT, 1 MG INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON-LYOPHILIZED (E.G. HCPCS Changes New Codes J8705 TOPOTECAN, ORAL, 0.25 MG J9033 INJECTION, BENDAMUSTINE HCL, 1 MG J9207 INJECTION, IXABEPILONE, 1 MG J9330 INJECTION, TEMSIROLIMUS, 1 MG HCPCS Changes Changed Descriptors J1572 INJECTION, IMMUNE GLOBULIN, (FLEBOGAMMA/FLEBOGAMMA DIF), INTRAVENOUS, J2788 INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, MINIDOSE, 50 MICROGRAMS (250 I.U.) J2790 INJECTION, RHO D IMMUNE GLOBULIN, HUMAN, FULL DOSE, 300 MICROGRAMS (1500 I.U.) HCPCS Deleted Codes Q4097 INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NONLYOPHILIZED (E.G. Q4098 INJECTION, IRON DEXTRAN, 50 MG J9182 Etoposide 100 mg • BACK IN ACTION J1750 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 MMSEA - Medicare, Medicaid, and SCHIP Extension Act of 2007 Authorized 2008 PQRI, 1.5% incentive, eliminated cap Incentive Required alternative reporting periods and alternative reporting criteria for 2008 and 2009 Requires alternative reporting for measures groups and for registrybased reporting 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 Section 132: e-Prescribing Incentive Program Authorized separate 2% incentive payment to EPs who successfully use a qualified eprescribing system eRx 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 Focus on Quality & Improvement PQRI reporting focuses attention on quality of care. Foundation is evidence-based measures developed by professionals. Reporting data for quality measurement is rewarded with financial incentive. Measurement enables improvements in care. Reporting is the first step toward pay for performance. Measures address various aspects of quality care Prevention Chronic Care Management Acute Episode of Care Management Procedural Related Care Resource Utilization Care Coordination PQRI : Eligible Professionals Physicians MD/DO Podiatrist Optometrist Oral Surgeon Dentist Chiropractor Therapists Physical Therapist Occupational Therapist Qualified SpeechLanguage Pathologist Practitioners Physician Assistant Nurse Practitioner Clinical Nurse Specialist Certified Registered Nurse Anesthetist Certified Nurse Midwife Clinical Social Worker Clinical Psychologist Registered Dietician Nutrition Professional Audiologist 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 Hematology-Oncology Measures 2009 MDS And Acute Leukemias Cytogenetic Testing (ICD-9 codes changed for 2009) MDS Documentation of Iron Stores Multiple Myeloma: Treatment With Bisphosphonates (Minor language and ICD-9 changes for 2009) CLL Baseline Flow Cytometry (ICD-9 codes changed for 2009) Hormonal Therapy for Stage IC-III ER/PR + Breast Cancer (CPT II codes changed; language change) Chemotherapy for Stage III Colon Cancer Patients (Updated language, CPT II codes changed, language changes) Breast Cancer Patients Who Have pT and pN category and histological grade for their cancer (Language changes, minor coding changes) Colorectal Cancer Patients Who Have pT and pN category and histological grade for their cancer (Language changes, minor coding changes) Inappropriate use of bone scan for staging low risk cancer patients (Denominator code change, language change) Adjuvant hormonal therapy for high-risk prostate cancer patients (Language, Instruction changes, minor coding changes) Three-dimensional radiotherapy for patients with prostate cancer (CPT II changes, language changes, reporting frequency) Melanoma: Follow Up Aspects of Care (2009) Melanoma: Continuity of Care (2009) Melanoma: Coordination of Care (2009) Oncology Med/Rad: Plan of Care for Pain (2009) goes with Oncology Med/Rad: Pain Quantified (2009) Oncology: Radiation Dose Limits to Normal Tissues (2009) Oncology Recording of Clinical Stage for Lung and Esophageal Cancer (2009) Notice #73 #74 #101 and #103 are gone 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 claimsbased submission and 3 for registry-based reporting): Reporting period: January 1, 2009 – December 31, 2009 Reporting period: July 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 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 Measure Applicability Validation Satisfactorily Report ≥ 80% on ≥ 3 Measures Satisfactorily Report ≥ 80% on < 3 Measures Not Subject to MAV Subject to MAV Did EP report at least 1 measure included in a MAV Clinically Related Cluster? Step 1 - Clinical Relation Test: No Eligible for Incentive Payment Yes Step 2 - Minimum Threshold Test: Did EP report number eligible claims above threshold ≥ (30 pts)? Yes Not Eligible for Incentive Payment Did EP report number eligible claims below threshold < (30 pts)? Yes Eligible for Incentive Payment MAV CLUSTER 16 PATHOLOGY #99 Breast Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade #100 Colorectal Cancer Resection Pathology Reporting: pT Category (Primary Tumor) and pN Category (Regional Lymph Nodes) with Histologic Grade 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 E-Prescribing Incentive Program MIPPA authorized a new incentive program, separate from PQRI, for EPs who are successful e-prescribers For 2009, successful e-prescribers are eligible for a incentive payment equal to 2% of estimated allowed charges submitted by 2/28/2010 2009 E-Prescribing Incentive Reporting Period: January 1, 2009 – December 31, 2009 MIPPA also requires that names of eligible professionals who are successful e-prescribers be posted on the CMS web site 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 TransMedical Record & Rx mitted to Generated Pharmacy Encounter Form Coding & Billing N-365 NCH Analysis Contractor Confidential Report National Claims History File Carrier/MAC Incentive Payment Reporting Scenarios E-Prescribing A 70 year old male patient presents to the clinician’s office for medical care. Scenario 1: The clinician discusses current medications and prescribes new medication, updates active medication list in eRx system, transmits prescription electronically to pharmacy Reports G8443 Scenario 2: The clinician documents there is no change in meds, no prescription generated. Reports G8445 Scenario 3: Pt has mail order pharmacy that cannot accept eRx & asks for hard copy. Physician updates meds in eRx system, eRx system provides hard copy of prescription to patient. Reports G8446 All of these scenarios represent successful 2009 reporting What is Not E-Prescribing 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 feefor-service plans - can e-prescribe, but this does not count toward incentive payment calculation) Reporting Measures with Claims PQRI Tools: Where to Begin Gather information and educational materials from the PQRI web page: www.cms.hhs.gov/pqri 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. Understanding the Measures: PQRI Quality-Data Codes Quality-Data Codes translate clinical actions so they can be captured in the administrative claims process The measure requirement was met – OR – The measure requirement was not met due to documented allowable performance exclusions (i.e., using CPT II performance exclusion modifiers) – OR – The measure requirement was not met and the reason is not documented or is not consistent with an accepted performance exclusion (i.e., using the 8P reporting modifier) Understanding the Measure Construct NUMERATOR CPT II Code or Temporary G Code (describes clinical action required for performance) ÷ DENOMINATOR ICD-9-CM & CPT Cat I Codes (Describes eligible cases for a measure: the eligible patient population as defined by denominator specification) Understanding the Measures: The Performance Modifiers Unique modifiers used with CPT II Codes only Performance Measure Exclusion Modifiers indicate that an action specified in the measure was not provided due to medical, patient or systems reason(s) documented in the medical record: 1P- Performance Measure Exclusion Modifier due to Medical Reasons 2P- Performance Measure Exclusion Modifier used due to Patient Reason 3P- Performance Measure Exclusion Modifier used due to System Reason One or more exclusions may be applicable for a given measure. Certain measures have no applicable exclusion modifiers. Refer to the measure specifications to determine the appropriate exclusion modifiers. Understanding the Measures: The Reporting Modifier Performance Measure Reporting Modifier facilitates reporting a case when the patient is eligible but the action described in a measure is not performed and the reason is not specified or documented 8P Modifier: action not performed, reason not otherwise specified Understanding the Measures: Performance Time Frame Some measures have a Performance Timeframe related to the clinical action that may be distinct from the reporting frequency. Perform within 12 months or annually Most Recent result Clinical test result needs to be obtained, reviewed, reported one time. It need not have been performed during the reporting period. Understanding the Measures: Reporting Frequency Each measure has a Reporting Frequency requirement for each eligible patient seen during the reporting period Report one-time only Report once for each procedure performed Report for each acute episode PQRI Measure #71 Changes for 2009 Coding Changes Different instructions Deleted: 3302F, 3303F, 3305F, 3306F, 3307F, 3309F, 3310F, 3311F, 3312F Added: 3370F = AJCC Breast Cancer Stage 0 documented 3372F = AJCC Breast Cancer Stage I: T1 mic, T1a, or T1b documented 3374F = AJCC Breast Cancer Stage I: TIC, Tumor Size >1 cm2cm 3376F = AJCC Breast Cancer Stage II documented 3378F = AJCC Breast Cancer Stage III documented 3380F = AJCC Breast Cancer Stage IV documented http://www.cms.hhs.gov/PQRI/15_MeasuresCodes.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 1C-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 [4179F & 3374F or 3376F or 3378F & 3315F] are required to report) Tamoxifen/ AI Not Prescribed for Medical, Patient, or System Reasons (Three CPT II Codes [4179F-1-3P & 33xxF & 3315F ] Tamoxifen/ AI Not Prescribed due to Stage or ER/PR Negative [3370F or 3372F or 3380F or 3316F]--ONE CODE ONLY Tamoxifen/ AI Not Prescribed; Reason Not Specified (Three CPT II Codes [4179F-8P & 33xxF & 3315F] are required to report) No documentation of cancer stage or ER/PR status [3370F-8P or 3316F-8P 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_MeasuresCodes.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 Measure % OK HCPCS Wrong Dx Wrong QDC Only NPI Problem #71 Breast Cancer with drug tx 83.70% 5.61% 4.04% 5.87% 13.38% #73 Plan of Chemotherapy 25.16% 52.70% 12.40% 8.00% 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.amaassn.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, G101, G0108, G0109. Notice some from original guidelines were removed. Coding for E-prescribing 2008-2009 Report on all eligible patients: G8443--All prescriptions created during the encounter were generated using an e-prescribing system. G8445--No prescriptions were generated during the encounter. Provider does have access to a qualified e-prescribing system. G8446--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.oncologyerx.com For more information, contact me! Future Penalties for Not Electronically Prescribing Eligible professionals who are not successfully using electronic prescribing by 2012 will be penalized 1% of their covered Medicare Part B charges. This means that these providers will be paid at 99% for their covered Medicare Part B fee schedule services. Limitation applies as for incentives Fee reduction is prospective, providers will have to electronically prescribe by a date to be determined to be sure their fees are not reduced in 2012. This date will not be before 2010. Hardship exemption on a case-by-case basis for small practices. Future Penalties for Not Electronically Prescribing In 2013 - 1.5% deducted from their covered Medicare Part B services. Professionals will be paid at 98.5% of the physician fee schedule for covered services. In 2014 and beyond penalty will increase to 2%. Professionals will receive 98% of the physician fee schedule for the covered services they provide. 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. 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. Audits may begin in May. 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 Info Sources for ESAs… View the policy itself at View CMS FAQs http://www.ascofoundation.org/portal/site/ASCO/menuitem.5d1b 4bae73a9104ce277e89a320041a0/?vgnextoid=24be6e750752 3110VgnVCM100000ed730ad1RCRD View CMS Transmittals R1412, R1413, R80NCD at http://www.cms.hhs.gov/mcd/ncpc_view_document.asp?id=12 View ASCO FAQs http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=203 http://www.cms.hhs.gov/Transmittals/2008Trans/list.asp View American Society of Hematology Guidelines (ASH) at http://www.hematology.org/policy/practice/01242008.cfm ESA/Anemia Billing Summary If the patient has cancer and is on chemotherapy, submit the “most recent” hemoglobin must be <10 (or Hct < 30%). Bill the H or H results and use -EA. Follow Carrier guidelines for diagnosis coding. If the patient is on Radiotherapy, submit the latest H or H result, use -EB, and get denied. If the patient does not have chemotherapy-induced anemia (or ESRD), submit the latest H or H, use -EC, and follow your Carrier’s guidelines for coding and billing. If the patient has cancer and is on an anemia drug which is not self-administered, submit the latest H or H result. All other guidelines are at Carrier discretion. © 2008, RemitDATA, Inc. ALL RIGHTS RESERVED. Strategies for Success Know where your MAC is at as far as anti-emetics. It is an aberration so far. Look at when your individual payers are going to adopt the new CPT codes. Analyze the reasons for rejected, denied, or delayed claims and fix it. If you do not have an EOB analyzer, you are behind the curve. Really consider doing PQRI and e-prescribing---4% is nothing to sneeze at. Enforce payments with private payers. Audit chemo prospectively; peer review E&M. Physicians must review consults before it is too late! Transmittal 788, CR 4215 (2005). Look at your billing profiles. Give $$ back before the RACs collect it for you! Participate in the struggle! Contact Info Contact [email protected] [email protected] 800-795-2633 Newsletter is free! E-prescribing is free! Thank You from onPoint Oncology LLC!