Download Changes to Oncology Coding 2009

Changes to Oncology
Coding 2009
Bobbi Buell
Version 9.0
April. 2009
Disclaimer
 Payers differ on their guidelines. Please verify coding for each
payer and claim.
 This is not legal or payment advice.
 This content is abbreviated for Medical Oncology. It does not
substitute for a thorough review of code books, regulations, and
Carrier guidance.
 This information is good for the date of the information and may
contain typographical errors.
 CPT is the trademark for the American Medical Association. All
Rights Reserved.
 All denial data from RemitDATA. Copyrighted to them and all
rights reserved.
Session Objectives
 Discuss the Stimulus Package Provisions
 Discuss Fee Schedule for 2009
 Discuss CPT Changes for 2009
 Discuss Drug Administration Coding for 2009
 Discuss Anti-Emetic Policies from NGS
 Discuss Coding/Options for PQRI 2009
 Discuss Coding for E-Prescribing 2009
 Discuss the Status of RACs and Other Audits
 Discuss What You Need to Do Next
Stimulus Package (AMA)
 COBRA
 Sixty-five percent temporary COBRA premium subsidy for workers
who have been involuntarily terminated between Sept. 1, 2008, and
Dec. 31, 2009.
 Subsidy available for up to 9 months.
 Subsidy would not be considered income for purposes of other
federal/state program eligibility.
 To be eligible for the subsidy, an individual must have a modified
adjusted gross income below $145,000 (or $290,000 for joint filers); if
the taxpayer’s income exceeds this threshold, then the premium
subsidy must be repaid. For taxpayers with AGI between $125,000
and $145,000 ($250,000 and $290,000 for joint filers), the amount of
the premium subsidy that must be repaid is reduced proportionately.
http://www.ama-assn.org/ama/pub/legislation-advocacy/current-topics-advocacy/hr1-stimulus-summary.shtml
Stimulus Package (AMA)
• Medicaid
▫ $87 billion in additional federal matching funds is provided (from Oct. 1, 2008-Dec. 31,
2010). Increases FMAP (Federal Medical Assistances Programs) for all states by 6.2%.
Holds states harmless against a drop in their FMAPs for FYs 2009, 2010, and first quarter
of FY 2011 (e.g., if 2008 FMAP is higher than 2009, the state gets the higher 2008 rate).
▫ States with large increases in unemployment would receive an additional FMAP
increase. It is estimated that the conference agreement would provide about 65% of its
spending via the hold harmless agreement and across-the-board increases, and about
35% via the unemployment-related increase. States must comply with current Medicaid
prompt pay requirements in order to receive FMAP increase.

Extends through June 30, 2009, the current moratorium on 4 Medicaid regulations relating to provider
taxes, targeted case management services, school-based services, and outpatient hospital services;
states the sense of the Congress that the HHS Secretary should not promulgate as final the proposed
regulations relating to cost limits on public providers, GME payments, and rehabilitative services.
▫ Provides for a temporary increase in state DSH allotments for FY 2009 and 2010.
http://www.ama-assn.org/ama/pub/legislation-advocacy/current-topics-advocacy/hr1-stimulus-summary.shtml
Stimulus Package (AMA)
 Health Information Technology
 Provides approximately $19 billion for Medicare and Medicaid
HIT incentives over five years. Officially establishes the Office of
the National Coordinator for Health Information Technology
(ONCHIT) within HHS to promote the development of a
nationwide interoperable HIT infrastructure; President Bush
already created ONCHIT by Executive Order in 2004.
 Establishes HIT Policy and Standards Committees that are
comprised of public and private stakeholders (e.g., physicians
 HHS would adopt through the rule-making process an initial set
of standards, implementation specifications, and certification
criteria by December 31, 2009.
 ONCHIT would be authorized to make available an HIT system
to providers for a nominal fee.
http://www.ama-assn.org/ama/pub/legislation-advocacy/current-topics-advocacy/hr1-stimulus-summary.shtml
Stimulus Package (AMA)
 Health Information Technology Incentives
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Provides financial incentives through the Medicare program to encourage physicians and hospitals to adopt HIT.
Medicare incentive payments would be based on an amount equal to 75% of the Secretary’s estimate of allowable
charges, up to $15,000 for the first payment year. Incentive payments would be reduced in subsequent years:
$12,000, $8,000, $4,000, and $2000, after 2015. Physicians who report using an EHR that is also capable of eprescribing would be eligible for EHR incentives only. Early adopters, whose first payment year is 2011 or 2012, would
be eligible for an initial incentive payment up to $18,000. In 2014, the payment limit would equal $12,000. Adopters,
whose first payment year is 2015, would receive $0 payment for 2015 and any subsequent year. Physicians who do not
adopt/use a certified HIT system would face reduction in their Medicare fee schedule of -1% in 2015, -2% in 2016, and
-3% in 2017 and beyond. E-prescribing penalties would sunset after 2014.
For eligible professionals in a rural health professional shortage area, the incentive payment amounts would be
increased by 10 percent.
Incentives under the Medicaid program are also available for physicians, hospitals, federally-qualified health centers,
rural health clinics, and other providers; however, physicians cannot take advantage of the incentive payment
programs under both the Medicare and Medicaid programs. Eligible pediatricians (non-hospital based), with at least
20 percent Medicaid patient volume, could receive up to $42,500, and other physicians (non-hospital based), with at
least 30 percent Medicaid patient volume, could receive up to $63,750, over a six-year period.
Allows HHS to increase penalties beginning in 2019, but penalties cannot exceed -5%. Exceptions would be made on
a case-by-case basis for significant hardships (e.g., rural areas without sufficient Internet access).
http://www.ama-assn.org/ama/pub/legislation-advocacy/current-topics-advocacy/hr1-stimulus-summary.shtml
Stimulus Package (AMA)
• More HIPAA
▫
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Federal privacy/security laws (HIPAA) are expanded to protect patient health information. HIPAA
privacy and security laws would apply directly to business associates of covered entities. Defines
actions that constitute a breach of patient health information (including inadvertent disclosures)
and requires notification to patients if their health information is breached.
Allows patients to pay out of pocket for a health care item or service in full and to request that the
claim not be submitted to the health plan.
Requires physicians to provide patients, upon request, an accounting of disclosures of health
information made through the use of an EHR.
Prohibits the sale of a patient’s health information without the patient’s written authorization,
except in limited circumstances involving research or public health activities.
Requires personal health record (PHR) vendors to notify individuals of a breach of patient health
information.
 Non-covered HIPAA entities such as Health Information Exchanges, Regional Health
Information Organizations, e-Prescribing Gateways, and PHR vendors are required to have
business associate agreements with covered entities for the electronic exchange of patient
health information.
Authorizes increased civil monetary penalties for HIPAA violations.
Grants enforcement authority to state attorneys general to enforce HIPAA.
http://www.ama-assn.org/ama/pub/legislation-advocacy/current-topics-advocacy/hr1-stimulus-summary.shtml
Stimulus Package (AMA)
• Comparative Effectiveness Research (“CER”)
▫
The government will increase funding for CER by $1.1 billion.
Both the Report on the Conference Agreement and that actual ARRA language
provide that the FCC-CER will not mandate coverage, reimbursement, or other
policies of public or private payers.
CER will not include national clinical guidelines or coverage determinations as ARRA
incorporates by reference the provisions in the Medicare Modernization Act of 2003
that explicitly preclude this.
Establishes the Federal Coordinating Council for Comparative Effectiveness Research
(FCC-CER), an advisory board that will be comprised of up to 15 representatives of
federal agencies—at least half will be physicians or other experts with clinical
expertise. The FCC-CER will coordinate CER to reduce duplication of efforts and
encourage coordinated and complementary uses of resources, coordinate related
health services research, and make recommendations to the President and Congress
on CER infrastructure needs.
The Agency for Healthcare Research and Quality (AHRQ) will receive $700 million for
CER; AHRQ must transfer $400 million to NIH to conduct or support CER
http://www.ama-assn.org/ama/pub/legislation-advocacy/current-topics-advocacy/hr1-stimulus-summary.shtml
Medicare Physician Payment Basics
 Payments are based on RVUs for each code
 The pool of RVUs is fixed – any changes must be budget
neutral--we had one of the few exceptions in 2004-2005.
 The Medicare conversion factor determines the overall level
of Medicare payments
 A formula spelled out in the Medicare statute determines the
annual update to the conversion factor and that has been a
disaster.
What Happened to the Conversion
Factor?
• Section 131 of the MIPPA substitutes a positive update
to payment rates under the MPFS of 1.1 percent for the
negative update that would have resulted from the
application of the statutory formula that includes the
sustainable growth rate. Section 133(b) of the MIPPA
also requires CMS to make a technical change in how a
statutorily required budget-neutrality adjustment is
applied. Section 133(b) of the MIPPA requires that the
budget-neutrality adjustment be applied instead to the
conversion factor…so, we end up at $36.0666 from
$38.0870. THIS HELPS PROCEDURAL SPECIALTIES
AND HURTS US.
Impact of 2009 PFS Changes
Impact of PFS Changes for 2009
Other Proposed Medicare FS Changes
2009
 Non-payment for preventable conditions is now part of
inpatient payment. CMS discusses the possibility of it in
physician payment and is still looking for comments.
 Nurse Practitioners who enrolled in the Medicare Program on
or after 1/1/2003 must have a Masters’ Degree or DNP.
 Reinstates the ability to use electronic facsimile transmission
of prescription until January 1, 2012. But, this is unrelated to
getting the incentive in 2009.
 G0332 is out!
Change in the Enrollment Methodology
 Establishment of an Effective Billing Date for Physicians and Non-
Physician Practitioners: The final rule establishes the effective date
of billing for physicians and non-physician practitioners as the later
of: (1) the date of filing of a Medicare enrollment application that
was subsequently approved by a Medicare contractor; or (2) the
date an enrolled physician or non-physician practitioner first
started furnishing services at a new practice location. In addition,
physicians and non-physician practitioners who meet all program
requirements may bill retrospectively:
 For services furnished up to 30 days prior to the effective date, rather than the
23 months allowed under current regulations; and
 For services furnished up to 90 days prior to the effective date if the President
has declared an emergency under the Robert T. Stafford Disaster Relief and
Emergency Assistance Act
Enrollment in Medicare
 Billing for 30 days prior to that date is permitted in
certain circumstances
 When the enrolling physician or NPP met all program
requirements including state licensure requirements,
 The services were furnished at the enrolled practice
location,
 And circumstances prevented enrollment prior to
providing services to Medicare beneficiaries
PECOS
• Starting January 1, enrollment for physicians or other providers in a
new location will be much more strict in terms of what you can bill-now it's 23 months; next year, it will be 30 days. The Internet-based
Provider Enrollment, Chain and Ownership System (PECOS) will allow
physicians and non-physician practitioners to enroll, make a change in
their Medicare enrollment, view their Medicare enrollment information
on file with Medicare, and check on the status of a Medicare
enrollment application via the Internet.
• Is supposed to reduce enrollment time.
• Physicians and non-physician practitioners in the District of Columbia
and the States shown above who wish to access Internet-based PECOS
may go to this place to check it out:
https://pecos.cms.hhs.gov/pecos/login.do
PECOS
 Physician or NPP cannot use PECOS in order to:
 Change his/her name or social security number
 Change an existing business structure
 To sole proprietorship from Professional Association,
Professional Corporation or LLC, or vice versa
 Reassign benefits to another supplier if that supplier does not
have a current Medicare enrollment record in PECOS
 For more information
http://www.cms.hhs.gov/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 Non-
Physician Practitioners: The rule requires physicians and nonphysician practitioners and physician and non-physician
practitioner organizations to notify their Medicare contractor
of a
 change of ownership,
 final adverse action,
 or change of location within 30 days of the reportable event.
 Failure to notify the designated contractor of a change
related to a final adverse action or a change of location may
result in an overpayment from the date of the reportable
event.
Lab Services
 Technical Component of Pathology Services for Hospital
Patients - Section 136 of the MIPPA allows independent
laboratories to bill Medicare directly for the technical component of
physician pathology services furnished to hospital inpatient and
outpatients until December 31, 2009, rather than requiring that it
be bundled into the payment to the hospital.
 Clinical Laboratory Fee Schedule Update - Section 145 of the
MIPPA sets the clinical laboratory fee schedule update at the
Consumer Price Index for all Urban Consumers (CPI-U) minus 0.5
percentage points for each of the calendar years 2009 through
2013, but repeals a competitive bidding demonstration program for
clinical laboratory services that had been required under the MMA.
 Must maintain ordering and referring information for 7 years.
Fee Schedule: Carry-over
• Anti-Markup Provisions (Delayed until 1/1/2009)
▫ CMS proposes to prohibit the markup of purchased diagnostic
services for both the technical and professional components
performed by outside suppliers.
▫ Two approaches this year:
 Physicians “who do not share the practice” will be subject to the anti-
markup. This includes contractors who serve several physicians. This
means they must be in the practice ≥ 75% of the time.
 Physicians who do not share the building will be subject to antimarkup. If the physician who provides the professional component, or
supervises the technical component, is an owner, employee, or
independent contractor of the billing physician and provides or
supervises the service in a building in which the ordering physician
provides the full range of services that the ordering physician
generally provides.
Telehealth Services
 The Final telehealth delivery of follow up inpatient consultations. The new
codes will enable practitioners to bill for follow-up inpatient consultations
delivered via telehealth. This provision effectively restores follow-up
inpatient consultations to the list of Medicare covered telehealth services.
They had been included prior to 2006, but ceased to be on the list of
Medicare telehealth services, when the CPT Editorial Panel of the
American Medical Association (AMA) deleted the specific codes for followup inpatient consultations and advised practitioners to report follow-up
inpatient consultation using more general codes (i.e. codes describing
subsequent hospital care) CMS did not add these more general codes to
the list of Medicare telehealth services because, in addition to follow-up
inpatient consultation, the subsequent hospital care codes could be used
to report services involving the on-going (day to day) management of a
hospital inpatient, which CMS believed would not be appropriately
furnished via telehealth.
 The new codes are 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
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that the patient is having that day, unless you are in a hospital.
Before/after infusions and pushes must always be categorized as
SEQUENTIAL or concurrent to sequential. They must be a different
substance to merit a separate code.
Hours following EACH infusion’s initial hour must be over 30
minutes.
Any infusion of 15 minutes or less is coded as a push.
One concurrent code per day regardless of substances or hours.
Hydration coding differs from non-chemo and chemo
administration.
 Port flushes are billable IF they are the only service of the day!
Common Coding Errors & Omissions
 Using more than one initial code per date of service
 Billing port flush with evaluation and management and/or
administration codes
 Assorted administration code omissions
Billing Port Flush with Administration and/or E&M
Service
“ Pay for 96523, irrigation of implanted venous
access device for drug delivery systems, if it is the
only service provided that day. If there is a visit or
other drug administration service provided on the
same day, payment for 96523 is included in the
payment for the other service.”
Routes of Drug Administration from
NGS
 Not only does the indication for the use of the drug need to meet medical
necessity requirements, but the route of administration is also subject to
medical necessity criteria.
 Contractors must continue to apply the policy that not only the drug is
medically reasonable and necessary for any individual claim, but also that
the route of administration is medically reasonable and necessary. That is, if a
drug is available in both oral and injectable forms, the injectable form of the
drug must be medically reasonable and necessary as compared to using the
oral form. ( Pub 100-02, Chapter 15, Sect 50.2 - Determining SelfAdministration of Drug or Biological (Rev. 91; Issued: 06-20-08;
Effective/Implementation Date: 07-21-08)).
 Medication given by injection (parenterally) is not covered if standard medical
practice indicates that the administration of the medication by mouth (orally)
is effective and is an accepted or preferred method of administration. (Pub
100-02, Chapter 15, Section 50.4.3)
Oral Anti-emetics
 For anti-emetic medication, CMS states:
It is recognized that a limited number of patients will fail on oral
anti-emetic drugs. Intravenous anti-emetics may be covered
(subject to the rules of medical necessity) when furnished to
patients who fail on oral anti-emetic therapy. (Pub 100-02,
Chapter 15, Section 50.5.4)
HCPCS Changes: New Chemo Codes
J8705 TOPOTECAN, ORAL, 0.25 MG
J9033 INJECTION, BENDAMUSTINE HCL,
1 MG
J9207 INJECTION, IXABEPILONE, 1 MG
J9330 INJECTION, TEMSIROLIMUS, 1 MG
HCPCS Changes
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
MIPPA - Medicare Improvements for Patients and Providers
Act
Section 131: 2009 PQRI

Authorized PQRI 2009 raised incentive to 2%, adds
qualified audiologists as eligible professionals, no effect
on 2007 or 2008 incentive payments

Requires CMS to post on our web site names of EPs
who satisfactorily report quality measures for 2009
PQRI
MMSEA - Medicare, Medicaid, and SCHIP Extension Act of
2007

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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 registry-based reporting
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
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
2009 PQRI Measures Groups
 7 measures groups:
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Diabetes Mellitus
Chronic Kidney Disease
Preventive Care
Coronary Artery Bypass Graft (CABG) (new)
Rheumatoid Arthritis (new)
Perioperative Care (new)
Back Pain* (new)
*
Measures in this measures groups are reportable only as a measures
group, not as individual measures
• ESRD measure group removed for 2009
2009 PQRI Reporting Periods
 Reporting period: January 1, 2009 – December 31, 2009
 2 reporting periods for reporting measures groups and
registry-based reporting:
 January 1, 2009 – December 31, 2009
 July 1, 2009 – December 31, 2009
2009 PQRI Satisfactory
Reporting Options
 Criteria for claims-based submission of individual measures
(1 option):
 Reporting period: January 1, 2009 – December 31, 2009
 3 PQRI measures or 1-2 measures
if < 3 apply*
 80% of applicable Medicare Part B FFS patient claims for 1-3
measures
* If < 3 measures, measures are subject to measure applicability
validation (MAV)
2009 PQRI Satisfactory
Reporting Options (ctd.)
 Criteria for registry-based reporting of individual
measures (2 options):
 Reporting period: January 1, 2009 – December 31, 2009
 ≥ 3 PQRI measures
 80% of applicable Medicare Part B FFS patient claims for
≥ 3 measures
 Reporting period: July 1, 2009 – December 31, 2009
 ≥ 3 PQRI measures
 80% of applicable Medicare Part B FFS patient claims for
≥ 3 measures
2009 PQRI Satisfactory
Reporting Options (ctd.)
 Criteria for measures groups (6 options: 3 for claims-based
submission and 3 for registry-based reporting):
 Reporting period: January 1, 2009 – December 31, 2009
 30 consecutive patients for 1 measures group OR
 80% of applicable Medicare Part B FFS patient claims for 1
measures group, with a minimum of 30 applicable patients
 Reporting period: July 1, 2009 – December 31, 2009
 80% of applicable Medicare Part B FFS patient claims for 1
measures group, with a minimum of 15 applicable patients
 Criteria for claims-based submission of measures groups
identical to criteria for registry-based reporting of measures
groups except only Medicare Part B FFS patients can be
included in consecutive patient sample for claims-based
submission of measures groups
PQRI Process
Visit Documented in
the Medical Record
Critical
Step
Encounter Form
Coding & Billing
N-365
NCH
Analysis Contractor
Confidential
Report
National Claims
History File
Carrier/MAC
Incentive Payment
The Medicare Incentive Schedule
and Penalties
Year
Successful
Not
2009
2%
0%
2010
2%
0%
2011
1%
0%
2012
1%
-1%
2013
0.5%
-1.5%
2014+
0%
-2%
In 2009 and 2010, physicians who successfully e-prescribe may receive a bonus payment of 2 percent of
their overall Medicare reimbursement in addition to a potential 2 percent incentive related to PQRI for a
potential bonus of 4 percent in Medicare reimbursement.
2009 Successful E-Prescribers
 “Successful E-Prescriber” is defined as an EP
who reports the e-prescribing measure established for
PQRI (i.e., Measure #125) for at least 50% of applicable
Medicare Part B FFS patients using a qualified system
 E-prescribing measure is reportable only through claims
 Limitation to applicability of incentive payment
 Denominator codes for the e-prescribing measure
must comprise at least 10% of an EP’s total allowed
charges for all covered services furnished by the EP
during the reporting period
2009 E-Prescribing Process
Critical
Step
PBM
Visit Documented in Rx 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:
Scenario 2:
The clinician discusses
current medications and
prescribes new
medication, updates
active medication list in
eRx system, transmits
prescription electronically
to pharmacy
Reports G8443
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
 IV Drugs in the office
 Calling in a prescription for NH patient
 Patient seen in ED and is sent home with a prescription
 Faxing a prescription to a pharmacy
 Sending a prescription via PDA (exception: depends on software used –
must meet e-prescribing system qualifications)
 Knowingly sending a computer-generated fax initiated at the doctor’s
office to a pharmacy (exception: if sent via qualified e prescribing system
and pharmacy system generates message as a fax, it is e-prescribing)
 Office visits provided as part of a global surgical package
 Medicare Advantage patients (exception: some private fee-for-service plans
- can e-prescribe, but this does not count toward incentive payment
calculation)
Billing Parameters for PQRI
Reporting Measures with Claims
C
PQRI Tools: Where to Begin
 Gather information and educational materials
from the PQRI web page:
www.cms.hhs.gov/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.
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 cm- 2cm
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
% OK
HCPCS
Wrong
Dx Wrong
QDC Only
NPI
Problem
#71 Breast Cancer 83.70%
with drug tx
5.61%
4.04%
5.87%
13.38%
#73 Plan of
Chemotherapy
25.16%
52.70%
12.40%
Measure
5.68%
#72 Stage III
Colon Cancer
56.25%
7.38%
12.00%
4.68%
9.31%
“Physician Quality Reporting Initiative 2007 Reporting Experience” available at http://www.cms.hhs.gov/pqri/
Hem-Onc Specific Errors
Measure
% OK
HCPCS
Wrong
Dx Wrong
QDC Only
NPI
Problem
#70 Baseline Flow
in CLL
77.31%
7.13%
10.35%
3.28%
12.50%
#67 MDS Baseline
Cytogenetic
Testing
66.63%
9.05%
9.47%
3.67%
10.31%
#69 Multiple
Myeloma Tx With
Biphosphonates
73.02%
12.21%
8.28%
4.46%
12.40%
#74 RT
Recommended
Breast Ca
15.45%
58.15%
1.03%
7.47%
7.31%
“Physician Quality Reporting Initiative 2007 Reporting Experience” available at http://www.cms.hhs.gov/pqri/
PQRI Things to Remember
• Patient must have the proper age, diagnosis and that must
be linked to the PQRI codes.
• Codes must be arrayed per measure specifications.
• Patient must meet the age requirement.
• Codes must be reported with the denominator CPT or
HCPCS codes.
• Claims must have an NPI.
• 80% is calculated by NPI.
• Get forms at http://www.ama-
assn.org/ama/pub/category/17432.html
Coding for E-Prescribing 2009
 You must use a QUALIFIED E-prescribing system AND
 Have an encounter with one of these codes
 90801, 90802, 90803, 90804, 90805, 90806, 90807, 90808,
90809, 92002, 92004, 92012, 92014, 96150, 96151, 96152,
99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213,
99214, 99215, 99241, 99242, 99243, 99244, 99245, G101,
G0108, G0109.
 Notice some from original guidelines were removed.
Coding for E-prescribing 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!
Part D Information
 The Secretary has the authority to change the requirements
for successful E-Prescribing in the future.
 The MIPPA legislation allows for future use of Part D data in
lieu of claims-based reporting by eligible professionals.
Redundancy of CMS Auditors
Roles of Medicare Improper Payment Review Entities
Source: American Hospital Association
Where Did RACs Find Overpayments?
Most overpayments were collected from inpatient
hospital services for medical necessity and coding
Incorrectly Coded
35%
Other
17%
Outpatient 4%
No/Insufficient
Documentation 8%
SNF 2%
Doc/Ambulance/
Lab/DME/Other 4%
Inpatient
Hospital 85%
Rehab 6%
Medically Unnecessary
40%
95% from
Hospitals
65
Source: CMS, The Medicare Recovery Audit Contractor Program: An Evaluation of the 3-Year Demonstration, June 2008
RAC Appeals Experience to Date
RAC Demo Findings
66
Recovery Audit Contractors (RACS)
 The Centers for Medicare & Medicaid Services (CMS) has updated
its Medicare recovery audit contractor (RAC) expansion schedule
map.
 According to the updated map, CMS intends to now implement the
permanent RAC program in 2 phases. The first phase will begin on
March 1, 2009 and involve about half the country. The second
phase will begin on August 1, 2009 or later.
 On February 6, 2009, CMS announced that the bid protests to the
permanent RAC program have been settled. Prior to the bid
protests, the CMS expansion schedule included 3 phases (with the
first phase beginning on October 1, 2008). However,
implementation was delayed due to the bid protests.
RAC Expansion
RAC Jurisdictions
A
D
B
March 1, 2009
March 1, 2009
August 1, 2009
C
69
3
What is a RAC?
RAC Program Mission
 The RACs will detect and correct past improper
payments so that CMS and the Carriers/FIs/MACs
can implement actions that will prevent future
improper payments
 Providers can avoid submitting claims that don’t comply
with Medicare rules
 CMS can lower its error rate
 Taxpayers and future Medicare beneficiaries are
protected
70
2
Overview of the RAC Initiative
 Section 306 of the Medicare Modernization Act directed CMS
to investigate Medicare claims payments using RACs under a
three year demonstration project whereby RACs would be
paid on a contingency basis.
 MSP RAC
 Claim RAC
 California, Florida and New York were chosen for the
demonstration project focusing on services provided from
October 1, 2001 - September 31, 2005.
Overview of the RAC Initiative
CMS and its 6 Recovery Audit Contractors (RACs)
Overview of the RAC Initiative
 CMS Payments to RACs
 Contingency basis for all accurately identified overpayments
 Percentage basis for all underpayments identified and
recovered
Overview of the RAC Initiative
 Selection of Claims for Review
 Must “target” claims through data analysis
 Cannot randomly select claims
 Cannot just focus on high payment claims
Overview of the RAC Initiative
 Claim Review Period
 Per Section 302 of the Tax Relief and Health Care Act of 2006,
“retrospectively (for a period of not more than 4
years prior to such fiscal year)”
 Draft – SOW for RAC
fiscal
“shall not attempt to identify any overpayment or
underpayment more than 3 years past the date of
the initial determination made on the claim”
Overview of the RAC Initiative
 Types of RAC “Targeted” Reviews
 Automated – No medical records involved in the
review, certainty that overpayment exists based on
data review
 Complex – Medical records are involved in the review,
high probability (but not certainty) that the service is
not covered
Overview of the RAC Initiative
 Responding to a RAC Record Requests
 Providers must respond to request for records within 45
CALENDAR days
 Providers may request an extension at any time prior to the 45th
day by contacting the RAC
 Appealing Denials
 Standard CMS appeal processing timelines
 All non-IP services handled through standard appeal processes
Overview of the RAC Initiative
 Services excluded from RAC Review
 Claims paid within the prior 12 month period (i.e. on June 1,
2007, RAC may not review claims with a claim processed/paid
date between June 1, 2006 and May 31, 2007)
 Services provided under a program other than Medicare FFS
(i.e., Medicare Managed Care, Medicare Drug card or drug
benefit programs)
Overview of the RAC Initiative
 Services excluded from RAC Review
 Cost report settlement issues (i.e., IME or GME)
 Part B Carrier Evaluation and Management (E&M) services
incorrectly coded (99201-99499), except*:
 E&M services that are not reasonable and necessary, but can notify
providers about doing level of service in the future.
 Appeals from ASCO and others on consults
 Violations of Medicare global surgical billing and payment rules
Overview of the RAC Initiative
 Services excluded from RAC Review
 Services previously evaluated by an “Affiliated Contractor (AC)”
(QIO, FI, Pt B or DME Carrier)
 Services being investigated as part of potential fraud cases by
Benefit Integrity Program Safeguard Contractors “Benefit
Integrity Contractor (BIC)” or law enforcement agency
Overview of the RAC Initiative
 Coordination of Contractor Reviews through the “RAC Data
Warehouse”
 Claims information entered by RAC, AC, and BIC
 Claims not available for review by RAC
 AC has ongoing post-pay review on the claim
 AC has previously made a prior authorization
 AC has requested the medical record
 AC has previously issue a full or partial denial on the claim.
Overview of the RAC Initiative
 Requirements for Permanent RACs that did not exist under
the demonstration project
 Medical Director required (no requirement previously)
 Clinicians and coding experts required (clinicians were required
but not coding experts)
 AC Validation Process (was optional before)
 Standardized medical record request letters (not previously
addressed)
Mechanics of the RAC Process
 Steps in the Process
 Initial Communication from RAC
 Receiving RAC Requests
 Responding to RAC Requests
 Notification of Outcome
 Appeal Processes
Mechanics of the RAC Process
 Initial Communication from the RAC
 Letter to designee introducing you to your RAC
 Request to designate a RAC Liaison
 Roles and Responsibilities of RAC Liaison
Mechanics of the RAC Process
 Receiving RAC Requests
 Typically sent to RAC Liaison/HIM Director
 Specificity of request
 Singular vs. volume of claim requests
 Series of claims for an individual
Mechanics of the RAC Process
 Responding to RAC Requests
 Timeliness
 Questions when preparing response
 Previously evaluated claims
 Amount of detail to submit
Mechanics of the RAC Process
 Notification of Outcome of RAC Review
 Length of time to receive notification of outcome
 Who receives the denial
 Reasons for denial, including regulatory citations
 Rights of appeal
 Contact information
 Payment refund procedures
Mechanics of the RAC Process
 Appeal Processes
 Timeline for appealing denials
 Phone vs. paper appeal
 Resubmission of records
 MACs/ Carriers per their
own internal screens
Who Else Can Ask
For/ Deny/Review
Stuff
 CERT Auditors
 Medical Integrity
Contractors
 Bundling and Medically
Unlikely Edits
 Private Insurance
Companies on behalf of
MA or themselves.
Preparing for Review
1.
Try to figure out what they are looking for…what do charts
requested have in common—drugs, procedures, visits…
2.
Get personally involved with seeing that charts are put together
correctly.
3.
Call the requestor, if you have questions…
4.
Copy ALL records involved in the request—office, hospital, lab.
5.
Check for legibility and continuity of charts. Find unfiled
documentation, if that is an issue
6.
When in doubt, send more rather than less---but do not send
unrelated material.
Preparing for Review
6.
Check for correct provider names, dates, authentication.
7.
For major audits, have a physician and nurse reviewer.
8.
Write addenda as necessary.
9.
Send to the correct contractor.
10. Make sure documentation gets there when it is due. Send
by traceable mail (Express, Fedex, etc)
11. Keep a record of records checked out, why request was
made, and to whom.
Strategies for Success

Cash is king, queen, jack, and ace…bring in as much as you can…

Know where your MAC is at as far as anti-emetics. NGS is an aberration so far.

Look at HOW your individual payers are going to adopt the new CPT codes.

Analyze the reasons for rejected, denied, or delayed claims and fix it.

Put together policies and procedures for the RAC coming to your area. Make sure clinicians are involved.

Really consider doing PQRI and e-prescribing---4% is nothing to sneeze at.

Enforce payments with private payers. They have been proven wrong!!

Look at your billing profiles from 10-1-07. Give $$ back before the RACs collect it for you!

Participate in the struggle!
Contact Info
 Contact
 [email protected]
 [email protected]
 800-795-2633
 Newsletter is free!
 E-prescribing is free!
 Go to our website: http://www.onpointoncology.com
Thank You from onPoint Oncology LLC!