Download Changes to Oncology Reimbursement 2009

Changes to Oncology
Reimbursement 2009
Bobbi Buell
Version 3.0
November 2008
Disclaimer
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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.
Session Objectives
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Provide update on changes in Medicare outpatient
payment for 2009
Show impact of new reimbursement changes on
services that you bill every day
Explain all applicable coding changes
Explain other changes
Discuss optimal strategies.
General References
 Physician Payment Rule =
http://www.cms.hhs.gov/PhysicianFeeSched/PFSFR
N/list.asp#TopOfPage
 Hospital Outpatient Rule =
http://www.cms.hhs.gov/HospitalOutpatientPPS/HO
RD/list.asp#TopOfPage
 ICD-9-CM Codes =
http://www.cms.hhs.gov/ICD9ProviderDiagnosticCod
es/07_summarytables.asp#TopOfPage
Medicare Physician Payment Basics
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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.

CMS previously applied a separate budget-neutrality adjustment to
work RVUs, but 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
2009 Changes to the GPCIs
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CMS has published a report on the proposed localities
on its web site.
http://www.cms.hhs.gov/PhysicianFeeSched/downloads/
ReviewOfAltGPCIs.pdf. This will not change in 2009,
according to the CMS web site.
Section 134 of the MIPPA extends the 1.0 floor on the
geographic adjustment to the physician work component
of the fee schedule through December 31, 2009. MIPPA
also establishes a 1.5 floor on the geographic
adjustment for physician work in Alaska, beginning
January 1, 2009. The geographic adjustment is a factor
used in the formula to calculate payments under the
MPFS to reflect state or local regional cost variations.
Sarah Palin must have lobbied for that one.
Adios, CAP!
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The Centers for Medicare &
Medicaid Services (CMS)
announced that it has postponed
the 2009 Medicare Part B
Competitive Acquisition Program
(CAP).
CMS received several qualified
bids from potential vendors but
contractual issues with the
successful bidders resulted in the
postponement. Consequently, the
election for participation in the
2009 CAP will not be held and
CAP drugs will not be available
from an approved CAP vendor for
dates of services after December
31, 2008.
2009 PFS--Drug Payment
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WAMP
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WAMP not been used yet to determine Part B payments,
even though, by law, they could have been used for a few
drugs.
In the proposed rule, if ASP exceeds EITHER WAMP or
5%, it can be used as a basis for payment. This has been
the threshold in previous years. According to a recent
report by the OIG, there are drugs that meet this criteria.
G0332 may not be billed with IVIG next year.
ASP for hospital outpatients goes to ASP+4% from
ASP+5%
Other Proposed Medicare FS
Changes 2009
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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.
Change in the Enrollment
Methodology
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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 nonphysician practitioners who meet all program
requirements may bill retrospectively:
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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
After Revocation of Billing
Privileges
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The final rule provides that a physician or nonphysician practitioner is not allowed to bill for
services furnished after certain reportable events,
including:
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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
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Revised Reporting Responsibilities for Physicians
and Non-Physician Practitioners: The rule requires
physicians and non-physician practitioners and
physician and non-physician practitioner
organizations to notify their Medicare contractor of a
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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
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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
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Anti-Markup Provisions (Delayed until 1/1/2009)
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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:
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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.
This means that, if you have a Pathologist who contracts
with your office < 75% of their time, you may not mark up
their fees--TC or PC.
Physician Fee Schedule 2009
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CMS looked at new provision for shared savings
between physicians and hospitals. But there is
criteria:
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Must have quality intent and last 1-3 years.
Cost savings must be objective and measurable.
Must have external oversight, i.e. medical review.
Physician pools must be ≥ 5 physicians.
Incentives must be derived from a pool on a per capita
basis.
Access may not be denied to FDA-approved supplies or
drugs.
Patients must be notified about the program
This is still an open issue.
Telehealth Services
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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 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 follow-up
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).
PQRI Update 2007-2009
SLIDES COURTESY OF CMS
www.cms.hhs.gov/pqri
Principals of PQRI
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Providers report by NPI, not by TIN.
Reporting is still voluntary.
May report in these ways
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Reporting successfully
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Claims
Registries
Claims groups
Three or more reporting measures ≥ 80%, if at least three
measures apply.
2% for 2009. No CAP applies.
2007 Incentive Payments
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Distributed by the Carrier or A/B Medicare Administrative
Contractor (MAC)
Issued beginning July 15, 2008
Some carriers were delayed in distributing incentive payments
 If you bill to multiple carriers, you will receive a separate
payment from each carrier
Identified as:
 Paper checks- an explanatory message on the P4R lump sum
bonus payments that says: “This check is for a P4R payment.”
 Electronic transmissions- provider adjustment code “LS” (lump
sum) will appear in PLB03-1 on the outgoing 835
Tax Identification Number (TIN) Level Lump-Sum Payment
2007 PQRI Incentive Payment
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NOTE: Only Medicare Part B claims which
contained an individual National Provider Identifier
(NPI) were included in the 2007 incentive payment
calculation. Medicare Part B Claims which contained
a legacy UPIN and no NPI were NOT included in the
2007 incentive payment calculation.
Incentive amounts were calculated at the individual
eligible provider (NPI) level
Incentive payments were paid at the practice (TIN)
level
Guide to Understanding the
2007 PQRI Incentive Payment
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To determine how the incentive payment was
calculated and to understand key terms used
in PQRI analysis and documentation
“A Guide for Understanding the 2007 PQRI
Incentive Payment” can be found at:
https://www.cms.hhs.gov/PQRI/Downloads/P
QRIIncentivePayment.pdf
2007 Feedback Report at a Glance
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Includes three tables
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Table 1
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Earned Incentive Summary for Taxpayer Identification Number (Tax
ID or TIN)
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NPI Reporting Detail (if submitted at least one valid QDC)
One for each participating EP
Table 3
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Accessible only by TIN
Up to TIN to distribute Table 2 information and, if applicable, Table
3, to individual EP’s NPI
Table 2
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All EPs’ NPIs within TIN
Breakdown of each individual’s earned incentive
NPI Performance Detail
Available if EP had at least one reported instance for a
PQRI measure
Analytic interpretation may vary from how the EP reported
the measure (i.e., codes were submitted from coder
inaccurately)
2007 Feedback Reports
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Feedback Reports & “2007 PQRI Feedback Report
User Guide” available on-line
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2007 Measure Applicability Validation (MAV)
process
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http://www.qualitynet.org/pqri
http://www.cms.hhs.gov/pqri/Downloads/PQRI_Validation.p
df
An Individual Authorized Access to CMS Computer
Services (IACS) log-in Account is required to access
feedback reports
Step-by-Step IACS
Registration
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For step by step instructions on attaining an Individuals
Authorized Access to CMS Services (IACS) account, please refer
to the following MLN Matters documents:
MLN SE0830 - Steps to Access 2007 PQRI Feedback Reports
by Individual Eligible Professionals
 https://www.cms.hhs.gov/PQRI/Downloads/PQRISE0830.pdf
-ORMLN SE0831 - Steps to Access 2007 PQRI Feedback Reports
by Organizations
 https://www.cms.hhs.gov/PQRI/Downloads/PQRISE0831.pdf
2007 PQRI Reporting
Participation Statistics
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109,349 NPI/TINs – Attempted to Submit
101,138 NPI/TINs – Submitted a Quality Data Code
Successfully
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70,207 NPI/TINS – Satisfactorily Reported 1 or more
measures
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A feedback report is available
A feedback report is available
56,722 NPI/TINs – Earned Incentive

A feedback report & incentive payment are available
MIPPA Legislation - PQRI
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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.
MIPPA Legislation – PQRI, Section
131

PQRI 2009 incentive provided and raised to 2%

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Eligible professionals shall be paid 2% incentive of
estimated allowable charges submitted not later than 2
months after the end of the reporting period for 2009
quality measures.
Adds qualified audiologists in the definition of
eligible professionals.
No effect on 2007 or 2008 incentive payments.
Registries
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CMS received over 55 self-nomination requests for
registries to become “qualified” to submit quality
data for possible incentive payment on behalf of
their clients.
32 registries have been selected for “production”
(eligible to earn a payment incentive for their
providers)
The final list of “qualified” registries is posted on the
PQRI website at:
http://www.cms.hhs.gov/PQRI/20_Reporting.asp#To
pOfPage and go to the first download (“2008 List of
Qualified Registries”)
Registries


Becoming a “qualified” registry is not a
guarantee by CMS that the registry will be
successful submitting data on behalf of their
clients.
These registries, however, have gone
through a complete evaluation of their
measure calculations and a test that their
system can successfully communicate with
our data warehouse.
6 Registry-Based Options
Reporting Period:
January 1, 2008 December 31, 2008
Reporting Period:
July 1, 2008 –
December 31, 2008
Individual Measures:
80% of applicable cases
Minimum 3 measures
Individual Measures:
80% of applicable cases
Minimum 3 measures
One Measures Group:
30 consecutive patients
OR
80% of applicable cases
One Measures Group:
15 consecutive patients
OR
80% of applicable cases
Do You Want to Use a
Registry?
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
Must be a registered registry with CMS and
approved for submission.
Must successfully report in 2008. This can
be a mystery right now. Not really known until
after 3/31/2009.
May charge you, so is it cheaper than doing it
claim by claim?
Hematology-Oncology
Measures 2009
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MDS And Acute Leukemias Cytogenetic Testing
MDS Documentation of Iron Stores
Multiple Myeloma: Treatment With Bisphosphonates
CLL Baseline Flow Cytometry
Hormonal Therapy for Stage IC-III ER/PR + Breast Cancer
Chemotherapy for Stage III Colon Cancer Patients
Breast Cancer Patients Who Have pT and pN category and histological grade for their cancer
Colorectal Cancer Patients Who Have pT and pN category and histological grade for their cancer
Inappropriate use of bone scan for staging low risk cancer patients
Adjuvant hormonal therapy for high-risk prostate cancer patients
Three-dimensional radiotherapy for patients with prostate cancer.
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)
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 and #74 are gone
MIPPA Legislation – Successful
Electronic Prescriber, Section 132

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
The MIPPA provides for a 2% incentive payment to eligible
professionals who successfully prescribe (as defined by the
statute) their patient’s medications electronically beginning in
2009.
The legislation specifically refers to the electronic prescribing
measure currently in 2008 PQRI (measure #125).
E-Prescribing measure will be removed from PQRI for 2009 and
added to the E-Prescribing incentive program as a stand-alone
benefit.
The Secretary has the authority to update the specifications of
the electronic prescribing measure in the future.
2008 PQRI – E-Prescribing Measure



Electronic Prescribing Structural Measure
(measure #125) qualifies as one of three
required measures in PQRI to earn an
incentive payment.
Requirement for 2008 PQRI is to report the
measure on 80% or more of eligible patients
BUT this goes to 50% in 2009.
No separate incentive for successful EPrescribing in 2008 PQRI
Electronic Prescribing Measure in
2008 PQRI
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Currently eligible professionals (EPs) can report that they
electronically prescribe (eRx) medications using a qualified
program as defined in PQRI measure #125 Adoption/Use of ePrescribing by reporting one of the G-codes in the measure
You must have and regularly use an electronic prescribing
program to report the measure
The electronic prescribing program must meet ALL of the
requirements listed in PQRI measure #125
If you have not adopted an electronic prescribing system that
meets the specifications of the measure you cannot report on this
measure.
Free E-Prescribing in
Oncology!

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That’s right!
Just for cancer
practices!
www.oncologyerx.com
For more information,
contact me!
Qualified Electronic Prescribing
Systems – 2009


The measure assesses eligible professional’s use of
electronic prescribing using a qualified system.
As a qualified system, the program must be able to
perform the following tasks:
 Communicate with the patient’s pharmacy;
 Help the physician identify appropriate drugs and
provide information on lower cost alternatives for
the patient;
 Provide information on formulary and tiered
formulary medications; and
 Generate alerts about possible adverse events,
such as improper dosing, drug-to-drug interactions,
or allergy concerns.
Successful Reporting of the eRx
Measure for 2009


The measure is intended to be reported on for
EVERY patient visit in the denominator.
Successful reporting is defined as reporting the
measure on at least 50% of eligible patients or an
amount of electronic submission of claims under
Part D.

Limitation: CPT codes that make up the denominator
MUST account for at least 10% of the provider’s total
allowed charges for Medicare Part B covered services OR
a parameter of claims NOT submitted to Part D (not in
2009).
Reporting of E-Rx in 2009

To get paid the incentive, you must have an eprescribing system, report a visit and choose a code
(not out yet) to state that the patient:



They did not prescribe any medications during the visit;
They used e-prescribing for any medications prescribed
during the visit; or
They did not use e-prescribing for a prescription because
the law prohibits electronic prescribing for the specific type
of drug, such as a controlled substance.
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.
Should You Go For It?

Let’s say you are a single Medical Oncologist
AND you want to know whether or not to go
for the incentive for your NPI




Your E/M revenue is $325,000
Your drug administration revenue, plus other
procedures is $275,000
Your Medicare % is 50%
Your PQRI plus E-Rx bonus would be $12,000.
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)

Primary A/B MACs will serve newly defined geographical regions

Issue of medical directors in each state unresolved

Contracts to be awarded December ’05 through September ‘08.

Transition from existing contractor to MAC: 6-13 months
Medicare Contractor Reform





On August 2, 2007, CMS announced that it had awarded the J4 A/B MAC contract to Trailblazer
Health Enterprises (Trailblazer). As the J4 A/B MAC, Trailblazer immediately began
implementation activities and will assume full responsibility for the work no later than Spring 2008.
On September 5, 2007, CMS announced that it had awarded the J5 A/B MAC contract to
Wisconsin Physicians Services Health Insurance Corporation (WPS). As the J5 A/B MAC, WPS
immediately began implementation activities and will assume full responsibility for the work no
later than September 9, 2008.
On October 24, 2007, CMS awarded the contract for the Jurisdiction 12 (J12) A/B MAC to
Highmark Medicare Services, Inc. (HMS). J12 includes the states of Delaware, District of
Columbia, Maryland, New Jersey and Pennsylvania.
On December 15, 2006, CMS posted on FedBizOpps the second RFP for jurisdictions 1, 2, 7, and
13. Proposals were due February 9, 2007. CMS anticipates awarding these contracts in spring
2008.
On October 25, 2007, CMS awarded the J1 A/B MAC contract to Palmetto GBA (Palmetto). J1
includes the states/territories of American Samoa, California, Guam, Hawaii, Nevada and the
Northern Mariana Islands. As a result of this decision, CMS authorized Palmetto to resume work
under J1 as of February 14, 2008. CMS expects Palmetto to assume full responsibility for the
work no later than October 1, 2008.
Medicare Contractor Reform




The Centers for Medicare and Medicaid Services (CMS) announced March 18, 2008 that National Government
Services (NGS) has been awarded a contract of up to five years for the combined administration of Part A and
Part B Medicare claims payment in Connecticut and New York. This is currently under appeal.
On May 06, 2008, CMS announced it has awarded the contract for the Jurisdiction 2 (J2) A/B MAC to National
Heritage Insurance Corporation (NHIC). J2 includes the states of Alaska, Idaho, Oregon and Washington. On
May 27, 2008, a protest against the award was filed with the Government Accountability Office (GAO). CMS is
currently taking corrective action on certain aspects of the award decision. In the meantime, the current fiscal
intermediaries and carriers will continue to provide Medicare claims processing services under their contracts.
On June 11, 2008, CMS announced it has awarded the contract for Jurisdiction 7 (J7) A/B MAC to Pinnacle
Business Solutions Inc. (PBSI). J7 includes the states of Arkansas, Louisiana and Mississippi. On July 2, 2008, a
protest against the award was file with GAO. GAO's decision on the protest must be issued no later than 100
days after the protest was filed. In this case, the deadline for the GAO decision on the protest is October 10,
2008. In accordance with the Competition in Contracting Act (CICA), the filing of the protest triggered an
automatic stay on performance of the PBSI- contract pending GAO's decision.
On September 12, 2008, CMS announced it has awarded the contract for Jurisdiction 9 (J9) to First Coast Service
Options, Inc (FCSO). FCSO will be responsible for the workload in Florida, Puerto Rico and U.S. Virgin Islands.
As the J9 A/B MAC, FCSO will immediately begin implementation activities and will assume full responsibility for
the work no later than March 2009. A background sheet and Qs & As related to the award are available below .
Description of RAC Program

RACs are paid contingency fees


For overpayments collected from providers
For underpayments identified and returned to providers

3-year demonstration (3/05 – 3/08)--last day to ask for
claims 2/1/2008 for Part B.

RACs were given 4 years of claims
(October 1, 2001 – September 31, 2005)

A database was created to exclude claims from the RACs
claims that:



E/M for medical necessity
were previously reviewed by a Medicare contractor or
are involved in a benefit integrity investigation
‘Improvements’ to Permanent
RAC Program








The ‘look back’ period has been changed from 4 years to three years. The
date for cut-off will be 10/1/2007. Current fiscal year claims will be eligible.
Certified coders will be required.
There will be medical record limits.
Denials must be discussed with a Medical Director.
Frequent problem reporting is mandatory.
RACs have to pay back their fees at all levels of appeal. This will ensure
that there is no incentive to take things to a higher level of appeal.
There will be a RAC web site to see status of claims.
Findings must be externally validated.
FY 2007 Improper Payments
Overpayment
s Collected
Underpayment
s Paid Back
(in millions)
(in millions)
$ 357.2
Costs:
+
$ 14.3
Overturned
on
Appeal
Total Improper
Payments
Identified
(in millions)
(in millions)
+
$17.8
=
$389.3
- $ 77.7
$ 247.4
Back to the Trust Funds
“collected” = dollars in the bank (cases lost on appeal have been backed out… contingency fees have NOT been backed out)
“identified” = dollars collected + dollars repaid
“costs” = RAC contingency fees + carrier/DMERC/FI costs + RAC Evaluation/Database
FY 2007 Improper Payments
by Provider Type (Claim RACs Only)
Inpt/
SNF
Outpt
Hosp
MDs
Amb,
Lab
DME
Total
Collected
New York
$99.2
$8.4
$1.6
$0.0
$3.3
$112.5
Florida
$115.1
$3.4
$5.1
$1.0
$0.0
$124.6
California
$98.5
$10.8
$5.5
$3.1
$2.2
$120.1
TOTAL
$312.8
$22.6
$12.2
$4.1
$5.5
$357.2
State
(in millions)
Source: CMS RAC Status Document Table 2-3
2007 Overpayments Collected
by Error Type (Net of Appeals)
Type of Error (in Inpt/SNF
millions)
Outpt
Hosp
MD
Ambul,
Lab,
Other
DME
TOTAL
Collected
Incorrectly
Coded
$123.8
$7.6
$4.8
$2.2
$4.7
$143.2
Medical
Necessity
$106.5
$4.8
$0.2
<$0.1
$0.0
$111.5
No/Insuff
Documentation
$29.6
$0.4
$0.2
<$0.1
<$0.1
$30.3
Other
$44.8
$5.4
$7.1
$1.2
$0.5
$59.0
TOTAL
$304.7
$18.2
$12.3
$3.5
$5.3
$344.0
Source: CMS RAC Status Document FY 2007
RACs

On October 6, 2008, the Centers for Medicare &
Medicaid Services (CMS) released a Fact Sheet
announcing the contractors selected for the permanent
Medicare Recovery Audit Contractor (RAC) program.
According to the Fact Sheet, the RACs are:




Diversified Collection Services, Inc. - for Region A and initially working in
Maine, New Hampshire, Vermont, Massachusetts, Rhode Island and
New York.
CGI Technologies and Solutions, Inc. - for Region B and initially working
in Michigan, Indiana and Minnesota.
Connolly Consulting Associates, Inc. - for Region C and initially working
in South Carolina, Florida, Colorado, and New Mexico.
HealthDataInsights, Inc. - for Region D and initially working in Montana,
Wyoming, North Dakota, South Dakota, Utah and Arizona.
Source: http://www.cms.hhs.gov/apps/media/press/factsheet
RACs

As part of the Medicare Recovery Audit Contractor (RAC)
award notice, the Centers for Medicare & Medicaid Services
(CMS) has released the contingency fee percentage for each
RAC. As reflected in the award notice, the contingency fee
percentages are:




Diversified Collection Services, Inc. (Region A) - 12.45%
CGI Technologies and Solutions, Inc. (Region B) - 12.50%
Connolly Consulting Associates, Inc. (Region C) - 9%
HealthDataInsights, Inc. (Region D) - 9.49%
Source: FedBizOpps.gov
Other 2008-2009 Issues
Cancer ICD-9-CM Codes
10/1/08




















199.2 Malignant neoplasm associated with transplant organ
203.02 Multiple myeloma, in relapse
203.12 Plasma cell leukemia, in relapse
203.82 Other immunoproliferative neoplasms, in relapse
204.02 Acute lymphoid leukemia, in relapse
204.12 Chronic lymphoid leukemia, in relapse
204.22 Subacute lymphoid leukemia, in relapse
204.82 Other lymphoid leukemia, in relapse
204.92 Unspecified lymphoid leukemia, in relapse
205.02 Acute myeloid leukemia, in relapse
205.12 Chronic myeloid leukemia, in relapse
205.22 Subacute myeloid leukemia, in relapse
205.32 Myeloid sarcoma, in relapse
205.82 Other myeloid leukemia, in relapse
205.92 Unspecified myeloid leukemia, in relapse
206.02 Acute monocytic leukemia, in relapse
206.12 Chronic monocytic leukemia, in relapse
206.22 Subacute monocytic leukemia, in relapse
206.82 Other monocytic leukemia, in relapse
206.92 Unspecified monocytic leukemia
Cancer ICD-9-CM Codes
10/1/08

207.02 Acute erythremia and erythroleukemia, in relapse
207.12 Chronic erythremia, in relapse
207.22 Megakaryocytic leukemia, in relapse
207.82 Other specified leukemia, in relapse
208.02 Acute leukemia of unspecified cell type, in relapse
208.12 Chronic leukemia of unspecified cell type, in relapse
208.22 Subacute leukemia of unspecified cell type, in relapse
208.82 Other leukemia of unspecified cell type, in relapse

208.92 Unspecified leukemia, in relapse







Cancer ICD-9-CM Codes
10/1/2008

209.00 Malignant carcinoid tumor of the small intestine, unspecified portion
209.01 Malignant carcinoid tumor of the duodenum
209.02 Malignant carcinoid tumor of the jejunum
209.03 Malignant carcinoid tumor of the ileum
209.10 Malignant carcinoid tumor of the large intestine, unspecified portion
209.11 Malignant carcinoid tumor of the appendix
209.12 Malignant carcinoid tumor of the cecum
209.13 Malignant carcinoid tumor of the ascending colon
209.14 Malignant carcinoid tumor of the transverse colon
209.15 Malignant carcinoid tumor of the descending colon
209.16 Malignant carcinoid tumor of the sigmoid colon
209.17 Malignant carcinoid tumor of the rectum
209.20 Malignant carcinoid tumor of unknown primary site
209.21 Malignant carcinoid tumor of the bronchus and lung
209.22 Malignant carcinoid tumor of the thymus
209.23 Malignant carcinoid tumor of the stomach
209.24 Malignant carcinoid tumor of the kidney
209.25 Malignant carcinoid tumor of foregut, not otherwise specified
209.26 Malignant carcinoid tumor of midgut, not otherwise specified
209.27 Malignant carcinoid tumor of hindgut, not otherwise specified

209.29 Malignant carcinoid tumor of other sites



















New Cancer ICD-9 Codes
10/1/2008














209.30 Malignant poorly differentiated neuroendocrine carcinoma, any site
238.77 Post-transplant lymphoproliferative disorder (PTLD)
289.84 Heparin-induced thrombocytopenia (HIT)
999.81 Extravasation of vesicant chemotherapy
999.82 Extravasation of other vesicant agent
999.88 Other infusion reaction
999.89 Other transfusion reaction
V07.51 Prophylactic use of selective estrogen receptor modulators (SERMs)
V07.52 Prophylactic use of aromatase inhibitors
V07.59 Prophylactic use of other agents affecting estrogen receptors and estrogen levels
V13.51 Personal history of pathologic fracture
V87.41 Personal history of antineoplastic chemotherapy
V87.42 Personal history of monoclonal drug therapy
V87.49 Personal history of other drug therapy
Other ICD-9-CM Changes




Secondary Diabetes Mellitus (249.xx)
New types of headaches (339.xx)
A gaggle of new PAP and anal smear codes
(795.xx-796.xx)
V87.xx for exposure to toxic (and potentially
carcinogenic) substances
Funniest 2009 ICD-9-CM Codes





339.43 Primary Thunderclap Headache
339.82 Headache Associated With Sexual Activity
339.85 Primary Stabbing Headache
372.74 Pingueculitis
611.81 Ptosis of Breast
Changed Codes of Note















203.00 Multiple myeloma, without mention of having achieved remission
203.10 Plasma cell leukemia, without mention of having achieved remission
203.80 Other immunoproliferative neoplasms, without mention of having achieved
remission
204.00 Acute lymphoid leukemia, without mention of having achieved remission
204.10 Chronic lymphoid leukemia, without mention of having achieved remission
204.20 Subacute lymphoid leukemia, without mention of having achieved remission
204.80 Other lymphoid leukemia, without mention of having achieved remission
204.90 Unspecified lymphoid leukemia, without mention of having achieved remission
205.00 Acute myeloid leukemia, without mention of having achieved remission
205.10 Chronic myeloid leukemia, without mention of having achieved remission
205.20 Subacute myeloid leukemia, without mention of having achieved remission
205.30 Myeloid sarcoma, without mention of having achieved remission
205.80 Other myeloid leukemia, without mention of having achieved remission
205.90 Unspecified myeloid leukemia, without mention of having achieved remission
Changed Codes of Note (2009)

206.00 Acute monocytic leukemia, without mention of having achieved remission
206.10 Chronic monocytic leukemia, without mention of having achieved remission
206.20 Subacute monocytic leukemia, without mention of having achieved remission
206.80 Other monocytic leukemia, without mention of having achieved remission
206.90 Unspecified monocytic leukemia, without mention of having achieved remission
207.00 Acute erythremia and erythroleukemia, without mention of having achieved
remission

207.10 Chronic erythremia, without mention of having achieved remission

207.20 Megakaryocytic leukemia, without mention of having achieved remission
207.80 Other specified leukemia, without mention of having achieved remission








207.20 Megakaryocytic leukemia, without mention of having achieved remission
207.80 Other specified leukemia, without mention of having achieved remission \
208.00 Acute leukemia of unspecified cell type, without mention of having achieved remission
208.10 Chronic leukemia of unspecified cell type, without mention of having achieved remission
208.20 Subacute leukemia of unspecified cell type, without mention of having achieved remission
208.80 Other leukemia of unspecified cell type, without mention of having achieved remission
208.90 Unspecified leukemia, without mention of having achieved remission

V45.71 Acquired absence of breast and nipple






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
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
HCPCS Changes 2009
(1/1/2009)

New Codes:
INJECTION, LEVOLEUCOVORIN
CALCIUM, 0.5 MG
INJECTION, DORIPENEM, 10 MG
INJECTION, FOSAPREPITANT, 1 MG
INJECTION, IMMUNE GLOBULIN
(PRIVIGEN), INTRAVENOUS, NONLYOPHILIZED (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
• They
reinstated
J1750
INJECTION, IRON DEXTRAN, 50
MG
Off-Label Use Update

THREE new compendia in addition to AHFSDI




NCCN 6/5/08
DrugDex 6/10/08
Gold Standard’s Clinical Pharmacology 7/2/08
Transmittal 96, CR 6191 states that these are
now official on the above dates. This is what
qualifies as medically necessary…
Off-Label Use Update

Contractors shall recognize medically accepted
indications as those that:



Are favorably listed in one or more of the compendia listed.
OR the contractor determines that this is true from peer
reviewed literature as listed by Medicare.
These listings are acceptable:


Indication is 1 or 2A in NCCN; or Class I, IIa, or IIb in
DrugDex
Narrative text in AHFS or Clinical Pharmacology is
supportive.
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 selfadministered, submit the latest H or H result. All other guidelines
are at Carrier discretion.
Private Payers Run Wild…
Insurer
AETNA
Anthem
CIGNA
Coventry
HealthNet
Humana
United
Contract
adherence
70.78%
72.14%
66.23%
86.74%
NR
84.20%
61.55%
Have Fee
Schedule?
No
Yes
No
No
No
Yes
Yes
Proprietary
Claim Edits
54.1%
16.0%
0.4%
0.0%
NR
71.9%
19.3%
% claim
lines
denied*
6.80%
4.62%
3.44%
2.88%
3.88%
2.90%
2.68%
* Medicare denies 6.85% of all line items
Source: 2008 National Health Insurer Report Card © Copyright the American Medical Association. All Rights
Reserved
Better Handle On Payers

AMA’s National Health Insurer Report Card (“NHIRC”) part of “HEAL
THAT CLAIM” effort





“HEAL THAT CLAIM” objective is to eliminate billions of dollars in
“administrative waste, if payers sent timely, accurate, and specific
response to each physician claim”.
To assist you in doing your part, the AMA has established a practice
management web site at www.ama-assn.org/go/pmc
Great tools for tracking and appealing claims are on that web
site…check it out!!!
They are also using NHIRC data to get payers to stick to their contracts
and publish all policies in an accessible format.
This is an effort worth participating in.
Better Handle On Private
Payers

835 Data (ERAs)
 Provides better storage and readability of EOBs.
 Aggregates denials in readable format for you to detect critical
denial patterns in your practice and by payers.
 Allows you to assess contract compliance by payers.
 Affords you the opportunity to select denials to be worked versus
wasting staff time.
 Gives you the opportunity to access compliance with prompt pay
laws.
 Provides trend analysis regarding payer portions of allowables.
 Affords state societies data to bring system-wide problems to
payers.
Strategies for Success







Analyze the reasons for rejected, denied, or delayed claims and fix
it.
Really consider doing PQRI and e-prescribing---4% is nothing to
sneeze at.
Enforce contracts with private payers. Check out the AMA Report
Card, if you think they are being straight with you.
Audit chemo prospectively; peer review E&M. Physicians must
review consults before it is too late! Transmittal 788, CR 4215
(2005).
Look back and see if you have off-label denials. Try to appeal
based on the new transmittal.
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!
Education for your staff--check it out at
http://www.eexpertpartners.com/payperview.h
tml
Thank You!