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Changes to Oncology Coding 2009-2010 Bobbi Buell Version 11.0 Fall 2009 Disclaimer Payers differ on their guidelines. Please verify coding for each payer and claim. RAC information is literally changing on a daily basis. 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 cartoons are purchased JPEG files. Session Objectives Discuss Proposed Fee Schedule for 2010 Discuss Coding/Options for PQRI 2009-2010 Discuss Coding for E-Prescribing 2009-2010 Discuss ICD-9-CM Codes 2010 Discuss HCPCS Codes 2010 Discuss the Status of RACs Know What You Need to Do Next Medicare Rules for 2010 Medicare Physician Payment Basics Payments are based on RVUs for each code (WRUs+PERVUs+MalRVUs) The pool of RVUs is fixed – any changes must be budget neutral-- we had one of the few exceptions in 2004-2005. RVUs are multiplied times GPCIs for your area. 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’s Happening to the Conversion Factor in 2010? The SGR formula which has been flawed for years signals that we will have a 21.2% DECREASE in the conversion factor. Physician drugs are now included in the SGR formula, allegedly skewing it upwards. CMS has eliminated Part B drugs from the SGR meaning lower future reductions. But, for right now, we are stuck with a conversion factor of $28.4061 down from $36.0666. Impact of 2010 MPFS Changes Other Fee Schedule Changes for 2010 CMS has long had confusing rules relative to consults. So, the easiest way to deal with the problem is to eliminate them altogether. What this means is: New consults in the office will be coded as New Patients (99201- 99205). This means that no one in practice has seen the patient at all for 36 months. Established consults in the office will be coded as Established Patients (99212-99215) Hospital consults will be coded as Admissions (99221-99223) with a new modifier signifying who was the admitting physician. The new modifier is not official yet. TeleHealth consults are the exception. They have special Gcodes. CPT Rule Changes 2010 Concurrent Care “Concurrent care is provision of similar services (e.g. hospital visits) to the same patient by more than one physician on the same day. When concurrent care is provided, no special reporting is required.” Transfer of Care “Transfer of care is the process whereby a physician who is providing management for all or some of a patient’s problems relinquishes this responsibility to another physician who EXPLICITLY agrees to accept this responsibility and, who from the initial encounter is not providing consultative services.” “Consultation codes should not be reported by the physician who has agreed to accept the transfer of care before the initial evaluation, but are appropriate to report if the decision to accept the transfer of care cannot be made until after the initial consultation…” CPT Consultations 2010 “A consultation is a type of evaluation and management service provided by a physician at the request of another physician or appropriate source to either recommend care for a specific condition or problem or determine whether to accept responsibility for ongoing management of the patient’s entire care or for the care of a specific condition or problem.” CPT Changes for Consultations 2010 Patients and/or families cannot initiate consultations. Transfer of care definition in both office and hospital consults. All admitting E/M services are bundled into an inpatient consultation on the date of admission. Only one consult in the hospital or nursing facility. This includes inpatient and outpatient. Documentation: Request Opinion Written report Changes to 2010 Fee Schedule Accreditation Standards for Imaging Technical Component (- TC) MIPPA limited payment to accredited suppliers, effective in 2012. Oncology practices are not an exception to the accreditation rule, which they are under DME. The final rule does not include who the accrediting organizations are. This should be posted by January 1, 2010. 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 FR 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 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. FR 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 2009-2010 PQRI Quality Measures 153 PQRI quality measures for 2009 168 PQRI quality measures proposed so far for 2010; this includes all ways of reporting. No earlier than November 15 and by December 31, 2009, measure specifications will be available at: http://www.cms.hhs.gov/pqri Oncology PQRI Changes 2010 The Oncology Pain Measures (#143 and 144) will be reportable ONLY by registries. The Melanoma measures (#136-138) will only be reportable by Registry in 2010. CMS is moving toward Registry reporting and away from claims-based reporting. There will be a new measure, “Cancer Stage Documented”. 2010 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 No Measures Groups for Oncology in 2010; but, will be 6 new ones if you are in a multi-specialty practice. 2010 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 In 2010, 2 reporting periods apply to claims, registries, and measures groups. 2009-2010 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) Criteria proposed for 2010 annual reporting also includes that each measure must have a minimum of 15 patients for each measure. THIS WAS NOT APPROVED IN THE FINAL RULE! New Reporting Option 2010 EHR/EMR Reporting 10 specific individual measures, but none in Oncology Must meet these criteria if Oncology does get EMR/ EHR reporting including Be able to transmit data elements per specific CMS criteria Be able to separate out and report on CMS FFS patients only Be able to transmit TIN/NPI information Be able to transmit in approved formats Be able to transmit in a HIPAA secure format Enter into legal arrangements that permit receipt of and transmission of patient-specific data Obtain permission by NPI number Must pass CMS test. “Group Practices” may report, but only if they have 200 providers. PQRI Things to Remember • Patient must have the right 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 Billing Parameters for PQRI Reporting Measures with Claims C E-Prescribing: The Carrot and the Stick 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. ***No double incentives for those participating in the ARRA EMR incentive program. 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 in 2009; in 2010, CMS proposes three methods—claims, registries, and EHRs. 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: 2009 Only 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 Coding for E-Prescribing 2009-2010 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. In 2010, it is proposed that these codes be added to reporting denominator and qualifications: 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, and 90862 E-Prescribing Reporting: 2010 Rule makes this much easier: Eliminates G8445 and G8446 Report G8443 for at least 25 ENCOUNTERS per Eligible Provider That’s It!!!!!!!!!!! Of course, you must e-prescribe… Free E-Prescribing in Oncology! • That’s right! • Just for cancer practices! • www.oncologyerx.com • For more information, contact me! ICD-9-CM 2009-2010 (10-1-2009) New Codes for Cancer Merkel cell carcinoma, specified site 209.3_ Merkel cell, carcinoma, unknown primary site 209.75 Secondary neuroendocrine tumor 209.7_ (except above) Low grade myelodysplastic syndrome lesions, Refractory anemia with excess blasts-1 (RAEB-1) 238.73 Neoplasms of unspecified nature, retina and choroid 239.81 Neoplasms of unspecified nature, other specified sites 239.89 Tumor lysis syndrome 277.88 Autoimmune lymphoproliferative syndrome 279.41 ICD-9-CM Coding 2009-2010 (10-1-2009) ICD-9-CM Changes 2010 (10-1-2009) New Codes to Describe Oncology Administrators, Coders, Billers After Seeing 2010 Regs!!! 799.21 Nervousness 799.22 Irritability 799.24 Emotional lability 799.25 Demoralization and apathy 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 36 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 37 RAC Jurisdictions A D B March 1, 2009 March 1, 2009 August 1, 2009 C 38 3 RAC Contacts at CMS CMS Contact Person Phone A Ebony Brandon 410-786-1585 B Scott Wakefield 410-786-4301 C Amy Reese 410-786-8627 RAC D Kathleen Wallace 410-786-1534 39 RAC Websites Region A (Northeast states) Diversified Collection Services, www.dcsrac.com/issues.html Region B (Great Lakes states) CGI, http://racb.cgi.com Region C (Mid Atlantic, South and Southeast states) Connolly Healthcare, http://www.conn0llyhealthcare.com/RAC Region D (Midwest, West Coast, Southwest states) HealthDataInsights www.healthdatainsights.com/RAC.aspx Issues in Oncology 10-09 Issue Date Region(s) Description Source Blood Transfusions 8.4.09 All Region D, plus Ala, Fla, Georgia, Ind, Mich, Minn, S.C. Blood transfusion codes do not exceed one unit CMS Pub 100-04, Chap 4, Sec 231.8 IV Hydration 8.4.09 All Region B, C, and D, plus Ala, Fla, Georgia, N.C, S.C. Hydration 1st hour (96360) do not exceed one unit CMS Pub 100-04, Transmittal 1019, CMS Pub 100-04, Chap 5, Sec 20.2 Once Per Lifetime Codes 8.4.09 All Region B, C, and D, plus Fla, Georgia, N.C, S.C. Procedure not possible more than once per lifetime CMS Pub. 100-08, Chapter 3, Section 3.6 Pegfilgastim, J2505 is 1 unit per 6 mg 8.4.09 All Region B, C, and D, plus Fla, Georgia, N.C, S.C. Units billed must be multiples of 6 mg CMS Pub `00-04, Transmittal 949 Clinical Social Worker 8.20.09 Florida Only CSWs may not be billed while patient is inpatient CMS 100-02, Chap 15, Section 170 Pharmacy Supply and Dispensing Fees 9.21.09 All Region A States Pharmacy Fee May only be billed on the same day as a Part Bcovered oral/or inhaled drug CMS Pub. 100-04, Chapter 17, Sec 80.7 What can providers do to get ready? Know where previous improper payments have been found Know if you are submitting claims with improper payments Prepare to respond to RAC medical record requests by appointing a reliable, trustworthy liaison 42 Know Where Previous Improper Payments Have Been Found Look to see what improper payments were found by the RACs: Demonstration findings: www.cms.hhs.gov/rac Permanent RAC findings: will be listed on the RACs’ websites Look to see what improper payments have been found in OIG and CERT reports OIG reports: www.oig.hhs.gov/reports.html CERT reports: www.cms.hhs.gov/cert 43 Prepare to Respond to RAC Medical Record Requests Tell your RAC the precise address and contact person they should use when sending Medical Record Request Letters Call RAC No later 1/1/2010: use RAC websites When necessary, check on the status of your medical record (Did the RAC receive it?) Call RAC No later 1/1/2010: use RAC44 websites Who will be in charge of responding to RAC Medical Record requests? What address will we use? Who will be in charge of tracking our RAC Medical Record requests? Appeal When Necessary The appeal process for RAC denials is the same as the appeal process for Carrier/FI/MAC denials Do not confuse the “RAC Discussion Period” with the Appeals process If you disagree with the RAC determination… Do not stop with sending a discussion letter File an appeal before the 120th day after the Demand letter 45 Who will be in charge of deciding whether to appeal a RAC denial? How will we keep track of what we want to appeal, what we have appealed, what our overturn rate is, etc.? Learn from Your Past Experiences Keep track of denied claims Look for patterns Determine what corrective actions you need to take to avoid improper payments Submit experience to me 46 Who will be in charge of tracking our RAC denials, looking for patterns? How will we avoid making similar improper payment claims in the future? MACs/ Carriers per their own internal screens CERT Auditors Who Else Can Ask For/ Deny/Review Stuff Medical Integrity Contractors Bundling and Medically Unlikely Edits Private Insurance Companies on behalf of MA or themselves. New HCPCS Codes 2010 Other HCPCS Changes J9170 for Docetaxel 20 mg has been deleted for dates of service after 12/31/09 -AI is for Principal Physician of Record, which may be use on hospital consults---but this is not official yet. Other Coding Issues Other Coding Issues What do I bill if the patient is in the outpatient department for a transfusion? When a patient is admitted to observation status for less than 8 hours on the same calendar date, the physician shall report Initial Observation Care using a code from CPT code range 99218 -99220. The Observation Care Discharge Service, CPT code 99217, shall not be reported for this scenario. When a patient is admitted for observation care and discharged on a different calendar date, the physician shall report an Initial Observation Care using a code from CPT code range 99218 -99220 and CPT code 99217 for the Observation Care Discharge Service. When a patient is admitted to observation status for a minimum of 8 hours but less than 24 hours and discharged on the same calendar date, the physician shall report the Observation or Inpatient Care Services (Including Admission and Discharge Services) using a code from CPT code range 99234 -99236, and no additional discharge service. This depends on the patient’s status in the hospital. Physician documentation shall meet the evaluation and management (E/M) documentation requirements for history, examination and medical decision making. In addition, the physician shall document he/she was physically present and that he/she personally performed the observation care services. The physician shall personally document the admission and discharge notes and include the number of hours the patient remained in observation care status. In rare circumstances when a patient is held in observation status for more than 2 calendar days, the physician shall bill a visit from CPT code range 99211 ? 99215 (Office or Other Outpatient Visit) furnished before the discharge date Strategies for Success Run your numbers for 2010 without consultations for Medicare patients. Make sure your physicians are re-educated before the end of 2009 regarding the proper coding and documentation for consults. Look for a CMS Transmittal before 12/31/09. Be aware of the new anemia code. This is sure to change some policies. Assess what private payers or doing. Update your Superbills, EMRs, and CDMs for new codes. Put together policies and procedures for the RAC doing complex reviews. Make sure clinicians are involved. Start getting prepared for “meaningful use” HIT incentives. Participate in the struggle! The fight is not over yet! Contact Info Contact [email protected] [email protected] 800-795-2633 Newsletter is free! Send all RAC information to me at the ABOVE E-mails or FAX to 650-618-8621 Go to our website: http://www.onpointoncology.com Thank You from onPoint Oncology LLC!
