Changes to Oncology Coding 2009Bobbi BuellVersion 8.0February-March 2009

Disclaimer• Payers differ on their guidelines. Please verify

coding for each payer and claim.• This is not legal or payment advice.• This content is abbreviated for Medical Oncology.

It does not substitute for a thorough review of code books, regulations, and Carrier guidance.

• This information is good for the date of the information and may contain typographical errors.

• CPT is the trademark for the American Medical Association. All Rights Reserved.

• All denial data from RemitDATA. Copyrighted to them and all rights reserved.

Session Objectives• Discuss 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

▫ Provides financial incentives through the Medicare program to encourage physicians and hospitals to adopt and use certified electronic health records (EHR) in a meaningful way (as defined by the Secretary and may include reporting quality measures). Authorizes ONCHIT to provide competitive grants to states for loans to providers.

▫ 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 e-prescribing 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

▫ 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$36.0666 from $38.0870. THIS HELPS PROCEDURAL SPECIALTIES AND HURTS US.

Impact of 2009 PFS ChangesCode Number Descriptor Work PE Mal Total RVUs 2009 Total RVUs 2008 RVU change 2008 $ 2009 $ Change Change w/4%

96360 Hydration initial 0.17 1.33 0.07 1.57 1.61 -0.04 60.56$ 56.62$ (3.94)$ (1.67)$ 96361 Hydration Add-on 0.09 0.33 0.04 0.46 0.49 -0.03 18.28$ 16.59$ (1.69)$ (1.03)$ 96365 Therapeutic initial 0.21 1.63 0.07 1.91 1.97 -0.06 73.89$ 68.89$ (5.00)$ (2.25)$ 96366 Therapeutic Add-on 0.18 0.39 0.04 0.61 0.64 -0.03 23.61$ 22.00$ (1.61)$ (0.73)$ 96367 Therapeutic Sequential 0.19 0.73 0.04 0.96 0.97 -0.01 38.09$ 34.62$ (3.47)$ (2.08)$ 96368 Therapeutic Concurrent 0.17 0.36 0.04 0.57 0.6 -0.03 22.09$ 20.56$ (1.53)$ (0.71)$ 96372 Therapeutic Injection 0.17 0.4 0.01 0.58 0.56 0.02 20.57$ 20.92$ 0.35$ 1.19$ 96374 Therapeutic Push initial 0.18 1.29 0.04 1.51 1.54 -0.03 57.89$ 54.46$ (3.43)$ (1.25)$ 96375 Therapeutic Push seq 0.1 0.52 0.04 0.66 0.68 -0.02 25.52$ 23.80$ (1.72)$ (0.76)$ 96401 Chemo injection non-h 0.21 1.65 0.01 1.87 1.73 0.14 64.75$ 67.45$ 2.70$ 5.39$ 96402 Chemo injection horm 0.19 0.82 0.01 1.02 1.09 -0.07 40.75$ 36.79$ (3.96)$ (2.49)$ 96409 Chemo Push initial 0.24 2.8 0.06 3.1 3.16 -0.06 119.21$ 111.81$ (7.40)$ (2.93)$ 96411 Chemo Push Sequent 0.2 1.51 0.06 1.77 1.81 -0.04 68.18$ 63.84$ (4.34)$ (1.79)$ 96413 Chemo infusion initial 0.28 3.73 0.08 4.09 4.27 -0.18 161.49$ 147.51$ (13.98)$ (8.08)$ 96415 Chemo infusion add-on 0.19 0.67 0.07 0.93 0.97 -0.04 36.18$ 33.54$ (2.64)$ (1.30)$ 96416 Chemo infusion long 0.21 4.17 0.08 4.46 4.63 -0.17 175.20$ 160.86$ (14.34)$ (7.91)$ 96417 Chemo infusion seql 0.21 1.76 0.07 2.04 2.12 -0.08 79.60$ 73.58$ (6.02)$ (3.08)$ 96523 Irrigate implanted dev 0.04 0.65 0.01 0.7 0.72 -0.02 27.42$ 25.25$ (2.17)$ (1.16)$

Impact of PFS Changes for 2009

Code Number Descriptor Work PE Mal Total RVUs 2009 Total RVUs 2008 RVU change 2008 $ 2009 $ Change Change w 4%99211 Office visit, established 0.17 0.34 0.01 0.52 0.54 -0.02 19.81$ 18.75$ (1.06)$ (0.30)$ 99212 Office visit, established 0.45 0.55 0.03 1.03 1.03 0 37.33$ 37.15$ (0.18)$ 1.30$ 99213 Office visit, established 0.92 0.75 0.03 1.7 1.68 0.02 59.80$ 61.31$ 1.51$ 3.97$ 99214 Office visit, established 1.42 1.09 0.05 2.56 2.53 0.03 89.89$ 92.33$ 2.44$ 6.13$ 99215 Office visit, established 2 1.38 0.08 3.46 3.43 0.03 121.50$ 124.79$ 3.29$ 8.28$ 99241 Office Consultation 0.64 0.66 0.05 1.35 1.34 0.01 47.99$ 48.69$ 0.70$ 2.65$ 99242 Office Consultation 1.34 1.08 0.1 2.52 2.5 0.02 89.12$ 90.89$ 1.77$ 5.40$ 99243 Office Consultation 1.88 1.45 0.13 3.46 3.43 0.03 122.26$ 124.79$ 2.53$ 7.52$ 99244 Office Consultation 3.02 1.93 0.16 5.11 5.06 0.05 179.01$ 184.30$ 5.29$ 12.66$ 99245 Office Consultation 3.77 2.3 0.21 6.28 6.25 0.03 220.90$ 226.50$ 5.60$ 14.66$

Other Proposed Medicare FS Changes 2009• Non-payment for preventable conditions is now part

of inpatient payment. CMS discusses the possibility of it in physician payment and is still looking for comments.

• Nurse Practitioners who enrolled in the Medicare Program on or after 1/1/2003 must have a Masters’ Degree or DNP.

• Reinstates the ability to use electronic facsimile transmission of prescription until January 1, 2012. But, this is unrelated to getting the incentive in 2009.

• G0332 is out!

Change in the Enrollment Methodology• Establishment of an Effective Billing Date for Physicians

and 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.dohttps://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 non-physician practitioners and physician and non-physician practitioner organizations to notify their Medicare contractor of a▫ change of ownership, ▫ final adverse action, ▫ or change of location within 30 days of the reportable

event. • Failure to notify the designated contractor of a

change related to a final adverse action or a change of location may result in an overpayment from the date of the reportable event.

Lab Services• Technical Component of Pathology Services for Hospital

Patients - Section 136 of the MIPPA allows independent laboratories to bill Medicare directly for the technical component of physician pathology services furnished to hospital inpatient and outpatients until December 31, 2009, rather than requiring that it be bundled into the payment to the hospital.

• Clinical Laboratory Fee Schedule Update - Section 145 of the MIPPA sets the clinical laboratory fee schedule update at the Consumer Price Index for all Urban Consumers (CPI-U) minus 0.5 percentage points for each of the calendar years 2009 through 2013, but repeals a competitive bidding demonstration program for clinical laboratory services that had been required under the MMA.

• Must maintain ordering and referring information for 7 years.

Fee Schedule: Carry-over

• Anti-Markup Provisions (Delayed until 1/1/2009)▫ CMS proposes to prohibit the markup of purchased

diagnostic services for both the technical and professional components performed by outside suppliers.

▫ Two approaches this year: Physicians “who do not share the practice” will be subject to

the anti-markup. This includes contractors who serve several physicians. This means they must be in the practice ≥ 75% of the time.

Physicians who do not share the building will be subject to anti-markup. If the physician who provides the professional component, or supervises the technical component, is an owner, employee, or independent contractor of the billing physician and provides or supervises the service in a building in which the ordering physician provides the full range of services that the ordering physician generally provides.

Telehealth Services• The final rule incorporates the requirement in section 149 of the MIPPA that,

effective for services furnished on or after January 1, 2009, CMS add three new facility types to the list of authorized telehealth originating sites: a hospital-based or CAH-based renal dialysis center (including satellites), a skilled nursing facility (SNF), and a community mental health center (CMHC).

• The final rule also adopts the proposal to add new HCPCS codes specific to the telehealth delivery of follow up inpatient consultations. The new codes will enable practitioners to bill for follow-up inpatient consultations delivered via telehealth. This provision effectively restores 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).

CPT Changes 2009•CPT decided to ‘go green this year and

changed the numbering for the Hydration and Therapeutic codes so they are in the same section as the Chemo codes.▫All Hydration and Therapeutic codes will be

“963” codes instead of “907” codes. 90761 = 96361 90767 = 96367 90772 = 96372 ETC.

Source: CPT 2009 Crosswalk available at http://www.asco.org

CPT Changes 2009•The Chemotherapy Section name has

changed to “Chemotherapy or Highly Complex Drug or Highly Complex Biologic Agent” Administration▫The word “highly complex” used with

frequency▫Will payers change admin codes on some

drugs?▫CMS leaves this up to the MACs and Carriers.▫Other payers may be more strict with drug

administration, but let’s wait and see what the AMA says.Descriptor Source: CPT 2009

Drug Admin Coding• 2005 Drug Administration Coding in REVIEW

▫ General Principals that live to this day One INITIAL code per day is the one that best describes

the service that the patient is having that day, unless you are in a hospital.

Before/after infusions and pushes must always be categorized as SEQUENTIAL or concurrent to sequential. They must be a different substance to merit a separate code.

Hours following EACH infusion’s initial hour must be over 30 minutes.

Any infusion of 15 minutes or less is coded as a push. One concurrent code per day regardless of substances or

hours. Hydration coding differs from non-chemo and chemo

administration. Port flushes are billable IF they are the only service of the

day!

Common Coding Errors & Omissions•Using more than one initial code per date

of service•Billing port flush with evaluation and

management and/or administration codes•Assorted administration code omissions

Initial 2009 Administration Codes

96360 Hydration IV infusion, 1st h

96365 Therapeutic IV infusion, 1st h

96374 Therapeutic IV injection

96409 Chemo IV push

96413 Chemo IV infusion, 1st h

Billing Port Flush with Administration and/or E&M Service

“Pay for 96523, irrigation of implanted venous access device for drug delivery systems, if it is the only service provided that day. If there is a visit or other drug administration service provided on the same day, payment for 96523 is included in the payment for the other service.”

Port Flush Billing Procedures• 96523 is payable with lab. • Do not use 96374-96375 for port access--this

is erroneous at best.• Do not change practice patterns to

accommodate a port flush…

Routes of Drug Administration from NGS

• Not only does the indication for the use of the drug need to meet medical necessity requirements, but the route of administration is also subject to medical necessity criteria.

• Contractors must continue to apply the policy that not only the drug is medically reasonable and necessary for any individual claim, but also that the route of administration is medically reasonable and necessary. That is, if a drug is available in both oral and injectable forms, the injectable form of the drug must be medically reasonable and necessary as compared to using the oral form. ( Pub 100-02, Chapter 15, Sect 50.2 - Determining Self-Administration of Drug or Biological (Rev. 91; Issued: 06-20-08; Effective/Implementation Date: 07-21-08)).

• Medication given by injection (parenterally) is not covered if standard medical practice indicates that the administration of the medication by mouth (orally) is effective and is an accepted or preferred method of administration. (Pub 100-02, Chapter 15, Section 50.4.3)

Oral Anti-emetics

•For anti-emetic medication, CMS states: It is recognized that a limited number of

patients will fail on oral anti-emetic drugs. Intravenous anti-emetics may be covered (subject to the rules of medical necessity) when furnished to patients who fail on oral anti-emetic therapy. (Pub 100-02, Chapter 15, Section 50.5.4)

Chapter 15, Section 50.2 • Policy about determining whether or not a

drug USUALLY is self-administered.▫ For the purposes of applying this exclusion, the

term “usually” means more than 50 percent of the time for all Medicare beneficiaries who use the drug. Therefore, if a drug is self-administered by more than 50 percent of Medicare beneficiaries, the drug is excluded from coverage and the [Part B] contractor may not make any Medicare payment for it. In arriving at a single determination as to whether a drug is usually self-administered, contractors should make a separate determination for each indication for a drug as to whether that drug is usually self-administered

Chapter 15, Section 50.2

•Reasonable and Necessary▫“Contractors will make the determination

of reasonable and necessary with respect to the medical appropriateness of a drug to treat the patient’s condition. Contractors will continue to make the determination of whether the intravenous or injection form of a drug is appropriate as opposed to the oral form.”

Chapter 15, Section 50.2• Conditions under which a drug is self-

administered▫ “For the purposes of determining whether a drug is

usually self-administered, an acute condition means a condition that begins over a short time period, is likely to be of short duration and/or the expected course of treatment is for a short, finite interval. A course of treatment consisting of scheduled injections lasting less than 2 weeks, regardless of frequency or route of administration, is considered acute. Evidence to support this may include Food and Drug administration (FDA) approval language, package inserts, drug compendia, and other information.”

HCPCS Changes 2009 (1/1/2009)•New Codes:

J0641 INJECTION, LEVOLEUCOVORIN CALCIUM, 0.5 MGJ1267 INJECTION, DORIPENEM, 10 MGJ1453 INJECTION, FOSAPREPITANT, 1 MGJ1459 INJECTION, IMMUNE GLOBULIN (PRIVIGEN), INTRAVENOUS, NON-LYOPHILIZED (E.G.

HCPCS Changes: New Codes

J8705 TOPOTECAN, ORAL, 0.25 MG

J9033 INJECTION, BENDAMUSTINE HCL, 1 MG

J9207 INJECTION, IXABEPILONE, 1 MG

J9330 INJECTION, TEMSIROLIMUS, 1 MG

HCPCS Changes

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, NON-LYOPHILIZED (E.G.

Q4098 INJECTION, IRON DEXTRAN, 50 MG

J9182 Etoposide 100 mg

J1750 INJECTION, IRON DEXTRAN, 50 MG

• BACK IN ACTION

MIPPA Legislation - PQRI

•The Medicare Improvements for Patients and Providers Act (MIPPA), passed in July 2008, contained several new authorities and requirements for quality reporting and PQRI for 2009 and beyond.

•Section 131 directly impacts PQRI•Section 132 contains the new electronic

prescribing incentive provisions.

Source of PQRI/ E-Prescribing Slides

•From Slides of Sylvia W. Publ,

MBA, RHIA, Consortium for

Quality Improvement and S&C

Operations, CQISCO, CMS •December 17, 2008•Subject to Disclaimers

Value-Based Purchasing and PQRI

• Key mechanism for transforming Medicare from passive payer to active purchaser.▫ Current Medicare Physician Fee

Schedule is based on quantity and resources consumed, NOT quality or value of services.

• Value = Quality / Cost▫ Incentives can encourage higher quality

and avoidance of unnecessary costs to enhance the value of care.

PQRI Legislative Background

TRHCA – Tax Relief & Health Care Act, 2006

• Established 2007 PQRI, 7/1-12/31/07, authorized 1.5% incentive subject to a cap, claims-based reporting by eligible professionals (EPs) of up to 3 individual applicable measures for 80% of eligible cases

MMSEA - Medicare, Medicaid, and SCHIP Extension Act of 2007

• Authorized 2008 PQRI, 1.5% incentive, eliminated cap Incentive

• Required alternative reporting periods and alternative reporting criteria for 2008 and 2009▫ Requires alternative reporting

for measures groups and for registry-based reporting

MIPPA - Medicare Improvements for Patients and Providers Act

Section 131: 2009 PQRI• Authorized PQRI 2009 raised

incentive to 2%, adds qualified audiologists as eligible professionals, no effect on 2007 or 2008 incentive payments

• Requires CMS to post on our web site names of EPs who satisfactorily report quality measures for 2009 PQRI

Section 132: e-Prescribing Incentive Program

• Authorized separate 2% incentive payment to EPs who successfully use a qualified eprescribing system

• eRx measure removed from 2009 PQRI --separately posted measure specifications.

• The Secretary has the authority to update the codes of the electronic prescribing measure in the future.

• Requires names of eligible professionals who are successful e-prescribers be posted on the CMS web site

PQRI : Eligible Professionals

• Physicians▫ MD/DO▫ Podiatrist▫ Optometrist▫ Oral Surgeon▫ Dentist▫ Chiropractor

• Therapists▫ Physical Therapist▫ Occupational

Therapist▫ Qualified Speech-

Language Pathologist

• Practitioners▫ Physician Assistant▫ Nurse Practitioner▫ Clinical Nurse▫ Specialist▫ Certified Registered

Nurse▫ Anesthetist▫ Certified Nurse

Midwife▫ Clinical Social Worker▫ Clinical Psychologist▫ Registered Dietician▫ Nutrition Professional▫ Audiologist

2009 PQRI Quality Measures

• 153 PQRI quality measures for 2009▫ Includes 101 measures from the 2008 PQRI

and 52 new measures▫ E-prescribing measure (Measure #125)

removed, as required by MIPPA as a separate program

▫ 18 measures reportable only through registries

▫ By December 31, 2008, measure specifications will be available at: http://www.cms.hhs.gov/pqri

Hematology-Oncology Measures 2009

• MDS And Acute Leukemias Cytogenetic Testing (ICD-9 codes changed for 2009)• MDS Documentation of Iron Stores • Multiple Myeloma: Treatment With Bisphosphonates (Minor language and ICD-9 changes for 2009)(Minor language and ICD-9 changes for 2009)• CLL Baseline Flow Cytometry (ICD-9 codes changed for 2009)• Hormonal Therapy for Stage IC-III ER/PR + Breast Cancer (CPT II codes changed; language change)• Chemotherapy for Stage III Colon Cancer Patients (Updated language, CPT II codes changed, language changes)• Breast Cancer Patients Who Have pT and pN category and histological grade for their cancer (Language changes,

minor coding changes)• Colorectal Cancer Patients Who Have pT and pN category and histological grade for their cancer (Language

changes, minor coding changes)• Inappropriate use of bone scan for staging low risk cancer patients (Denominator code change, language change)• Adjuvant hormonal therapy for high-risk prostate cancer patients (Language, Instruction changes, minor coding

changes) • Three-dimensional radiotherapy for patients with prostate cancer (CPT II changes, language changes, reporting

frequency)• Melanoma: Follow Up Aspects of Care (2009)• Melanoma: Continuity of Care (2009)• Melanoma: Coordination of Care (2009)• Oncology Med/Rad: Plan of Care for Pain (2009) goes with• Oncology Med/Rad: Pain Quantified (2009)• Oncology: Radiation Dose Limits to Normal Tissues (2009)• Oncology Recording of Clinical Stage for Lung and Esophageal Cancer (2009)• Notice #73 #74 #101 and #103 are gone

2009 PQRI Measures Groups• 7 measures groups:

▫ Diabetes Mellitus▫ Chronic Kidney Disease▫ Preventive Care▫ Coronary Artery Bypass Graft (CABG) (new)

▫ Rheumatoid Arthritis (new)

▫ Perioperative Care (new)

▫ Back Pain* (new)

* Measures in this measures groups are reportable only as a measures group, not as individual measures

• ESRD measure group removed for 2009

2009 PQRI Reporting Periods

• Reporting period: January 1, 2009 – December 31, 2009

• 2 reporting periods for reporting measures groups and registry-based reporting:▫ January 1, 2009 – December 31, 2009▫ July 1, 2009 – December 31, 2009

2009 PQRI Satisfactory Reporting Options

• Criteria for claims-based submission of individual measures (1 option): ▫ Reporting period: January 1, 2009 –

December 31, 2009▫ 3 PQRI measures or 1-2 measures

if < 3 apply* ▫ 80% of applicable Medicare Part B

FFS patient claims for 1-3 measures* If < 3 measures, measures are subject to measure

applicability validation (MAV)

2009 PQRI Satisfactory Reporting Options (ctd.)

• Criteria for registry-based reporting of individual measures (2 options): ▫ Reporting period: January 1, 2009 – December

31, 2009 ≥ 3 PQRI measures 80% of applicable Medicare Part B FFS

patient claims for ≥ 3 measures ▫ Reporting period: July 1, 2009 – December 31,

2009 ≥ 3 PQRI measures 80% of applicable Medicare Part B FFS

patient claims for ≥ 3 measures

2009 PQRI Satisfactory Reporting Options (ctd.)

• Criteria for measures groups (6 options: 3 for 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

Measure Applicability Validation

YesYes

Yes

NoDid EP report at least 1 measure included in a MAV Clinically Related

Cluster?

Eligible for Incentive Payment

Satisfactorily Report ≥ 80% on < 3 Measures

Subject to MAV

Step 1 - Clinical Relation Test:

Did EP report number eligible claims below threshold < (30 pts)?

Step 2 - Minimum Threshold Test:

Did EP report number eligible claims above threshold ≥ (30 pts)?

Eligible for Incentive Payment

Not Eligible for Incentive Payment

Satisfactorily Report ≥ 80% on ≥ 3 Measures

Not Subject to MAV

PQRI Process

Visit Documented in the Medical Record

Encounter Form Coding & Billing

Carrier/MAC

NCH

Analysis Contractor National Claims History File

Incentive PaymentConfidential Report

CriticalStep

N-365

E-Prescribing Incentive Program

• MIPPA authorized a new incentive program, separate from PQRI, for EPs who are successful e-prescribers

• For 2009, successful e-prescribers are eligible for a incentive payment equal to 2% of estimated allowed charges submitted by 2/28/2010

• 2009 E-Prescribing Incentive Reporting Period: January 1, 2009 – December 31, 2009

• MIPPA also requires that names of eligible professionals who are successful e-prescribers be posted on the CMS web site

2009 Successful E-Prescribers

• “Successful E-Prescriber” is defined as an EP who reports the e-prescribing measure established for PQRI (i.e., Measure #125) for at least 50% of applicable Medicare Part B FFS patients using a qualified system

• E-prescribing measure is reportable only through claims

• Limitation to applicability of incentive payment ▫ Denominator codes for the e-prescribing measure

must comprise at least 10% of an EP’s total allowed charges for all covered services furnished by the EP during the reporting period

2009 E-Prescribing Process

Visit Documented in Medical Record & Rx

Generated

Encounter Form

Coding & Billing

Carrier/MACAnalysis Contractor

NCH

National Claims History File

Incentive PaymentConfidential

Report

CriticalStep

Rx Trans-mitted to Pharmacy

N-365

PBM

Reporting ScenariosE-Prescribing

All of these scenarios represent successful 2009 reporting

Scenario 1:

The clinician discusses current medications and prescribes new medication, updates active medication list in eRx system, transmits prescription electronically to pharmacy

Reports G8443

Scenario 2:

The clinician documents there is no change in meds, no prescription generated.

Reports G8445

Scenario 3:

Pt has mail order pharmacy that cannot accept eRx & asks for hard copy. Physician updates meds in eRx system, eRx system provides hard copy of prescription to patient.

Reports G8446

A 70 year old male patient presents to the clinician’s office for medical care.

What is Not E-Prescribing• Calling in a prescription for NH patient• Patient seen in ED and is sent home with a

prescription• Faxing a prescription to a pharmacy• Sending a prescription via PDA (exception: depends

on software used – must meet e-prescribing system qualifications)

• Knowingly sending a computer-generated fax initiated at the doctor’s office to a pharmacy (exception: if sent via qualified e prescribing system and pharmacy system generates message as a fax, it is e-prescribing)

• Office visits provided as part of a global surgical package

• Medicare Advantage patients (exception: some private fee-for-service plans - can e-prescribe, but this does not count toward incentive payment calculation)

C

Reporting Measures with Claims

Billing Parameters for PQRI

PQRI Tools: Where to Begin

• Gather information and educational materials from the PQRI web page: www.cms.hhs.gov/pqri on the CMS website (e.g., Measures/Codes, Educational Resources, Tool Kit web pages).

• Gather information from other sources, such as your professional association, specialty society or the American Medical Association.

Understanding the Measures:PQRI Quality-Data Codes

Quality-Data Codes translate clinical actions so they can be captured in the administrative claims process

• The measure requirement was met – OR –

• The measure requirement was not met due to documented allowable performance exclusions (i.e., using CPT II performance exclusion modifiers)

– OR – • The measure requirement was not met and the reason

is not documented or is not consistent with an accepted performance exclusion (i.e., using the 8P reporting modifier)

Understanding the Measure Construct

NUMERATORCPT II Code or Temporary G Code

(describes clinical action required for performance)

÷DENOMINATOR

ICD-9-CM & CPT Cat I Codes(Describes eligible cases for a measure: the

eligible patient population as defined by denominator specification)

Understanding the Measures: The Performance Modifiers

• Unique modifiers used with CPT II Codes only• Performance Measure Exclusion Modifiers indicate that an

action specified in the measure was not provided due to medical, patient or systems reason(s) documented in the medical record:▫ 1P- Performance Measure Exclusion Modifier due to

Medical Reasons▫ 2P- Performance Measure Exclusion Modifier used due to

Patient Reason▫ 3P- Performance Measure Exclusion Modifier used due to

System Reason• One or more exclusions may be applicable for a given

measure. Certain measures have no applicable exclusion modifiers. Refer to the measure specifications to determine the appropriate exclusion modifiers.

Understanding the Measures: The Reporting Modifier

Performance Measure Reporting Modifier

• facilitates reporting a case when the patient is eligible but the action described in a measure is not performed and the reason is not specified or documented▫ 8P Modifier: action not performed,

reason not otherwise specified

Understanding the Measures: Performance Time Frame

•Some measures have a Performance Timeframe related to the clinical action that may be distinct from the reporting frequency. ▫ Perform within 12 months or annually▫ Most Recent result

Clinical test result needs to be obtained, reviewed, reported one time.

It need not have been performed during the reporting period.

Understanding the Measures: Reporting Frequency

• Each measure has a Reporting Frequency requirement for each eligible patient seen during the reporting period

▫ Report one-time only

▫ Report once for each procedure performed

▫ Report for each acute episode

PQRI Measure #71 Changes for 2009• Coding Changes

▫ Different instructions▫ Deleted: 3302F, 3303F, 3305F, 3306F, 3307F,

3309F, 3310F, 3311F, 3312F▫ Added:

3370F = AJCC Breast Cancer Stage 0 documented 3372F = AJCC Breast Cancer Stage I: T1 mic, T1a, or T1b

documented 3374F = AJCC Breast Cancer Stage I: TIC, Tumor Size >1

cm- 2cm 3376F = AJCC Breast Cancer Stage II documented 3378F = AJCC Breast Cancer Stage III documented 3380F = AJCC Breast Cancer Stage IV documentedhttp://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 reportingonce per reporting period for all females 18 and over having breast cancer

seen during the reporting period.▫ Numerator Coding for patients receiving tamoxifen and AIs and have Stage 1C-III,

ER/PR+; coding now depends upon the submission of one to three numerator codes in some cases. Tamoxifen/AI Prescribed (Three CPT II Codes [4179F & 3374F or 3376F or

3378F & 3315F] are required to report) Tamoxifen/ AI Not Prescribed for Medical, Patient, or System Reasons (Three

CPT II Codes [4179F-1-3P & 33xxF & 3315F ] Tamoxifen/ AI Not Prescribed due to Stage or ER/PR Negative [3370F or

3372F or 3380F or 3316F]--ONE CODE ONLY Tamoxifen/ AI Not Prescribed; Reason Not Specified (Three CPT II Codes

[4179F-8P & 33xxF & 3315F] are required to report) No documentation of cancer stage or ER/PR status [3370F-8P or 3316F-8P

ONLY]▫ Denominator Coding

Patient is 18 years old or older Breast Cancer Dx Codes (174.0-174.6, 174.8, 174.9) E/M codes (99201-99205, 99212-99215)

http://www.cms.hhs.gov/PQRI/15_MeasuresCodes.asp

PQRI Errors• Errors from 2007

▫ 1,711,975 (12.15%) of QDC submission attempts had a missing NPI.

▫ 2,662,023 (18.89%) of QDC submission attempts occurred with an incorrect HCPCS code.

▫ 1,963,196 (13.93%) of QDC submission attempts occurred with an incorrect Dx code.

▫ 1,019,422 (7.24%) of QDC submissions had an incorrect HCPCS and Dx code.

▫ 700,201 (4.97%) had only the QDC code and no other line items were billed.

• “Physician Quality Reporting Initiative 2007 Reporting Experience” available at http://www.cms.hhs.gov/pqri/

Oncology-Specific Errors

Measure % OK HCPCS Wrong

Dx Wrong QDC Only NPI Problem

#71 Breast Cancer with drug tx

83.70% 5.61% 4.04% 5.87% 13.38%

#73 Plan of Chemotherapy

25.16% 52.70% 12.40% 8.00% 5.68%

#72 Stage III Colon Cancer

56.25% 7.38% 12.00% 4.68% 9.31%

“Physician Quality Reporting Initiative 2007 Reporting Experience” available at http://www.cms.hhs.gov/pqri/

Hem-Onc Specific Errors

Measure % OK HCPCS Wrong

Dx Wrong QDC Only NPI Problem

#70 Baseline Flow in CLL

77.31% 7.13% 10.35% 3.28% 12.50%

#67 MDS Baseline Cytogenetic Testing

66.63% 9.05% 9.47% 3.67% 10.31%

#69 Multiple Myeloma Tx With Biphosphonates

73.02% 12.21% 8.28% 4.46% 12.40%

#74 RT Recommended Breast Ca

15.45% 58.15% 1.03% 7.47% 7.31%

“Physician Quality Reporting Initiative 2007 Reporting Experience” available at http://www.cms.hhs.gov/pqri/

PQRI Things to Remember• Patient must have the proper age, diagnosis

and that must be linked to the PQRI codes.• Codes must be arrayed per measure

specifications.• Patient must meet the age requirement.• Codes must be reported with the denominator

CPT or HCPCS codes.• Claims must have an NPI.• 80% is calculated by NPI.• Get forms at

http://www.ama-assn.org/ama/pub/category/17http://www.ama-assn.org/ama/pub/category/17432.html432.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.co

m• For more

information, contact me!

Future Penalties for Not Electronically Prescribing• Eligible professionals who are not successfully using

electronic prescribing by 2012 will be penalized 1% of their covered Medicare Part B charges. ▫ This means that these providers will be paid at 99% for

their covered Medicare Part B fee schedule services.• Limitation applies as for incentives• Fee reduction is prospective, providers will have to

electronically prescribe by a date to be determined to be sure their fees are not reduced in 2012.

• This date will not be before 2010.• Hardship exemption on a case-by-case basis for small

practices.

Future Penalties for Not Electronically Prescribing•In 2013 - 1.5% deducted from their

covered Medicare Part B services.▫Professionals will be paid at 98.5% of the

physician fee schedule for covered services.

•In 2014 and beyond penalty will increase to 2%.▫Professionals will receive 98% of the

physician fee schedule for the covered services they provide.

Part D Information

•The Secretary has the authority to change the requirements for successful E-Prescribing in the future.

•The MIPPA legislation allows for future use of Part D data in lieu of claims-based reporting by eligible professionals.

Recovery Audit Contractors (RACS)• The Centers for Medicare & Medicaid Services (CMS) has

updated its Medicare recovery audit contractor (RAC) expansion schedule map.

• According to the updated map, CMS intends to now implement the permanent RAC program in 2 phases. The first phase will begin on March 1, 2009 and involve about half the country. The second phase will begin on August 1, 2009 or later.

• 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

Who Else Can Ask For/ Deny/Review Stuff•MACs/ Carriers per their own internal

screens•CERT Auditors•Medical Integrity Contractors•Bundling and Medically Unlikely Edits•Private Insurance Companies on behalf of

MA or themselves.

Preparing for Review

1. Get personally involved with seeing that charts are put together correctly.

2. Call the requestor, if you have questions…3. Copy ALL records involved in the request

—office, hospital, lab.4. Check for legibility and continuity of

charts. Find unfiled documentation, if that is an issue

5. 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. Send to the correct contractor.8. Make sure documentation gets there

when it is due. Send by traceable mail (Express, Fedex, etc)

9. Keep a record of records checked out, why request was made, and to whom.

Strategies for Success

• Know where your MAC is at as far as anti-emetics. NGS is an aberration so far.

• Look at when and HOW your individual payers are going to adopt the new CPT codes.

• Analyze the reasons for rejected, denied, or delayed claims and fix it. If you do not have an EOB analyzer, you are behind the curve.

• Put together policies and procedures for the RAC coming to your area.

• Really consider doing PQRI and e-prescribing---4% is nothing to sneeze at.

• Enforce payments with private payers. • Audit chemo prospectively; peer review E&M. Physicians

must review consults before it is too late! Transmittal 788, CR 4215 (2005).

• Look at your billing profiles from 10-1-07. Give $$ back before the RACs collect it for you!

• Participate in the struggle!

Contact Info

•Contact▫bbuell@covad.net▫bobbibuell1@yahoo.com▫800-795-2633

•Newsletter is free!•E-prescribing is free!

Thank You from onPoint Oncology LLC!