Changes to Oncology Coding 2010

Bobbi BuellVersion 12.0Winter 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 G-codes.

Budget Neutrality???

Consult Code Maps to Percentage Mapped

2010 Price

99241($48.69)

9920199211

50%50%

$38.95$19.12

99242($91.61)

9920299212

50%50%

$67.44$38.95

99243($125.15)

9920399213

50%50%

$97.74$65.54

99244($185.38)

992o499214

50%50%

$151.48$98.46

99245($226.50)

9920599215

50%50%

$190.43$132.73

Source: CMS Website; 2010 NF RVUs; 2009 CF and GPCIs =1

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 Consultations

Evaluation and Management (E/M): Consultations: To clarify the two situations under which consultations may be reported, the Evaluation and Management (E/M) section subheading, "Consultations" has been revised.  These situations are: 1) to provide opinion/services for a specific condition or problem, or 2) to allow a determination to be made on whether to accept the ongoing management of the patient's entire care or for the care of a specific condition or problem (i.e. transfer of care AFTER an evaluation of the patient's problem). CPT outlined that documentation of the written or verbal request for a consultation can be done by either the consultant or by the requesting physician or other appropriate source.  You may remember that Medicare requires (until January 1) that BOTH the requesting and consulting physicians document the request.  But, the request DOES need to be documented.

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 stay. This includes inpatient and outpatient consultations.

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

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

FR 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.

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 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

2009-2010 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.http://www.ama-assn.org/ama/pub/category/17432.htmlhtml

C

Reporting Measures with Claims

Billing Parameters for PQRI

PQRI Error Report for 2008

Measure Total QDCs

Valid QDCs

Valid %

Biggest Error

% Error QDCs

#71 Breast Cancer

76,278 48,973 64.20% Diagnosis 29.30%

#72 CRC Stage III

49,702 12,790 25.73% Diagnosis 68.69%

#73 Plan for Chemo

32,734 7,960 24.32% HCPCS 29.36%

#68 Iron Stores with EPO

10,943 8,919 81.50% Diagnosis 13.10%

#105 3-D RTx in Prostate Cancer

61,761 59,753 96.75% HCPCS 1.80%

Source: CMS Report “QDC Submission Error Report by Measure” at cms.hhs.gov

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

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: 2009 Only

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.

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.cowww.oncologyerx.comm

• 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

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Where Did RACs Find Overpayments?

Most overpayments were collected from inpatient

hospital services for medical necessity and coding

SNF 2%Doc/Ambulance/

Lab/DME/Other 4%InpatientHospital 85%

Incorrectly Coded 35% Other

17%

No/InsufficientDocumentation 8%

Medically Unnecessary 40%

95% from Hospitals

Source: CMS, The Medicare Recovery Audit Contractor Program: An Evaluation of the 3-Year Demonstration, June 2008

Rehab 6%

Outpatient 4%

RAC Demo Findings

40

RAC Appeals Experience to Date

41

D

C

B

A

RAC Jurisdictions

March 1, 2009

March 1, 2009

August 1, 2009

3

RAC Contacts at CMS

42

RACCMS

Contact Person

Phone

A Ebony Brandon 410-786-1585

B Scott Wakefield

410-786-4301

C Amy Reese 410-786-8627

D Kathleen Wallace

410-786-1534

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 10-09Issue Date Region(s) Description Source

Blood Transfusions

8.4.09 All Region B, D, plus Ala, Fla, Georgia, 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 B-covered oral/or inhaled drug

CMS Pub. 100-04, Chapter 17, Sec 80.7

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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

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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

47

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 RAC 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?

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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

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.?

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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

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?

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.

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.

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 bbuell@covad.net bobbibuell1@yahoo.com 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!