Changes to Oncology Reimbursement 2009

Bobbi Buell

Version 3.0

November 2008

Sponsored by:

www.remitdata.com

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.

Session Objectives

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/PFSFRN/list.asp#TopOfPage

Hospital Outpatient Rule = http://www.cms.hhs.gov/HospitalOutpatientPPS/HORD/list.asp#TopOfPage

ICD-9-CM Codes = http://www.cms.hhs.gov/ICD9ProviderDiagnosticCodes/07_summarytables.asp#TopOfPage

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.

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 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$

2009 Changes to the GPCIs

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! 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 WAMP

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

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 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

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.

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

CMS looked at new provision for shared savings between physicians and hospitals. But there is criteria: 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 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/pqriwww.cms.hhs.gov/pqri

Principals of PQRI

Providers report by NPI, not by TIN. Reporting is still voluntary. May report in these ways

Claims Registries

Reporting successfully Claims groups Three or more reporting measures ≥ 80%, if at least three

measures apply.

2% for 2009. No CAP applies.

2007 Incentive Payments 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

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

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/PQRIIncentivePayment.pdf

Includes three tables Table 1

Earned Incentive Summary for Taxpayer Identification Number (Tax ID or TIN) All EPs’ NPIs within TIN Breakdown of each individual’s earned incentive

Accessible only by TIN Up to TIN to distribute Table 2 information and, if applicable, Table 3,

to individual EP’s NPI Table 2

NPI Reporting Detail (if submitted at least one valid QDC) One for each participating EP

Table 3 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 Report at a Glance

2007 Feedback Reports

Feedback Reports & “2007 PQRI Feedback Report User Guide” available on-line http://www.qualitynet.org/pqri

2007 Measure Applicability Validation (MAV) process http://www.cms.hhs.gov/pqri/Downloads/

PQRI_Validation.pdf An Individual Authorized Access to CMS Computer

Services (IACS) log-in Account is required to access feedback reports

Step-by-Step IACS Registration 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 -OR-

MLN SE0831 - Steps to Access 2007 PQRI Feedback Reports by Organizations https://www.cms.hhs.gov/PQRI/Downloads/PQRISE0831.pdf

2007 PQRI Reporting Participation Statistics

109,349 NPI/TINs – Attempted to Submit 101,138 NPI/TINs – Submitted a Quality Data Code

Successfully A feedback report is available

70,207 NPI/TINS – Satisfactorily Reported 1 or more measures A feedback report is available

56,722 NPI/TINs – Earned Incentive A feedback report & incentive payment are available

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.

MIPPA Legislation – PQRI, Section 131

PQRI 2009 incentive provided and raised to 2% 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 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#TopOfPage 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: Reporting Period:January 1, 2008 - July 1, 2008 – December 31, 2008 December 31, 2008

Individual Measures: Individual Measures:80% of applicable cases 80% of applicable casesMinimum 3 measures Minimum 3 measures

One Measures Group: One Measures Group:30 consecutive patients 15 consecutive patients OR OR80% of applicable cases 80% of applicable cases

Do You Want to Use a Registry?

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 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

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 E-Prescribing in 2008 PQRI

Electronic Prescribing Measure in 2008 PQRI

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 e-Prescribing 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!

That’s right! Just for cancer

practices! www.oncologyerx.comwww.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 e-prescribing 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 singlesingle 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.

Overpayments Collected(in millions)

Underpayments Paid Back

(in millions)

Overturned on

Appeal (in millions)

Total Improper Payments Identified (in millions)

$ 357.2 + $ 14.3 + $17.8 = $389.3

Costs: - $ 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

Status Document

For FY 2007 on

www.cms.hhs.gov/RAC

FY 2007 Improper Payments

FY 2007 Improper Paymentsby Provider Type (Claim RACs Only)

StateState(in millions)(in millions)

Inpt/Inpt/

SNFSNF

OutptOutpt

HospHosp

MDsMDs Amb, Amb, LabLab

DMEDME Total Total CollectedCollected

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

Source: CMS RAC Status Document Table 2-3

2007 Overpayments Collected by Error Type (Net of Appeals)

Type of Error (in millions)

Inpt/SNF 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, 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

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 CodesQ4097 INJECTION, IMMUNE GLOBULIN

(PRIVIGEN), INTRAVENOUS, NON-LYOPHILIZED (E.G.

Q4098 INJECTION, IRON DEXTRAN, 50 MG

J1750 INJECTION, IRON DEXTRAN, 50 MG

• They reinstated

Off-Label Use Update

THREE new compendia in addition to AHFS-DI 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

http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=203 View CMS FAQs

http://www.cms.hhs.gov/mcd/ncpc_view_document.asp?id=12 View ASCO FAQs

http://www.ascofoundation.org/portal/site/ASCO/menuitem.5d1b4bae73a9104ce277e89a320041a0/?vgnextoid=24be6e7507523110VgnVCM100000ed730ad1RCRD

View CMS Transmittals R1412, R1413, R80NCD at 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 self-administered, 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 itemsSource: 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 bbuell@covad.net bobbibuell1@yahoo.com 800-795-2633

Newsletter is free! Education for your staff--check it out at

http://www.eexpertpartners.com/payperview.html

Thank You!