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CHANGES FOR MEDICAL ONCOLOGY PRACTICES 2010—WHAT YOU NEED TO KNOW

Presented by:Roberta L. Buell, MBA, principal, onPoint Oncology LLC, Sausalito, California

800-795-2633bbuell@covad.net

Updated May 14, 2010

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DISCLAIMER

• Much is not known about Health Reform. This is what we know right now.

• Payers differ on their guidelines. Please verify coding for each payer and claim.

• All Medicare and RAC information is literally changing on a daily basis. What is presented herein may or may not be valid for 2010.

• 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.

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SESSION OBJECTIVES

• Discuss Fee Schedule for 2010• Discuss Timeline For Health Reform• Discuss the Status of RACs• Discuss Latest Audits• Discuss Proposed ICD-9-CM Codes• Discuss Latest Transmittals• Discuss Signatures• Know What You Need to Do Next

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MEDICARE PHYSICIAN PAYMENT BASICS

• Payments are based on RVUs for each code (WRVUs+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 1.00 GPCI Floor has been eliminated.

• 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.

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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 after 4/1/10.

• 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 $28.3895 down from $36.0666 after the 2 month hold. For 3 months, CF = $36.0846

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The SGR Saga• Was pulled out of the House and Senate bills because of cost: $210-240 billion to fix,

not patch, the SGR

• House passed a separate “fix” bill but Senate failed• 2-month patch in the defense bill averted the 21.2% Medicare cut until 3/1--CMS holds

Medicare claims• House passes an “extenders” bill including 30-day patch through 4/1 (also included

COBRA and unemployment insurance extensions)• Senate unable to pass the bill before 3/1 over Senator Bunning’s objections • CMS holds claims for 10 days • Senate passes bill

• House passes another “extenders” bill including 30-day patch through 5/1 (also includes COBRA and unemployment insurance extensions)

• Attempt to go back to the House with changes to the bill fails. House leaves on 2-week recess• Senate unable to pass the bill over Senator Coburn’s and unified GOP objections; Senate

leaves on 2-week recess • CMS holding claims for 10 days • Senate returns on 4/12 to take up measure • Senate passes the bill, followed by House passage and President signs into law. • Provides a patch till 6/1

• A true SGR fix unlikely; most likely scenario is 5-year patch — maybe following 4-7 month patch 5-year patch in the Senate Budget Resolution

From:Ted Okon’s Health Reform Slides

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What Will You Do?

• Frank Cohen Study (www.frankcohen.com)• Over 33% said they would go non-PAR• Over 2/3rds will limit Medicare patients• Over 2/3rds will re-negotiate any contract

based on Medicare rates

• A Sermo survey of 1500 physicians showed 84% of physicians will stop seeing patients if the cuts go through…

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IMPACT OF 2010 MPFS CHANGES

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Health Reform

• 2010 Provisions• Immediate access for patients with pre-existing

conditions: High risk pools will be formed in June to take care of these folks.

• Practices with imaging must provide their patients with a statement evidencing facilities where they can get same services. This dates back to January 1.

• Small business tax credits: Small businesses can get tax credits for insurance, up to 35% but the average salary must be $40K or less.

• Prohibition of rescissions: Prohibits insurers from retroactively denying access based on current or previous diagnoses.

• Claims filing limit to Medicare will be one year.

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Health Reform

• 2010 Provisions (Cont’d)• Begins to eliminate lifetime limits and

restricts use of annual limits: This will start in September, making insurance verification easier.

• Dependent coverage extended to the age of 26: Starts September of 2010.

• Doughnut hole starts to close a little. Patients who enter this year will get a $250.00 rebate. In 2011, there will be a 50% discount on all brand name drugs. During the next ten years, the gap will go from 100% to 25% coinsurance in 2020.

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Health Reform

• 2010 Provisions• GPCI Floor extended in 2010. Work RVU

adjustment at 1.00 in 2010. Adjustments in 2011 for frontier states.

• Medicare Independent Payment Advisory Board established. This Board will oversee Medicare with 15 members who will take over some Congressional duties.

• Expansion of Medicaid. A new option is established to allow states to fund patients at 133% FPL.

• Encourages new therapies for acute and new therapies with $1 billion cap for credits.

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Health Reform

• 2010 Provisions (Cont’d)• Special provision of Blue Cross/Blue

Shield which states that the non-profit Blues must a a medical loss ratio of 85%. That means that to keep their non-profit status they must spend 85% on care.

• Imaging will take reductions of 50% of the –TC for multiple procedures at an increased rate of 50% starting July 1.

• Indoor tanning gets taxed by 10%. Lotions, gels, and spray on tans are not taxed.

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Health Reform

• 2011 Provisions• PQRI is extended through 2014 and then

becomes mandatory. You get 1% in 2011 and 0.5% 2012-2014; then, the hammer comes down in 2015, you get -1.5% for non-participation and -2% thereafter.

• Increased reimbursement for primary care with a 10% incentive for all physicians listed with Medicare as family medicine, internal medicine, and pediatrics where 60% of charges are concentrated in the office. This will be around 2011-2016.

• 10% bonus for surgeons in HPSA areas.

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Health Reform

• 2011 Provisions (Cont’d)• Improves preventative care by

eliminating co-pays and deductibles for preventative services. Not clear yet what these are.

• Development of a Physician Compare web site. Opens in 2013.

• Employers must report health benefits on W-2.

• Pharma writes big checks. Imposes an annual, non-deductible fees on firms that have BRANDED pharmaceuticals with revenues over $5 million.

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Health Reform

• Provisions 2012-2013• Encouragement of Accountable Care Organizations

(ACOs). More about this in a minute.• Administrative simplification starts again. This will be

to standardize claims, verification, prior auth, and all remittance processing. But, this must be enforced.

• Practice expense adjustments for geographical differences.

• No more employer subsidies for Part D. • Tax deductions for health insurance expense will go

from 10% to 7.5% unless you are over 65.• Increased Medicare tax on individuals. Will be 2.35%

on wages; 3.8% on unearned income.

Accountable Care Organizations

Beginning January 1, 2012, groups of qualifying providers will have the opportunity to form Accountable Care Organizations (ACOs) and share in cost savings they achieve for Medicare program. Providers include:

Physician group practice arrangements

Networks of practices

Hospital-physician joint ventures

Hospitals employing physicians and other clinical professionals (physician assistants, nurse practitioners, or clinical nurse specialists)

Accountable Care Organizations

To qualify as an ACO, an organization must:• Agree to become accountable for the overall care of their

Medicare fee-for-service beneficiaries• Agree to a minimum three-year participation per cycle• Have a formal legal structure enabling it to receive and

distribute bonuses to participating providers• Provide information on the physicians participating in the ACO• Have a management and leadership structure in place• Define processes to promote evidence-based medicine and

patient engagement, report on quality and cost measures, and coordinate care

• Demonstrate that it meets any patient-centeredness criteria determined by the HHS Secretary

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Health Reform

• 2014 Provisions• The hammer comes down on insurance

companies. Strong provisions will be enforced to ensure access regardless of health status. Limits on coverage will be eliminated. Premium variability will be minimized.

• Health Insurance Exchanges will be established. These will be set up in each state to assure affordable coverage for individuals and small business.

• Coverage of individuals and routine costs associated with clinical trials.

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Health Reform

• 2014 Provisions (Cont’d)• Penalties will be levied for no insurance.

This is being legally challenged in several states.

• Payers pay up. Health insurers will pay according to market share, if they have premiums over $25 million.

• IPAB submits recommendations to curb spending, if costs are greater than inflation.

• Medicaid expansion is implemented.

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Health Reform

• 2015 Provisions• Independent Payment Advisory Board

submits ‘proposals’ to Congress to ‘increase solvency’ of the Medicare Program.

• Physicians will ‘paid on value’ not volume. Value-based pricing will kick in.

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The Future of PQRI

• Health Reform reinforced PQRI for the foreseeable future.• 1% in 2011• 0.5% in 2012-2014; still voluntary• 2015: -1.5% for non-participation• After 2015: -2.0%

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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.

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Oncology Issues

• Blood Transfusion Units of Service

• IV Hydration Units of Service

• Neulasta Units of Service

• Pump/Pump Supplies

• Facility versus Non-Facility

• SNF Billing

• A4221 Units of Service

• Global versus –TC, -TC in facility

• CSW During Inpatient

• Services to Hospice Patients

• “New” versus Established patients

• DME Charged After date of Death

• MUEs (Connelly)

These are changing daily—Check the Web Site often

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Other Audits

• High dollar claims—WPS

• 99211 and Coumadin checks----WPS

• Non-chemo drugs with chemo admin codes (2005-2007)—Palmetto GBA

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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

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New ICD-9 Codes 10-1-2010

• New Hem-Onc Codes• Red blood cell disorders (275.0_)

• Transfusion circulatory overload (276.61)

• Post-transfusion purpura (287.41)

• Other secondary thrombocytopenia (287.49)

• Febrile non-hemolytic transfusion reaction (780.66)

• Jaw pain (784.92)

• Hemoptysis, unspecified (786.30)

• Feces disorders (787.6_)

• Transfusion reactions (999.6_-999.8_)

• Do not resuscitate status (V49.86)

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Deleted ICD-9-CM Codes 10-1-2010

• Iron Disorders (275)

• Fluid disorders (276.6)

• Secondary thrombocytopenia (287.4)

• Hemoptysis (786.3)

• Incontinence of feces (787.6)

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PECOS

• Claims ordered / referred must:• NPI of ordering provider• Name in PECOS or MAC system • Specialty as listed• Grace Period• Phase 1: 10/5/09 to 1/2/11 warning message on

remittance• Phase 2: 1/3/11 and after: claim rejected if

referring individual not in Pecos or MAC list

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PECOS

• To assist providers in their quest to get physicians enrolled in PECOS, the Part B MACs will be sending revalidation letters to all physicians who have not updated their Medicare enrollment in over 6 years. (Medicare contractors first began updating the PECOS database with physician enrollments in November of 2003; therefore, physicians enrolled prior to this date will not be in the database.). The letter will instruct the physician to submit either an updated paper enrollment form or to enroll online via PECOS.

• Revalidation of some labs

• Need to update any changes within 30 days• Address, phone, suite• New members in group• Other changes

• If no claims to Medicare in one year—physician is disenrolled in Medicare

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Drug Waste

• Transmittal 762, Change Request 6711, effective July 30, 2010• Use of –JW still optional at discretion of Carrier• Depends upon J-code. Let’s say J-code is 1

mg. You use 9 mg and waste 1 mg. You would bill 2 lines• 9 units on one line• 1 unit with –JW on another line

• But, if the J-code is 10 mg, you would just bill the one line.

• Must document waste in either case.

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Imaging Reduction

• Transmittal 694, CR 6965, effective July 1 and implemented July 6, 2019• Implements Health Reform Provision• Reduction of –TC increased from 25% to 50%

for additional procedures done in the same session on the same day.

• Many experts thought this would not happen until 2011.

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Claims Filing

• Transmittal 697, CR 6960, effective January 1, 2010 and implemented October 4, 2010

• Claims must be filed within one calendar year. Implementation will be according to this schedule:• 1) claims with dates of service prior to October 1, 2009 will be

subject to pre-PPACA timely filing rules and associated edits; • 2) claims with dates of service October 1, 2009 through

December 31, 2009 received after December 31, 2010 will be denied as being past the timely filing statute and;

• 3) claims with dates of service on or after January 1, 2010 received more than 1 calendar year beyond the date of service will be denied as being past the timely filing statute (ex: claim DOS = 3/15/10, claim must be received by COB 3/15/11).

• One exception is a mistake by CMS or agents thereof.

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Signatures: Review Criteria

• Auditors: MACs, CERTs, and RACs, just to name a few. CMS requires that orders for healthcare services and the services that were provided be authenticated by the author using either a handwritten or electronic signature. CMS has made it clear that stamped signatures are not an acceptable form of authentication. The previous language in the CMS Program Integrity Manual required a “legible identifier”. The recent CMS Transmittal 327 has added additional clarification and signature assessment requirements.• If the reason for a pre- or post-payment denial is unrelated to the signature requirement, the contracted reviewer can

disregard the signature authentication process. However, if the criteria in the specific Medicare policy cannot be met because the documentation is missing a signature or it is not legible, the reviewer is instructed to proceed to the signature assessment procedure.

• If the signature is missing from an order, the reviewer has been instructed to disregard the order during the review of the claim.

• If the signature is illegible, the reviewer can request a signature log or attestation statement to determine the identity of the author of a medical record entry. Although there is not a specific attestation form at this time, the transmittal does provide specific language that should be considered if the provider is using this process.

• If the signature is missing from any other medical documentation, excluding the order, the reviewer should accept a signature attestation from the author of the medical record entry. Providers should not add late signatures to the medical record “beyond the short delay that occurs during the transcription process” and should instead use the signature attestation process. Other providers in the same group may not attest to the original author’s signature.

• In addition, if the Medicare policy is “silent” on whether a signature must be dated, the reviewer has been instructed to ensure that the rest of the documentation contains enough information to determine the date when the service was ordered and/or performed. For example, the reviewer finds that the first and third order on a page have a specific date; however, the second order on the same page is not dated. It could be assumed that the second order occurred on the same date.

• All providers should be reviewing all documentation for dates and signatures in a timely manner and prior to considering the medical record complete.

• Providers should also be reviewing all documentation prior to sending medical record copies to contractors for review.  If a signature is not legible or is missing, the providers should take the appropriate steps to comply with the requirement in advance to prevent delays regarding the outcome of the review.  Also, review all request letters for any additional language the reviewer might add reminding you that a signature log or attestation can be submitted with the copies as part of the Additional Documentation Request (ADR).

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SURVIVAL STRATEGIES• Cash is the practice’s most vital resource. Make sure you have your cash

requirements in mind with every decision you make. Do not live beyond your means.

• Remember that collections start with the referral and ends with payment. Collections also start at the top with the physicians. Patients should pay balances with every encounter.

• Do not get behind in your payments to distributors. This is the beginning of the end of your survival. Nobody is your friend if you owe them money.

• Ensure that your billing system is sophisticated enough to meet your needs. You need to keep close tabs on your production by code, your DSO, and your Accounts Receivable. This system is your lifeline.

• Practices with imaging must be giving the patients a statement RIGHT NOW. Examples on COA web site.

• Run the numbers, if you have imaging, for the July reduction.

• Check the signatures in your records for compliance.

• If you haven’t participated in PQRI, use a REGISTRY.

• Start getting prepared for “meaningful use” HIT incentives and direct submission of PQRI data. Get with your EMR vendor!

• Make sure you are prepared for more cash flow interruptions.

• Participate in the struggle! The fight is not over yet!

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• CAN Web Site• The latest news• Forms• Regulations• Newsletters• Presentations• http://communityoncology.info

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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

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THANK YOU FROM ONPOINT ONCOLOGY LLC!