Transcript Medicare Prescription Drug, Improvement, and Modernization

ASCO
Clinical Practice
Series
Updated: 3/22/05
Practice Management
Series
2004 - 2005
Practice Management Curriculum
1. Adapting to Changes in Medicare
2. Generating Practice Efficiencies
3. Organizing for Service Expansion
2
Adapting to Changes in Medicare
Identifying and understanding the Medicare changes in
2005 and their effect on your practice.
3
Who should attend
Physician Leader of the Practice
 President of the PA, Founder
Practice Administrator
 CEO, Executive Director, COO
Contracting Officer
 Contract Administrator, Director of Billing
Clinical Manager
 Medical Director, Nursing Team Leader
4
After this session, you will be able to:
Identify changes in Medicare from 2003-2006.
Assess the degree to which your practice has made the
necessary changes to adapt to new Medicare
regulations.
Define new opportunities for oncology practices.
Understand changes to margins for chemotherapeutic
and supportive care products.
Understand the role of the physician practice leader
and the administrator in adapting to these changes.
5
Medicare Prescription Drug Improvement and
Modernization Act (MMA)
What happened in 2004?
Average Wholesale Price decreased with most drugs at
80 -85% of AWP April 1, 2003
99211 can no longer be billed with chemotherapy but…
0.17 RVUs added for physician work component of
chemotherapy administration
6
What happened in 2004?
Increase in practice expense component of
chemotherapy administration
2004 Conversion factor of $37.3374 (1.5% over 2003)
32% transitional add-on to the practice expense
component of chemotherapy administration
 This 32% kept most oncology practices “whole,”
comparable to 2003
7
MMA….2005
AWP is gone
Drug reimbursement now based on Average
Sales Price (ASP)
 Effective 1/1/05 drugs furnished incident to a
physician’s service are paid at ASP + 6%
 ASP data will be updated quarterly with a two quarter
lag (ex. 4/1/05 payments based on 4th qtr 2004 data)
8
What is ASP?
ASP = total US sales for an NDC (national drug code)
divided by the total number of units sold (incl discounts)
Unit is defined as the lowest identifiable quantity of the
drug or biological by NDC that is dispensed, exclusive of
diluents
Manufacturers must report ASP quarterly
12 month averaging is used to smooth price changes
ASP must include volume discounts, prompt pay
discounts, free goods that are contingent on any
purchase requirement, charge backs and all rebates other
than the Medicaid rebates
9
MMA….2005
ASP
 If data is not available to calculate ASP (ex. new
drugs), payment will be made based on wholesale
acquisition cost or the methodologies in effect on
11/1/03 to determine payment amounts, “for a limited
period”
 Influenza, pneumococcal and hepatitis B vaccines will
be paid based on 95% of AWP – AWP will be updated
quarterly
 ASP payment files are available at
http://www.cms.hhs.gov/providers/drugs/default.asp
10
ASP Update - April 1, 2005
Significant decrease in payment for Carboplatin (from
$125.47 to $75.75)
Payment rate published for paclitaxel protein-bound
particles (Abraxane) at $8.44/1 mg.
IVIG codes have changed:
 Q9941 IVIG lyophilized
1 gram
$56.36
 Q9942 IVIG lyophilized
10 mg.
$0.56
 Q9943 IVIG non-lyophil.
1 gram
$39.14
 Q9944 IVIG non-lyophil.
10 mg.
$0.39
11
ASP Update - April 1, 2005
Revisions to first quarter payment rates
CMS has not yet issued implementation instructions
Q1 2005
Q1 2005
Revised
Q2 2005
Normal Saline
J7030, 1ooo ml
$0.10
$0.99
$0.98
Normal Saline
J7040, 500 ml
$0.05
$0.50
$0.49
Epoetin alpha
Q0136, 1000 units
$10.18
$10.60
$9.81
12
ASP Update - April 1, 2005
More revisions
Q1 2005
Q1 2005
Revised
Q2 2005
$356.35
$359.63
$358.98
Etoposide
J9181, 10 mg
$0.45
$0.49
$0.73
Etoposide
J9182, 100 mg
$4.51
$4.86
$7.31
$43.29
$43.30
$38.66
Doxorubicin liposome
J9001, 10 mg
Cladribine
J9065, 1 mg
13
A few ASP examples…
HCPCS
Description
Dosage
2004
AWP
4/1/05 ASP
+ 6%
J1626
Granisetron
100 mcg.
$15.62
$7.11
J2405
Ondansetron
1 mg.
$5.58
$3.73
J2430
Pamidronate
30 mg.
$237.88
$57.35
J7030
Normal saline 1000 cc.
$7.43
$0.98
J9045
Carboplatin
50 mg.
$135.15
$75.75
J9185
Fludarabine
50 mg.
$318.59
$257.63
J9265
Paclitaxel
30 mg.
$138.28
$18.76
J9310
Rituximab
100 mg.
$438.38
$439.81
Q0136
Epoetin alpha
1000 units
$11.62
$9.81
Q9941
IVIG lyophil
1 gram
$66.00
$56.36
Your cost?
14
ASP - Your “To Do” List
Complete ASCO’s ASP spreadsheet and send to ASCO
Know the current Medicare payment amounts and
update your system every quarter
Watch for drugs that cost more than your Medicare
payment
 Inform ASCO, CMS
 Shop aggressively
 Understand financial implications before you begin
treatment
15
MMA….2005
Drug Administration Payment Policy and Coding
 MMA required evaluation of existing drug
administration codes with any changes exempt from
budget neutrality requirements
 MMA required the “use of existing processes” and
consultation with physician specialties affected by the
provisions that change Medicare payment for drug
administration
16
MMA….2005
Drug Administration Payment Policy and Coding
 AMA CPT Editorial Panel formed a workgroup;
presented recommendations to CPT Editorial Panel in
August; AMA RUC met in September; ASCO very
involved in process
 Established new interim G-codes for 2005
 These codes correspond with new CPT codes that will
become active in 2006 and replace the G-codes
 NOTE: 32% add-on decreases to 3% add-on in 2005
17
MMA….2005
Established new codes in three categories
 Infusion for hydration
 Non-chemotherapy therapeutic/diagnostic injections
and infusions other than hydration
 Chemotherapy administration (other than hydration)
which includes infusions/injections
These codes are for use in office-based practices only
18
MMA….2005
Changes in Drug Administration Coding
 Under the new codes, chemotherapy administration
codes apply to:
 parenteral administration of non-radionuclide antineoplastic drugs
 anti-neoplastic agents provided for the treatment of
non-cancer diagnoses (e.g., cyclophosphamide for
autoimmune conditions)
19
MMA….2005
More changes…
 Infusion of substances such as monoclonal antibody agents or
other biologic response modifiers is reported under the
chemotherapy administration codes
 Drugs commonly considered to fall under the category of monclonal
antibodies: infliximab, rituximab, alemtuzumab, gemtuzumab, and
trastuzumab
 Administration of anti-anemia drugs and anti-emetics by
injection or infusion for cancer patients is not considered
chemotherapy administration and should be reported using
new codes G0347 – G0354
 CMS will NOT be developing a national list of approved
chemotherapy drugs but will allow each carrier to develop
such a list; check your local policies
20
MMA….2005
More changes…
 There are new codes in both the chemotherapy and nonchemotherapy sections for reporting the “additional
sequential infusion” of different substances or drugs
 Injection services (therapeutic, prophylactic or
diagnostic injections) are now separately paid even if
another physician fee schedule service is billed for the
same patient that day
21
MMA….2005
ASCO handout – “Coding and Payment Changes for
Medicare Drug Administration Codes”
A complete cross-walk between 2004 CPT codes and
2005 Medicare G-codes
Includes RVUs for 2004 and 2005
Includes national average payment rates for 2004
(including 32% add-on) and 2005 (including 3% add-on)
22
Let’s Define Some Terms…
Initial Service
The initial code is the code that best describes the service
the patient is receiving and the additional codes are
secondary to the initial code
If a combination of chemotherapy drugs, nonchemotherapy drugs, and/or hydration is administered
by infusion sequentially, the initial code that best
describes the service should always be billed irrespective
of the order in which the infusions occur
23
Initial Service
Only one initial drug administration service code should
be reported per patient per day, unless protocol requires
that two separate IV sites must be utilized
If a patient has to come back for a separate identifiable
service on the same day, or has two IV lines per protocol,
these services are separately payable and reported with
modifier -76 (repeat procedure by same physician)
24
What is a push?
Federal Register definition:
 Intravenous or intra-arterial push is defined as an
injection/infusion of short duration (i.e., 30
minutes or less) in which the healthcare
professional who administers the substance/drug is
continuously present to administer the injection
and observe the patient
25
What is a push?
CPT revision February, 2005:
 Intravenous or intra-arterial push is defined as a)
an injection in which the healthcare professional
who administers the substance/drug is
continuously present to administer the injection
and observe the patient or b) an infusion of 15
minutes or less.
Additional guidance from CMS is expected soon
26
New Service Codes
Several new service codes have been added
 Codes are intended to recognize additional work and
practice expense associated with the provision of
multiple drugs
 Several of these new codes are add-on codes and
should be used for drugs provided after the first
 Add-on codes include: G0346, G0348, G0349,
G0350, G0354, G0358, G0360, G0362
27
Hydration
CPT
G-code
Descriptor
90780
G0345
Intravenous infusion, hydration; initial up
to one hour
90781
G0346
each additional hour, up to 8 hours
Codes G0345 and G0346 are intended to report an IV infusion that
consists of a prepackaged fluid and/or electrolyte solution, but are not
used to report infusion of drugs or other substances
On 1/27/05, CMS clarified that electrolytes that are prepackaged or
mixed are reported using the hydration codes
Continue to use -59 modifier to indicate that hydration is performed
before or after the chemotherapy infusion
28
Hydration
Report G0346 for hydration infusions of greater than 30
minutes beyond one-hour increments
Also report G0346 for hydration greater than 30 minutes
when it is provided as a secondary or sequential service
after a different initial infusion or chemotherapy service
 Example – use G0346 for hydration of >30 minutes
following chemotherapy infusion using G0359
29
Injections and Infusions
(non-chemotherapy, other than hydration)
CPT
G-code
Descriptor
90780
G0347
Intravenous infusion, for
therapy/diagnosis, initial, up to one hour
90781
G0348
each add’l hour, up to eight hours
90781
G0349
add’l sequential infusion, up to one hr
N/A
G0350
concurrent infusion
30
Injections and Infusions
(non-chemotherapy, other than hydration)
G0350 - concurrent infusion – simultaneous infusion of
two or more non-chemotherapy drugs
 Cannot bill for multiple hours of concurrent infusion
 No concurrent infusion code for chemotherapy drugs
Clarification from CMS to ASCO 1/6/05 – “not limited to
one concurrent infusion per encounter”
31
Concurrent Infusion
On 2/24/05 CMS informed ASCO that “carriers have
discretion” on policy for concurrent infusions
Check with your carrier on specific coverage issues
Some carriers are not covering concurrent infusions
when two drugs are administered from the same bag
 The Illinois carrier has stated: “It is not appropriate to
bill an infusion administration code for each drug that is
contained within an IV bag. Only one IV bag is being
administered and should be billed as one infusion
service.”
32
Injections and Infusions
(non-chemotherapy, other than hydration)
CPT
G-code
Descriptor
90782
G0351
Therapeutic or diagnostic injection
90784
G0353
IV push, single or initial substance/drug
N/A
G0354
each add’l sequential IV push
33
Injections and Infusions
(non-chemotherapy, other than hydration)
G0354 - each additional sequential intravenous push,
non-chemotherapy
 It is possible that a non-chemotherapy drug
administered IV push may follow the administration of
a chemotherapy drug by IV push; G0354 would then be
an add-on to G0357
 Example:
Vinorelbine
G0357
Palonosetron
G0354
34
Chemotherapy Administration
CPT
G-code
Descriptor
96400
G0355
Chemotherapy administration; subcutaneous or
intramuscular, non-hormonal anti-neoplastic
96400
G0356
hormonal anti-neoplastic
96408
G0357
IV push, single or initial substance/drug
96408
G0358
IV push, each add’l substance/drug
Drugs commonly considered to fall under the category of hormonal
anti-neoplastics include leuprolide acetate and goserelin acetate.
35
Chemotherapy Administration
CPT
G-code
Descriptor
96410
G0359
Chemotherapy administration, IV infusion, up to
one hour, single or initial substance/drug
96412
G0360
each add’l hour, one to eight hours
96412
G0362
each add’l sequential infusion, up to one hour
96414
G0361
initiation of prolonged chemo infusion, > 8 hrs
N/A
G0363
Irrigation of implanted venous access device for
drug delivery systems
36
Chemotherapy Administration
G0362 – each additional sequential infusion, up
to one hour
 Example: if you administer three chemotherapy
drugs by infusion, you should report one “initial”
code (G0359) and two “additional sequential”
codes (G0362)
37
Chemotherapy Administration
G0363 - Irrigation of an implanted venous access device
(“port flush”)
 Medicare will pay for G0363 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 this service is
bundled into payment for the other service
 No longer use 99211 for port flush; G0363 is a more accurate
definition of service and has better reimbursement
 Some carriers pay for heparin used in port flush; check your
carrier for their policy
38
Chemotherapy Administration
G0363 - Irrigation of an implanted venous
access device (“port flush”)
 Communication from CMS to ASCO 1/6/05 –
“Payment is allowed for G0363 if it is the only
physician fee schedule service provided for a
patient on that day. Payment could be made for
G0363 and clinical laboratory services paid under
the clinical laboratory fee schedule.”
39
Some codes are NOT changing in 2005
 90783 Therapeutic or diagnostic injection,
intra-arterial
 90788 Intramuscular injection of antibiotic
 NOTE: CPT will be deleting 90788 (intramuscular injection of
antibiotic) in 2006. CMS is maintaining 90788 until it is changed in
the CPT system.
 96405
 96406
Chemotherapy administration, intralesional, up
to and including 7 lesions
more than 7 lesions
40
More codes that are NOT changing in 2005
 96420





96422
96423
96425
96440
96445
 96450
Chemotherapy administration, intra-arterial,
push technique
infusion technique, up to one hour
infusion , each add’l hour, one to eight hours
infusion, initiation of prolonged infusion
Chemotherapy administration into pleural cavity
Chemotherapy administration into peritoneal
cavity
Chemotherapy administration into CNS
41
More codes that are NOT changing in 2005
 96520
 96530
 96542
Refilling and maintenance of portable pump
Refilling and maintenance of implantable pump
Chemotherapy injection, subarachnoid or
intraventricular via subcutaneous reservoir,
single or multiple agents
42
Relative Value Comparison
96410 Chemo infusion, 1st hour
G0359 Chemo infusion, single/initial drug, 1st hour
RVU
CF
Fee Schedule
Add-0n
Payment
2003
96410
2004
96410
2005
G0359
1.61
4.41
4.55
36.7856
37.3374
37.8975
$59.2248
$164.6579
$172.4336
0
(32%)
(3%)
$52.6905
$5.1730
$217.35
$177.60
$59.23
43
Example of coding for chemotherapy and related services
Service
Hydration (saline)
Time
9:00 – 9:45
Codes
G0346-59
(45 minutes)
Anti-emetic
9:45– 10:00 (≤15 min)
G0354 – add’l seq push
OR
9:45 – 10:10 (>15 min) G0349 – add’l seq inf
Chemotherapy
(first drug)
10:15 – 11:15
Chemotherapy
(second drug)
11:15 – 1:00
(1 hour, 45 minutes)
G0362 – add’l seq inf
G0360 – ea add’l hr
Anti-emetic
1:00 – 1:15 (15 min)
G0354 – add’l seq push
(1 hour)
G0359
INITIAL SERVICE
44
A Clinical Example…
Carboplatin/Docetaxel
Carboplatin 600 mg. over 45 minutes
Docetaxel 135 mg. over 60 minutes
Dexamethasone 20 mg. infused over 15 minutes
Ondansetron 24 mg. infused over 15 minutes
Compare chemotherapy administration codes and
payment rates for 2004 and 2005
45
Carboplatin/Docetaxel
(includes
32% add-on)
2004
IV infusion, up to one
hour
90780
$117.79
Dexamethasone,
ondansetron
Chemo infusion, up to
one hour
96410
$217.35
Carboplatin,
Docetaxel
Chemo infusion, each
add’l hour
96412
$48.30
$383.44
46
Carboplatin/Docetaxel
(includes
3% add-on)
2005
Chemo IV infusion,
single/initial drug, initial hour
G0359
$177.60
Carboplatin
Each add’l seq. admin infused
chemo drug, up to one hour
G0362
$86.65
Docetaxel
Each add’l seq. push tx drug, inf
of 15 min or less**
G0354
$27.72
Dexamethasone
Each add’l seq. push tx drug, inf
of 15 min or less**
G0354
$27.72
Ondansetron
$319.69
**CMS clarification on administrations > 15 minutes is forthcoming. For now,
follow your local carrier guidelines.
47
Chemo Admin Codes - Your “To Do” List
Put two sets of codes in place in your office for 2005 –
one for Medicare (new G codes) and one for other payers
(CPT codes)
Train your staff
Update your office tools – ex: charge ticket, fee
schedules, pharmacy inventory cabinet
Make sure your nursing documentation is complete and
reflective of these new codes and their descriptions
Talk to your non-Medicare payers about their plans
regarding codes for chemotherapy services
48
Severe drug reaction management
A severe drug reaction management code was requested
and denied during the CPT process
CMS “recognizes that considerable physician effort may
be required to monitor and attend to patients” with
adverse reactions and complications
CMS: These services can be billed using existing CPT
codes
49
Severe drug reaction management
Bill for the Physician Visit
 If a patient has a significant adverse reaction to drugs
during a chemotherapy session and the physician
intervenes, the physician could bill for a visit in addition
to the chemotherapy administration services
 Assumes no other physician visit on date of service
 E & M guidelines should be used to determine the
appropriate level of service to report; documentation
must support the service level billed
50
Severe drug reaction management
Bill for the Higher-Level Physician Visit
 If the patient had already seen the physician prior to a
chemotherapy session….the physician may bill a visit for
a significant adverse drug reaction. The total time,
resources, and complexity of the physician’s interaction
with the patient may justify a higher level of visit
service.
 E & M guidelines should be used to determine the
appropriate level of service to report; documentation
must support the service level billed
51
Severe drug reaction management
Bill for a Prolonged Service (99354 – 99355)
 If the patient had a physician visit prior to the chemotherapy
session and experienced a significant adverse reaction to
drugs on the same day, the physician can bill a prolonged
service code in addition to the physician visit. The physician
must have a face-to-face encounter with the patient and must
spend at least 30 minutes beyond the typical time for that
level of visit for the physician to bill for the prolonged service
code.
 There are several code combinations to use depending on the
number of minutes involved.
52
Severe drug reaction management
Bill for Critical Care Services (99291 – 99292)
 If the patient had a physician visit prior to the
chemotherapy session and experienced a lifethreatening adverse reaction to the drugs, the physician
could bill for a critical care service in addition to the visit
if the physician’s work involves at least 30 minutes of
direct face-to-face involvement managing the patient’s
life-threatening condition.
 Examples of life-threatening conditions: central nervous
failure, circulatory failure, shock, renal, hepatic, metabolic
and/or respiratory failure.
53
Bone Marrow Aspiration and Biopsy
Bone Marrow Aspiration and Biopsy through the Same
Incision on the Same Date of Service
 New add-on G-code, G0364: Bone aspiration performed with
bone marrow biopsy through same incision on same date of
service
 Use CPT 38221 for bone marrow biopsy and G0364 for
second procedure, bone marrow aspiration
 CMS clarifies: “If the two procedures, aspiration and biopsy, are
performed at different sites (for example, contralateral iliac
crests, sternum/iliac crest or two separate incisions on the same
iliac crest), the -59 modifier is appropriate to use and Medicare’s
multiple procedure rule will apply”
 Use 38221 for biopsy and 38220-59 for aspiration
54
Specimen Collection
G0001 (routine venipuncture for collection of specimen)
has been deleted
Medicare will now accept 36415 (collection of venous
blood by venipuncture)
36416 (finger/heel/ear stick) is NOT covered by
Medicare
55
The Demonstration Project
From CMS:
 “In order to identify and assess certain oncology services
in an office-based oncology practice that positively affect
outcomes in the Medicare population, we will initiate a
one-year demonstration project for CY 2005.
 While we encourage optimal care in all facets of
treatment, the focus of the demonstration project will be
on three areas of concern often cited by patients: pain
control management, the minimization of nausea and
vomiting, and the reduction of fatigue.”
56
The Demonstration Project
What do practitioners need to do?
 Practitioners must “provide and document” specified
measurements related to pain control management,
minimization of nausea and vomiting, and the reduction of
fatigue.
 The assessment may be taken either by the practitioner or by a
qualified employee of the office under the supervision of the
practitioner (incident to). If the assessment is performed by an
employee, CMS expects the practitioner to review the data as
part of the patient assessment.
 CMS states “We expect that the patient’s responses will be
recorded and included as part of the patient’s medical records.”
57
The Demonstration Project
How is the assessment performed?
 Patients will assess their symptoms for the past week using four
patient assessment levels: "not at all," "a little," "quite a bit,"
"very much"
 These levels, based on the Rotterdam scale, were chosen by CMS
because they appear to be less burdensome for the practitioner
and more easily understood by the patient
 The responses are submitted on the claim form
58
The Demonstration Project
Assessment is to be performed at the time of a “patient
chemotherapy encounter”
What is a patient chemotherapy encounter?
 Chemotherapy administered through intravenous infusion (G0359)
or push (G0357), limited to once per day; injections are not included
Who can participate?
 Any office-based physician or non-physician practitioner operating
within the State scope of practice
 Must be providing chemotherapy to oncology patients in an office
setting
 By billing the designated G-codes, the practitioner self-enrolls in the
project and agrees to all of the terms and conditions of the
demonstration project
59
The Demonstration Project
Patient reported
assessment:
Nausea and/or
Vomiting
Pain
Lack of Energy
(Fatigue)
Not at all
G9021
G9025
G9029
A little
G9022
G9026
G9030
Quite a bit
G9023
G9027
G9031
Very much
G9024
G9028
G9032
60
The Demonstration Project
During the course of the project, an additional payment
of $130 per encounter will be paid to participating
practitioners for submitting the patient assessment data.
A G-code for each patient status factor must appear on
the claim for payment to be made under the
demonstration project. Three codes are required, one
from each symptom category. Claims without three
codes will be denied.
61
The Demonstration Project
CMS will pay based on the lesser of 80% of the actual
charge or the allowance by code:
 G9021 – G9024
 G9025 – G9028
 G9029 – G9032
$43.34
$43.33
$43.33
These services are paid on an assignment basis and the
usual Part B coinsurance and deductible apply.
62
The Demonstration Project
The three symptom codes (one from each category)
should be reported on the same claim and for the same
date of service as either a chemotherapy infusion
(G0359) or a chemotherapy push (G0357).
The patient must have a cancer diagnosis.
The place of service is office (11).
Only Medicare beneficiaries who are NOT enrolled in a
Medicare Advantage plan are included within the
demonstration project.
63
Demonstration Project - Your “To Do” List
Use these codes for ALL Medicare patients receiving
chemotherapy (except Medicare Advantage patients)
Put systems in place in your office for 2005 to:
 Identify appropriate patients
 Determine who will obtain this information (MD, nurse,
MA, other staff member)
 Establish a process for documentation and billing
 Update your office tools as needed
Be proactive with your non-Medicare payers – discuss
this program and ask about their plans
64
Putting it all together…
Carboplatin/Docetaxel regimen
 Carboplatin 600 mg. over 45 minutes
 Docetaxel 135 mg. over 60 minutes
 Dexamethasone 20 mg. infused over 15 minutes
 Ondansetron 24 mg. infused over 15 minutes
 Epo 40,000 units on the day of treatment
 Participating in Demo Project
65
Medicare allowable
Carboplatin/Docetaxel 2004
(% of AWP)
IV infusion, up to one hour
90780
(incl 32%)
(Dexamethasone, ondansetron)
Chemo infusion, up to one hour
96410
$217.35
(incl 32%)
(Carboplatin, Docetaxel)
Chemo infusion, ea add’l hour
$117.79
96412
$48.30
(incl 32%)
Carboplatin 50 mg x 12
J9045
$1621.80
Docetaxel 20 mg x 7
J9170
$2109.80
Dexamethasone 1 mg x 20
J1100
$2.00
Ondansetron 1 mg x 24
J2405
$133.92
Erythropoietin 1000 u x 40
Q0136
$464.80
Therapeutic or diagnostic injection
90782
0
$4,715.76
66
Medicare allow
Carboplatin/Docetaxel 2005 – Q1
(Q3 ASP)
Chemo IV inf, single/initial drug, initial hour (carboplatin)
G0359
$177.60
(incl 3%)
Ea add’l seq admin infused chemo drug, up to 1 hr
G0362
$86.65
(incl 3%)
G0354
$27.72
(incl 3%)
Ea add’l seq. IV push tx drug (short infusion) (ondansetron)
G0354
$27.72
(incl 3%)
Carboplatin 50 mg x 12
J9045
$1505.64
Docetaxel 20 mg x 7
J9170
$2083.06
Dexamethasone 1 mg x 20
J1100
$2.80
Ondansetron 1 mg x 24
J2405
$89.52
Erythropoetin 1000 u x 40
Q0136
$407.20
Therapeutic or diagnostic injection (epo)
G0351
$19.13
(docetaxel)
Ea add’l seq. IV push tx drug (short infusion)
(dexamethasone)
$4,427.04
Demonstration project (G9021 – G9032)
6.12% ↓
$130.00
$4,557.04
3.36% ↓
67
Medicare allow
Carboplatin/Docetaxel 2005 – Q2
(Q4 ASP)
Chemo IV inf, single/initial drug, initial hour (carboplatin)
G0359
$177.60
(incl 3%)
Ea add’l seq admin infused chemo drug, up to 1 hr
G0362
$86.65
(incl 3%)
G0354
$27.72
(incl 3%)
Ea add’l seq. IV push tx drug (short infusion) (ondansetron)
G0354
$27.72
(incl 3%)
Carboplatin 50 mg x 12
J9045
$909.00
Docetaxel 20 mg x 7
J9170
$2069.83
Dexamethasone 1 mg x 20
J1100
$2.80
Ondansetron 1 mg x 24
J2405
$89.52
Erythropoetin 1000 u x 40
Q0136
$392.40
Therapeutic or diagnostic injection (epo)
G0351
$19.13
(docetaxel)
Ea add’l seq. IV push tx drug (short infusion)
(dexamethasone)
$3,802.37
Demonstration project (G9021 – G9032)
19.3% ↓
$130.00
$3,932.37
16.6% ↓
68
Another example
CHOP/Rituxin
 Cytoxan 1850 mg over 45 minutes
 Adriamycin 90 mg IV push
 Vincristine 2 mg IV push
 Rituxin 700 mg over several hours, reaction at 1 hour,
infusion stopped then resumed
 Decadron, Aloxi, Benedryl
 Participating in Demo Project
69
Medicare allowable
CHOP/Rituxin 2004
(% of AWP)
IV infusion, up to one hour (Decadron)
90780
$117.79
IV infusion, ea additional hour
(hydration after reaction)
90781
$33.02
Chemo infusion, up to one hour (Cytoxan)
96410
$217.35
Chemo infusion, ea add’l hour
(Rituxin, 1 hr before reaction, 3 hrs after reaction)
96412 x 4
$193.20
Chemo IV push (Adriamycin, Vincristine)
96408 x 2
$309.52
Decadron 20 mg.
J1100 x 2
$2.00
J2469
$202.51
J9000 x 9
$73.44
Vincristine 2 mg.
J9375
$60.81
Cytoxan 1850 mg.
J9070 x 19
497.47
Rituxin 700 mg.
J9310 x 7
$3,068.66
Benadryl 50 mg.
J1200
$1.43
Saline 500 ml.
J7040
$5.64
Aloxi 0.25 mg.
Adriamycin 90 mg.
$4,382.84
70
Medicare allow
CHOP/Rituxin 2005 – Q1
(Q3 ASP)
Chemo IV inf, single/initial drug, initial hour
(Cytoxan)
G0359
$177.60
Ea add’l seq admin infused chemo drug, up to 1 hr
(Rituxin)
G0362
$86.65
G0360 x 3
$120.60
G0349
$43.72
Ea add’l seq. push, therapeutic (Aloxi, Benadryl)
G0354 x 2
$55.44
Ea add’l seq. push, chemo (Adriamycin, Vincristine)
G0358 x 2
$146.00
Ea add’l hour, hydration (after reaction)
G0346-59
$20.69
Ea add’l hr of chemo infusion (Rituxin)
Ea add’l seq. infused tx drug, up to one hour
(Decadron over 25 minutes)
Continued…
71
Medicare allow
CHOP/Rituxin 2005 – Q1
Decadron 20 mg.
(Q3 ASP)
J1100 x 2
$2.80
J2469
$182.20
J9000 x 9
$38.25
Vincristine 2 mg.
J9375
$7.00
Cytoxan 1850 mg.
J9070 x 19
$44.65
Rituxin 700 mg.
J9310 x 7
$3,094.07
Benadryl 50 mg.
J1200
$0.94
Saline 500 ml.
J7040
$0.05
Aloxi 0.25 mg.
Adriamycin 90 mg.
$4,020.66
Demonstration Project
8.27% ↓
$130.00
$4,150.66
5.3% ↓
72
Medicare allow
CHOP/Rituxin 2005 – Q2
(Q3 ASP)
Chemo IV inf, single/initial drug, initial hour
(Cytoxan)
G0359
$177.60
Ea add’l seq admin infused chemo drug, up to 1 hr
(Rituxin)
G0362
$86.65
G0360 x 3
$120.60
G0349
$43.72
Ea add’l seq. push, therapeutic (Aloxi, Benadryl)
G0354 x 2
$55.44
Ea add’l seq. push, chemo (Adriamycin, Vincristine)
G0358 x 2
$146.00
Ea add’l hour, hydration (after reaction)
G0346-59
$20.69
Ea add’l hr of chemo infusion (Rituxin)
Ea add’l seq. infused tx drug, up to one hour
(Decadron over 25 minutes)
Continued…
73
Medicare allow
CHOP/Rituxin 2005 – Q2
Decadron 20 mg.
(Q3 ASP)
J1100 x 2
$2.80
J2469
$180.80
J9000 x 9
$48.51
Vincristine 2 mg.
J9375
$5.92
Cytoxan 1850 mg.
J9070 x 19
$36.10
Rituxin 700 mg.
J9310 x 7
$3,078.67
Benadryl 50 mg.
J1200
$0.58
Saline 500 ml.
J7040
$0.49
Aloxi 0.25 mg.
Adriamycin 90 mg.
$4,004.57
Demonstration Project
8.63% ↓
$130.00
$4,134.57
5.66% ↓
74
20% Co-insurance Decreases…
A Plus for Our Patients
Regimen
2004
Medicare
Allowable
Carboplatin/
Docetaxel
$4,715.76
CHOP/Rituxin
$4,382.84
2004
20%
$943.15
2005 – Q2
Medicare
Allowable
2005
20%
Includes Demo
Project
Includes Demo
Project
$3,932.37
$786.47
16.6% ↓
$876.56
$4,134.57
$830.13
5.66% ↓
75
MMA 2005 - FAQs
How are the “each additional hour” and the “additional
sequential drug” codes different?
 Several codes have been added for “additional
sequential drugs.” These codes are intended to
recognize the additional work and practice expense
associated with the provision of multiple drugs. The
“initial” code refers to the first drug/agent administered
and the “additional sequential drug” codes should be
used for each drug provided after the first. The “each
additional hour” codes should be reported if a particular
drug is infused for more than one hour and 30 minutes.
76
FAQs
Do we need to use the -25 modifier to report E & M visits
conducted on the same day as chemotherapy?
 CMS continues to require that the -25 modifier be attached
to E & M services provided on the same day as
chemotherapy. Significant, separately identifiable E & M
services will be paid if appropriate documentation is
provided. Additional documentation beyond what is
outlined in the 1995 or 1997 E & M guidelines should not
be required by your carrier. For E & M services provided
on the same day, a different diagnosis is NOT required.
77
FAQs
If multiple injections of the same drug are given because
of clinical protocol or package insert instructions, can
both injections be reported? For example, the package
insert for Vidaza states “doses greater than 4 mL should
be divided equally into 2 syringes and injected into 2
separate sites?
 CMS has responded to this question and said that they will
defer to local carriers on this policy as local carriers are
responsible for decisions regarding reasonableness and
medical necessity. Check with your local carrier for their
policy.
78
FAQs
If an electrolyte is not prepackaged and requires mixing
before infusion, is this included in the hydration codes or
can it be billed using the therapeutic/diagnostic infusion
codes?
 According to CMS electrolytes that are prepackaged or
mixed are reported using the hydration codes (G0345,
G0346).
79
FAQs
Can a level one office visit be billed on the same day as
chemotherapy?
 No. Under Medicare, a level one office visit (99211)
cannot be billed on the same day as chemotherapy.
After CMS adopted this policy for 2004, ASCO
requested reconsideration. However, CMS has not
changed its position. If appropriate documentation can
be provided, a higher level office visit may be billed.
 Also, CMS has clarified that 99211 may not be billed
with diagnostic or therapeutic injections codes in 2005.
80
FAQs
I understand that the code changes include clarification
of reporting times for infusion codes. Is that true?
 Yes. Reporting times for infusion codes (hydration, nonchemotherapy infusions, and chemotherapy infusions)
have been clarified as follows:
 After the first hour of infusion, round infusion times to
the nearest 30 minutes. For 30 minutes or less, round
down. For greater than 30 minutes, round up.
continued…
81
FAQs
Example…
 If you infuse one chemotherapy drug for 1 hour, 45
minutes, you would bill:
G0359
Chemo IV infusion, initial hour
G0360
Chemo IV infusion, ea add’l hour
 Start the timing over when you switch to a different drug
(e.g. another chemotherapy agent or anti-emetic)
82
FAQs
If a patient is infused with saline concurrent with
infusion of a chemotherapy drug, can the hydration be
billed separately?
 No. Hydration may be billed separately only if it is given
prior to chemotherapy infusion or subsequent to drug
infusion. If hydration is provided to facilitate drug
delivery, then it is considered incidental to that infusion
and is not separately billable.
83
FAQs
Do we need to use a -59 modifier to report multiple
infusion services?
 ASCO’s interpretation is that the -59 modifier is not
needed to report multiple infusion services since the
code descriptors now provide clear differentiation
between the first and subsequent drugs.
 The -59 modifier should continue to be used to report
hydration prior to or subsequent to chemotherapy
administration.
84
FAQs
Do we need to use the -59 modifier to bill for hydration
provided on the same day as chemotherapy?
 Yes. The -59 modifier should be used to indicate that
hydration was provided prior to or following
chemotherapy. Hydration provided at the same time as
chemotherapy to facilitate drug delivery is not
separately reportable.
85
FAQs
In the past, CMS has not covered injections when
provided on the same day as other services. Has CMS
revised its policy on injection payments?
 Yes. Effective January 1, 2005, Medicare will now pay
separately for non-chemotherapy injections and IV
pushes even if another service is billed that day.
Therefore, codes G0351-G0354 will be eligible for
separate payment.
86
FAQs
When we have tried to bill prolonged and critical care
service codes, they are frequently denied or our carrier
requires significant document. What is ASCO’s advice?
 ASCO has urged that CMS a) remind carriers that codes for
prolonged and critical care services can be billed in the
office setting, b) recognize time spent with the patient (as
documented in nursing notes) and a brief description of
the problem as sufficient documentation to support billing
for critical care services, c) eliminate pre-payment reviews
or pre-payment demands for documentation with respect
to these services, and d) restrict post-payment audits for
these services to situations where they appears to be a
pattern of excessive use.
87
FAQs
Are the new G codes for drug administration available
for services provided in the outpatient hospital setting?
 No. The new drug administration codes are to be used
in the office setting only.
88
FAQs
Will the Medicare codes for 2005 mirror the 2004 CPT
code?
 No. The changes reflected in the new G codes will not
be published as CPT codes until 2006.
89
What about 2006?
Competitive Acquisition Program (CAP) is planned
 Proposed rule published on 3/4/05
 This is not a mandatory program; physicians will
choose ASP + 6% or CAP
 Proposed rule discusses phase-in period beginning
1/1/06; categories of drugs still to be determined
 Significant paperwork requirements
 ASCO’s summary of the rule can be accessed at:
http://www.asco.org/asco/downloads/ASCO_CAP_S
ummary.pdf
90
What about 2006?
Comments on the CAP program must be submitted by
April 26, 2005
 Submit your questions and concerns independently or
to ASCO for inclusion in ASCO’s comments
 Email to [email protected]
G codes will transition to CPT codes
 New codes and definitions will be published in CPT
 Most private payers are expected to convert to the new
codes at this time
Demonstration Project ???
91
More “To Do”…
Stop billing leaks
 Capture all service charges





E&M
Chemotherapy administration
Therapeutic Infusion
Laboratory
Documentation is critical
 Don’t lose any drug charges!
 Chemotherapy
 Supportive care
92
More “To Do”…
Understand rule changes
 Document and bill by the rules (CMS, AMA)
 Disseminate billing and coding information in your
practice
 Update drug pricing/charges ASAP
 Update fee schedule, superbill at least yearly
 Don’t miss any billing opportunities
Ensure that your documentation is complete, especially
nursing documentation for the new administration codes
93
More “To Do”…
Financial consultation
 Know your patients insurance status BEFORE
treatment
 Identify co-pay, co-insurance problems
 Have a plan for indigent care





local/state resources
pharmaceutical companies
www.needymeds.com
www.helpingpatients.org
www.rxassist.org
94
Role of the Physician
Practice Leader
Stay current on the moving target of Medicare rules and
regulations
Reinforce to your partners the importance of Medicare
compliance
A great resource is the CMS Carrier Advisory website,
and the CAC website
Work with your state society to establish productive
relationships with your Medicare carrier and commercial
payers
Support your Practice Administrator as they implement
policies to deal with these changes
95
Role of the Administrator
Update your coding books, reference materials, fee
schedule, charge ticket annually or as changes occur
Ensure that your staff is knowledgeable about
reimbursement issues for all payers
Establish and implement policies to immediately
respond to changes as they occur
Enroll in Medicare list serves to stay up-to-the-minute
on changes
Work cooperatively with your physician leader in
providing leadership for your staff in this challenging
environment
96
Know Your Medicare Carrier
Carrier Website
Carrier Medical Director
Carrier Contact Information
 Subscribe to your carrier’s listserv
 Circulate carrier bulletins to staff
97
The CMS Website…www.cms.hhs.gov
To access the Physician page…
 www.cms.hhs.gov/physicians/
To access manuals…
 www.cms.hhs.gov/manuals/
To access the Drug Pricing page…
 www.cms.hhs.gov/providers/drugs/default.asp
98
Know Medicare Nationally
99
Know Medicare Nationally
100
ASCO Resources
“Practical Tips for the Practicing Oncologist”
3rd edition
“Practical Tips for the Practicing Oncologist”
Supplement for 2005… coming soon
Ask a Coding Question:
Call 703-299-1050 or
Email [email protected]
101
ASCO Resources
www.asco.org/MMA
 Look for the FAQs - updated as new
information is available
www.asco.org/CAC
 A great resource for information on the
Medicare Carrier Advisory Committee process
102