What’s New Right Now

Bobbi Buell July 2008

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 2008-2009  Show impact of new reimbursement changes on services that you bill every day  Explain all applicable coding changes  Explain other changes  Discuss optimal strategies.

July 1, 2008 Medicare Payment

 Senate Democrats and nine Republican senators were unable to muster the 60 votes needed to bring the Medicare Improvements for Patients and Providers Act of 2008, S. 3101 6-17-08. This would have prevented 7/1/08 cuts.

 Sen. Ted Kennedy returned to the Senate for his vote. Nine Republicans flipped their vote. The bill passed, but a veto is expected.

 Payments are frozen until July 14

July 1, 2008: Medicare Payment

 What did the bill say?

  0.5% increase would last for the next six months- -there is no change.

5.4% decrease for next year avoided and there will be a 1.1% increase.

 It did not  Provide relief from the distributors’ prompt pay discount.

July 1, 2008: Medicare Payment

 What will happen?

  Claims will be released Coinsurance should be adjusted.

  Things should go back to normal with no readjustments.

Radiopharmaceuticals will be paid separately in hospital outpatient.

 What is dubious  Physician scarcity payments  GPCI floor

Physician Quality Reporting Initiative (PQRI)



Quality Measures

 66 “2007 PVRP” quality measures posted on December 5, 2006 adopted in statute    8 additional measures added, as allowed by statute for a final list of 74 PQRI for 2007.

119 are valid for 2008.

Two reporting periods: calendar year and last six months starting July 1.

circumstances… You can only report starting July 1, 2008 under certain

2008 PQRI: The Medicare, Medicaid, and SCHIP Extension Act of 2007 (MMSEA)

MMSEA authorized continuation of PQRI for 2008 • Eliminated cap on incentive payment • • Incentive payment remained 1.5% of total allowable charges for PFS covered professional services furnished during reporting period Required alternative reporting periods and alternative reporting criteria for 2008 and 2009.

2008 Reporting Options Overview

 Two Reporting Periods   12 months (January 1 - December 31, 2008) 6 months (July 1 - December 31, 2008)  Total of 9 PQRI Reporting Methods   3 claims-based 6 registry-based

Physician Quality Reporting Initiative (PQRI) Participation Decision Tree I WANT TO PARTICIPATE IN 2008 PQRI FOR INCENTIVE PAYMENT

(Select Reporting Method)

CHOOSE CLAIMS-BASED REPORTING OPTIONS

REGISTRY REPORTING < 3 MEASURES APPLY ONLY OPTION IS TO REPORT CLAIMS FOR

12-MONTH

REPORTING PERIOD 1/1/08-12/31/08 REPORT EACH MEASURE

≥ 80%

OF APPLICABLE PATIENTS Subject to Measure-Applicability Validation (MAV) CHOOSE TO REPORT ON ≥ 3 MEASURES FOR

12 MONTHS

1/1/08-12/31/08 REPORT

≥ 80%

OF APPLICABLE PATIENTS ON AT LEAST 3 MEASURES 3 OR MORE MEASURES APPLY CHOOSE TO REPORT

MEASURES GROUP

FOR

6 MONTHS

7/1/08-12/31/08 REPORT

≥ 80%

OF ELIGIBLE PATIENTS FOR A MEASURES GROUP THE FULL 6 MONTHS REPORT 100% OF

15 CONSECUTIVE

ELIGIBLE PATIENTS ANYTIME WITHIN 6 MONTHS

6

CLAIMS-BASED REPORTING

I WANT TO PARTICIPATE IN 2008 PQRI FOR INCENTIVE PAYMENT

(Select Reporting Method)

CHOOSE REGISTRY-BASED REPORTING OPTIONS

CHOOSE TO SUBMIT DATA ON

80%

OF ELIGIBLE PATIENTS ON AT LEAST 3 MEASURES CHOOSE TO REPORT

12 MONTHS

1/1/08-12/31/08 CHOOSE TO REPORT

6 MONTHS

7/1/08-12/31/08 CHOOSE TO SUBMIT DATA ON

MEASURES GROUP

SUBMIT DATA ON 100% OF

30 CONSECUTIVE

ELIGIBLE PATIENTS WITHIN 12 MONTHS SUBMIT DATA ON

80%

OF APPLICABLE PATIENTS FOR THE MEASURES GROUP SUBMIT DATA ON 100% OF

15 CONSECUTIVE

ELIGIBLE PATIENTS WITHIN 6 MONTHS SUBMIT DATA ON

80%

OF ELIGIBLE PATIENTS FOR A MEASURES GROUP SUBMIT

12 MONTHS

1/1/08-12/31/08 SUBMIT

6 MONTHS

7/1/08-12/31/08

7

Physician Quality Reporting Initiative (PQRI)

 Determination of Successful Reporting   Reporting thresholds   If 4 or more measures apply, at least 3 measures must be reported for at least 80% reportable… of the cases in which the measure was Analysis is expected to be performed at the individual level for the payment.

 If there are no more than 3 measures that apply , each measure must be reported for at least 80% of the cases in which a measure was reportable. You can report less than 3 measures but those are subject to statistical validation.

Requires accurate and consistent use of individual National Provider Identifier (NPI) on claims

Physician Quality Reporting Initiative (PQRI)

 Bonus Payment      Participating eligible professionals who successfully report may earn a 1.5% bonus.

 1.5% bonus calculation based on total allowed charges during the reporting period for professional services billed under the Physician Fee Schedule . Bonus payments will be made in a and mid-2009. You must register on the web site now for 2007.

lump sum in mid-2008 Bonus payments will be made to the holder of record of the Taxpayer Identification Number (TIN) No beneficiary coinsurance No Medicare Advantage patients

2007 PQRI Incentive Payments

 Incentive payments for satisfactory 2007 reporting issued mid-late July, 2008  Electronically or via check  Payment made to Taxpayer Identification (Tax ID Number or TIN) under which claims were paid  i.e. Physician Fee Schedule (PFS) charges for period show up on 1099 IRS form  Payments for individual professionals whose billings are paid to another TIN are rolled up to TIN

2007 PQRI Incentive Payments

(ctd.)

 Payments to TINs billing through multiple Carriers/Medicare Administrative Contractors (MACs) may be split among Carriers/MACs  TINs will receive Remittance Advice (RA)  Feedback reports available separately

2007 PQRI Incentive Payments

(ctd.)

 Lump-Sum Incentive Payment Calculations  1.5% incentive based on CMS’ estimate of all allowed charges for covered services:  During 2007 reporting period  Submitted to Carrier or A/B MAC by February 29, 2008     Paid under Medicare Physician Fee Schedule (PFS) at TIN level Incentive payment calculation each eligible professional’s (EP’s) NPI within TIN reports 3+ measures >80% of reporting opportunities.  1 or 2 measures reported >80% of opportunities additional applicable measures – and EP not found by MAV process to have been required to submit – the EPI’s NPI/TIN is eligible for an incentive payment Analysis performed at individual NPI within TIN EPs may earn incentives under multiple TINs

2007 PQRI Incentive Payments

(ctd.)

 2007 payment caps  Calculated at individual EP-level within TIN by multiplying:  Total instances of reporting quality data for all reported measures (not limited only to measures meeting the 80% threshold), by  300%, and by  CMS national average-per-measure payment amount (one value for all measures and all participants)

2007 PQRI Incentive Payments

(ctd.)

 Questions about issuance of any incentive payment participants may have earned should be directed to Carrier/MAC Call Center  See Provider Call Center Toll-Free Numbers Directory at: http://www.cms.hhs.gov/MLNGenInfo/01_Overvie w.asp

2007 PQRI Feedback Reports

   At organization or individual level only those with 2007 PFS professional service paid charges

and

at least one participating EP (with National Provider Identifier or NPI) with ≥1 valid quality-data code (QDC) will have feedback reports Reports accessible through a secure, on-line mechanism Available mid-July, 2008

2007 PQRI Feedback Reports

(ctd.)

 In Adobe ® Acrobat ® PDF format (readable by software available free online)  Include:   TIN-level reporting and financial information Individual professional-level reporting if submitted at least one valid 2007 QDC   Individual-level performance information National-average performance comparison information

To Access Reports

 Each organization or individual will need to register in “IACS” (Individuals Authorized Access to CMS Computer Services)  On-line application used to register and provision authorized users, including PQRI participants, for access to CMS business applications and systems  IACS process is free

To Access Reports

To access reports obtain IACS account  Individuals  Those who do not reassign Medicare benefits to another party (such as employer, partnership or group) and will access PQRI reports personally  Organizations  Those who receive reassigned payments (such as employer partnership or group) from individual professional

To Access Reports

 Register in “IACS”  Group (Organization)  Individual professional  Group (Organization)  Delegated authority model  Security Official  User Group Administrator  End users  Individual  Register directly

To Access Reports

 Individual professionals who receive their own payments and will access PQRI report personally  Register in IACS online   Requires Provider Enrollment and Chain Ownership System (PECOS) enrollment Those enrolled Nov 2003 or after should be in PECOS  Those not in PECOS need to complete enrollment form  Organizations  Delegated authority model for security

To Access Reports

 IACS Registration for Organizations  Security Official (SO)   One SO needed for the organization (TIN) SO not specific to PQRI, cannot access PQRI data/report    SO approves User Group Administrator (UGA) registration UGA approves End User registration SO can authorize UGA and End User to access PQRI report

IACS Registration

  CMS Application website  https://applications.cms.hhs.gov

Registration   Online process for solo practitioners accessing their own information on their behalf Online process with some follow-up for group practices and/or solo practitioners wanting other person(s) to access information on their behalf

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. .

On March 18, 2008, CMS awarded the J13 A/B MAC contract to National Government Services (NGS). As the J13 A/B MAC, NGS will immediately begin implementation activities and will assume responsibility for the work no later than November 2008. A Background Sheet and Qs & As related to the award are available at the A/B MAC Procurement and Implementation link to the left. On May 06, 2008, CMS awarded the J2 A/B MAC contract to National Heritage Insurance Corporation (NHIC). However, on May 27, 2008 a protest against the award was filed 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 September 2, 2008. In accordance with the Competition in Contracting Act (CICA), the filing of the protest triggered an automatic stay on performance of the NHIC's contract pending GAO's decision.  Any inquiries concerning these RFPs should be directed to the contracting officers

                  

Cancer ICD-9-CM Codes

 

10/1/08

199.2 Malignant neoplasm associated with transplant organ

New fifth digits for MM, leukemia--0, 1, 2

 0: without mention of having achieved remission, failed remission; 1: in remission, 2: in relapse 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) 249.xx: Secondary diabetes mellitus 289.84 Heparin-induced thrombocytopenia (HIT) 511.81 Malignant pleural effusion 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 (tamoxifen, etc.) V07.52 Prophylactic use of aromatase inhibitors V07.59 Prophylactic use of other agents affecting estrogen receptors and estrogen levels (fulvestrant) V87.41 Personal history of antineoplastic chemotherapy V87.42 Personal history of monoclonal drug therapy V87.49 Personal history of other drug therapy

And, there are many, more---THIS IS THE YEAR TO GET A BOOK!

Compendia Changes

 Let’s review the history of the compendia and coverage  Two compendia available to CMS and most states for coverage decisions   American Hospital Formulary Service Drug Information USP-DI  Deficit Reduction Act states that ‘successor publications’ will be accepted by Medicaid (and then Part D), i.e.

DrugPoints

  DrugDex for Medicaid This is under evaluation RIGHT NOW…

Compendia Changes

 March 20, 2006 Medicare Evidence Development and Coverage Advisory Committee (MedCAC) met to discuss compendia  ASCO recommended NCCN be added  MedCAC not really satisfied with the compendia when they compared 14 drug regimens. This has been substantiated in the printed study by the Agency for Healthcare Research and Policy (AHRQ).

 No decision was made as no publication allows for enough transparency to satisfy all criteria .

To see the printed study go to: www.cms.hhs.gov/ determinationprocess/downloads/id46TA.pdf

Compendia Changes

  Physician Payment Regulations (Proposed) 2008; NOT clearer in FR .

 Statement on USP DI: “We interpret this DRA [Deficit Reduction Act of 2005] as explicitly authorizing the Secretary to continue recognition of the compendium known as USP-DI after its name change if the Secretary determines that it is in fact a successor publication rather than a substitute publication.” page 38177,

Federal Register

, Volume 72, Number 133, July 12, 2007 What does it mean in your state? What backs up off label here?

Compendia Changes

 Physician Regulations 2008    Proposing a process for updating the compendia on an annual basis. This has been codified and is in process.

So far these have been approved…  DrugDex®   NCCN Gold Standard’s Clinical Pharmacology BUT, the regulations are not out yet!

Expansion of Peer-Reviewed Journals

 Current Journals for CMS (Possible) Off Label Coverage   American Journal of Medicine Annals of Internal Medicine   The Journal of the American Medical Association Journal of Clinical Oncology          Blood Journal of the National Cancer Institute The New England Journal of Medicine British Journal of Cancer Cancer Drugs European Journal of Cancer Lancet Leukemia

Expansion of Peer-Reviewed Journals

 In Transmittal 78, CR 5729, list was expanded to include:       Annals of Oncology Biology of Blood and Marrow Transplantation Bone Marrow Transplantation Gynecological Oncology Clinical Cancer Research International Journal of Radiation, Oncology, Biology, and Physics      Journal of NCCN Radiation Oncology Annals of Surgical Oncology Journal of Urology Lancet Oncology

Proposed MPFS Regulations 2009

 Was 5.4% decrease. This has gone to a 1.1% increase, if the bill is passed as expected.

 G0332 can no longer be used for IVIG. Medicare thinks you are doing okay.

 CMS adds more codes to multiple imaging reduction set. This now includes MRI of the breast 77058 77059.

 PE transition continues with more consideration for high cost supplies. Changes to codes 96440, 96445, 96450, and 96542--mostly not good.

Proposed MPFS 2009

     Reconfiguration of payment localities for GPCIs.

WAMP/AMP thresholds stay the same.

There will be new G-codes for telehealth follow-up consults. These CPT codes were deleted but do apply to telehealth.

There will be new HCPCS codes for prostate saturation biopsy.

CAP changes:  NPPs may participate in CAP   Drugs may be moved between satellites Drugs may not be shipped to physicians who have been suspended.

Proposed MPFS 2009

    Nurse Practitioner qualification standards may change in that anyone who registered as an NP on or after 1/1/2003 with Medicare must be an RN in their state, registered as an NP, and has a Masters’ degree.

CMS will take tougher action against those who fail to report legal actions against them. This may or may not include IRS actions.

Ordering and referring information in records must be maintained for 10 years.

Physician certification and recertification of Home Health Care will now require active physician involvement. Want feed-back on this one.

Proposed MPFS 2009

 Two possible approaches to enrollment…now CMS believes there is too big of a window:  Cannot bill until your date of ENROLLMENT   Cannot bill until date of application OR started billing at a new practice location. But, if it is denied, you are out the $$$.

PECOS system will be open to most states by “early” 2009 and to California, missouri, and New York by September, 2009.

Anti-Markup Rule

 Back again for 2009--No markup on -PC    First approach, this would only apply if the billing physician and performing physician do not “share a practice”.

Second approach, this would apply if the billing and performing physicians are in the same “site” or building. For the -TC, they would have to be in the same suite CMS wants your comments.

Proposed MPFS 2009

 Shared arrangements      Sometimes known as gain-sharing CMS wants to encourage due to current Demonstration Projects Must be five or more physicians participating Patients must be told about the the program.

Programs must last 1-3 years.

Proposed MPFS 2009

              Medicare wants ANY practices that is performing diagnostic services (except mammography) to enroll as an IDTF meaning Must have comprehensive liability insurance of at $300,000 per facility.

Must respond to beneficiary questions and complaints.

Post these standards openly.

Enroll each location.

Have a visible sign showing business hours.

Limiting a supervising physician to providing general supervision to no more than three IDTF sites. Requiring a supervising physician to prove proficiency in the performance and interpretation of each type of diagnostic procedure furnished in the office Keeping equipment calibrated, maintaining it as indicated in the manual, and maintaining an inventory of diagnostic testing equipment Complying with all applicable federal and state licensure and regulatory requirements for the health and safety of patients Providing complete and accurate information on Medicare enrollment applications, and reporting to the administrative contractor any changes in ownership, location, and general supervision, as well as any adverse legal actions, within 30 days. Other changes to information on the enrollment application would have to be reported within 90 days.

Maintaining a physical facility with space for equipment appropriate to the services designated on the enrollment application, adequate patient privacy accommodations, and storage of both business records and current medical records within the office setting Maintaining a primary business phone under the name of the physician or NPP Having proper storage for medical records and being able to retrieve medical records upon request from CMS or its fee-for-service contractor within two business days Permitting unannounced and on-site inspections to confirm compliance with these standards.

Proposed MPFS 2009

 PQRI  The rule proposes a total of 175 measures for reporting under the Physician Quality Reporting Initiative (PQRI) in 2009, an increase of 56 measures from 2008, including three new measures related to diagnostic radiology. The proposed rule would allow claims based reporting either for individual measures or for Measures Groups (i.e. Preventive Care, Perioperative Care). CMS is also proposing to conduct another self-nomination process so that additional registries can submit quality measures data. In addition, if the 2008 Measure Testing Process is successful, CMS proposes to begin accepting data from Electronic Health Records (EHRs) for a limited subset of the proposed 2009 PQRI quality measures starting Jan. 1, 2009. Finally, Congress has not yet specifically authorized funding for bonus payments in 2009 and the proposed rule includes no provisions for bonus payments to clinicians that successfully reporting.

Proposed MPFS 2009

  New Cancer Measures Proposed    Melanoma--Follow Up Aspects of Care Melanoma--Continuity of Care and Recall Melanoma--Coordination of Care     Cancer Care--Medical and Radiation--Plan of Care for Pain Cancer Care---Pain Intensity Quantified Radiation Oncology--Radiation Dose Limits to Normal Tissue Cancer Care---Recording of Clinical Stage for Lung Cancer and Esophageal Cancer Gone for Next Year--Measures #74 and #103

Preview of Next Month

 New Requirements for ESAs  Calculation of MPFS impact in Oncology  More ICD-9?

“To Do” List

 Get A/R back in shape.

 Watch for Compendia Rule.

 Watch for the change in ESA labeling.

 Get a new ICD-9-CM book.

 Respond to the Proposed MPFS.

 Be happy we did not take a 10.6% cut…

Contact Info

 Contact    [email protected]

[email protected]

800-795-2633  Newsletter is free!