Advanced Workshop for Oncology Regulations, Billing and ...

Advanced Workshop for Oncology Regulations, Billing and ...

Whitewater Management Successfully Navigating Oncology Management in Turbulent Times Disclaimer This should not be the only source used for coding and billing. All coding and billing decisions should be made on a case-by-case basis based upon documentation and insurance guidelines. All information contained herein is valid for the date of this seminar only. This presentation is based on national guidelines. Your Medicare Carrier may differ. Many coding guidelines are currently unknown. Check your Carriers web sites as often as possible for changes. This presentation is a summary only. For Medicare regulations, see www.cms.hhs.gov or your local Medicare web site. Nothing in this presentation instructs practices on how to set charges for products and services. 03/02/20

CPT Codes American Medic al Association. All right 2 Meeting Agenda Medicare Regulations 2005-2006: Part B Office Medicare Drug Admin Coding 2005-2006 Other Medicare Initiatives 2005-2006 ICD-9-CM for 2006 Commercial Insurance Changes 2005 Survival Strategies 2005-2006 Ready! Set! Go for 2006! 03/02/20 CPT Codes American Medic al Association. All right 3 Medicare Regulations 2005-2006

Office Based Oncology Presentation References Medicare Physician Fee Schedule Final Rule, November 15, 2004 and Proposed Rule for 2006 Transmittals #129-OTN, 12/10/04 #14, CR 3670, 12/30/04 #148, 4/15/05 ASCO (www.asco.org) Special alerts Presentations AMA Posting of Codes for 2006 03/02/20 CPT Codes American Medic al Association. All right 5 Medicare Fee Schedule Review

Work RVUs Practice Expense RVUs Malpractice RVUs GPCIs Conversion Factor ((WRVUs *WGPCI)+(PERVUs * PEGPCI)+ (MALRVUs * MALGPCI)) X The Conversion Factor = Medicare Fee Schedule Amount 03/02/20 CPT Codes American Medic al Association. All right 6 Medicare Physician Fee Schedule

Medicare Conversion Factor Bumped Up $37.8975 is the CFpublished 11/15/04 and effective 1/1/05. 2006 Conversion Factor Still slated to decrease 4.3% Impacts 875,000 physicians Caused by the SGR sometimes known as the Medicare boomerang Includes Part B drugs, which are not a fee schedule item. For physicians that give drugs, this is the double hit. 03/02/20 CPT Codes American Medic al Association. All right 7 Medicare Fee Schedule 2006 Proposed Rule: Impact on Oncologists Rule states an 8.1% increase in revenue based upon VOLUME INCREASE

The real truth about profit 4.3% decrease due to the conversion factor for all fee schedule services 3.0% gross decrease (for drug admin) due to drug administration transition 15.0% decrease due to lack of Demo So far, very few RVU changes in drug administration CMS projects this to be a 5.6% decrease overall in the the PR. 03/02/20 CPT Codes American Medic al Association. All right 8 Proposed Regulations Other components Multiple imaging codes -TC component will be reduced by 50% These codes must fall into the same family MRI, MRA, CT, CTA, Ultrasound Hard on physicians that own their

own equipment/free-standing imaging 03/02/20 CPT Codes American Medic al Association. All right 9 Proposed Regulations Other Components Application of Stark to Nuclear Medicine in office Group practice exceptions apply as they do in other ancillary services. Check with your attorney if you are in a Joint Venture. 03/02/20 CPT Codes American Medic al Association. All right 10

Proposed Regulations Other components ASP drug pricing tightened up. Will reportedly have no impact overall revenue (according to CMS). But, studies by the Office of Inspector General are ongoing for market pricing. Thus, some drug pricing will change based on this formula: FOR SINGLE SOURCE DRUGS, the ASP will be the lower of ASP plus 6% or WAC plus 6%. For BOTH single source drugs and multi-source, ASP will be compared to WAMP or AMP. In 2005, if the ASP exceeds WAMP or AMP by 5%, the payment will be the lesser of WAMP or 103% of AMP. In 2006, this threshold will change Opting out of Medicare provisions are shored up in terms of penalties. Opting out is not really an option for many (if any practices) 03/02/20 CPT Codes American Medic al Association. All right 11

Recent Developments OIG Report: Adequacy of Medicare Part B Drug Reimbursement to Physician Practices for the Treatment of Cancer Patients September 2005 House Resolution 261 that urged CMS to extend the oncology demonstration project beyond 2005 passed October 6, 2005 OIG report in response to Grassley letter states concerns re: cost, beneficiary liability, utility of data collected, and perceived disparity between level of physician reimbursement & services provided. October 14, 2005 03/02/20 CPT Codes American Medic al Association. All right 12 Coding for Cancer Services 2005 03/02/20

CPT Codes American Medic al Association. All right 13 Medicare Physician Fee Schedule 2005 Drug Administration Coding (Revised 4/15/2005, effective 3/15/05) General Principals One INITIAL code per day is the one that best describes the service that the patient is having that day. Before/after infusions and pushes must always be categorized as SEQUENTIAL or concurrent to sequential. Hours following EACH infusions initial hour must start over 30 minutes. Any infusion 15 OR LESS minutes is a push. One concurrent code per day (G0350) as of 5/16/05, but start now! The regulation is effective 3/15/05. Port flushes are billable IF they are the only service of the day! (G0363) 03/02/20

CPT Codes American Medic al Association. All right 14 New Drug Administration Coding Current Issues and Mysteries Billing of concurrent drugs with chemo Billing of concurrent non-chemo drugs Unbundling edits CCI Version 11.1--will other things like this happen? 03/02/20 CPT Codes American Medic al Association. All right 15 Coding for Therapeutic Infusions

2005 Code 2006 Code Description 2005 Transitio nal Payment G0345 90760 Initial Infusion, hydration, up to one hour $64.80 G0346

90761 Hydration, next 1-8 hours $20.68 G0347 90765 IV infusion for therapy/diagnosis, up to one hour $79.24 G0348 90766 IV infusion, next 1-8 hours $26.54

G0349 90767 IV infusion, additional sequential CPT Codes American Medic infusion, up to one $43.72 03/02/20 al Association. All right 16 Therapeutic Injections/Pushes 2005

Code 2006 Code Description 2005 Transitio nal Payment G0351 90772 Therapeutic or diagnostic injection $19.13 G0353 90774

IV push, non-chemo, single or initial $58.95 G0354 90775 IV push, each additional sequential push $27.71 03/02/20 CPT Codes American Medic al Association. All right 17 Chemotherapy Injections/Pushes 2005

Code 2006 Code Description 2005 Transitio nal Payment G0355 96401 Chemotherapy administration, sc or im non-hormonal $53.09 G0356 96402

Chemo admin, sc or im, hormonal $36.69 G0357 96409 Chemotherapy, IV push, initial or single $125.69 G0358 96411 Chemotherapy, IV push, each additional substance

$73.00 03/02/20 CPT Codes American Medic al Association. All right 18 Chemotherapy Infusions 2005 Code 2006 Code Description 2005 Transitio nal Payment G0359 96413

Chemotherapy, intravenous, single or initial drug, up to one hour $177.61 G0360 96415 Each additional 1-8 hours $40.21 G0361 96416 Initiation of prolonged infusion

$190.88 G0362 96417 03/02/20 Each additional sequential infusion, up to CPT Codes American Medic one hourAll right al Association. $86.66 19 Miscellaneous Chemo Procedures 2005 Code 2006 Code

Description 2005 Transition al Payment G0363 96523 Irrigation of a Venous Access Device, billed when no other drug delivery service is performed that day (T-status) $28.88 96520 96521 Refilling and/or

maintenance of a portable pump $157.31 96530 96522 Refilling and maintenance of an CPT implanted Codes American pump Medic $113.59 03/02/20 al Association. All right 20 2006 Code Descriptions Hydration, Therapeutic, Prophylactic, and

Diagnostic/Injections and Infusions Diagnostic Injections and Infusions (Excludes Chemotherapy) Physician work related to hydration, injection, and infusion services predominantly involves affirmation of treatment plan and direct supervision of staff. If a significant separately identifiable Evaluation and Management service is performed, the appropriate E/M service code should be reported using modifier 25 in addition to 90760-90779. For same day E/M service a different diagnosis is not required. If performed to facilitate the infusion or injection, the following services are included and are not reported separately: a. Use of local anesthesia b. IV start c. Access to indwelling IV, subcutaneous catheter or port d. Flush at conclusion of infusion e. Standard tubing, syringes, and supplies (For declotting a catheter or port, see 36550) 03/02/20 CPT Codes American Medic al Association. All right 21

2006 Code Descriptors Hydration, Therapeutic Injections and Infusions When multiple drugs are administered, report the service(s) and the specific materials or drugs for each. When administering multiple infusions, injections or combinations, only one initial service code should be reported, unless protocol requires that two separate IV sites must be used. The initial code that best describes the key or primary reason for the encounter should always be reported irrespective of the order in which the infusions or injections occur. If an injection or infusion is of a subsequent or concurrent nature, even if it is the first such service within that group of services, then a subsequent or concurrent code from the appropriate section should be reported (eg, the first IV push given subsequent to an initial one-hour infusion is reported using a subsequent IV push code). When reporting codes for which infusion time is a factor, use the actual time over which the infusion is administered. 03/02/20 CPT Codes American Medic al Association. All right 22

2006 Code Descriptors Hydration Codes 90760-90761 are intended to report a hydration IV infusion to consist of a pre-packaged fluid and electrolytes (eg, normal saline, D5- normal saline+30mEq KCl/liter), but are not used to report infusion of drugs or other substances. Hydration IV infusions typically require direct physician supervision for purposes of consent, safety oversight, or intraservice supervision of staff. Typically such infusions require little special handling to prepare or dispose of, and staff that administer these do not typically require advanced practice training. After initial set-up, infusion typically entails little patient risk and thus little monitoring. 90760 Intravenous infusion, hydration; initial, up to 1 hour (Do not report 90760 if performed as a concurrent infusion service) 90761 each additional hour, up to 8 hours (List separately in addition to code for primary procedure)(Use 90761 in conjunction with 90760) (Report 90761 for hydration infusion intervals of greater than 30 minutes beyond 1 hour increments) (Report 90761 to identify hydration if provided as a secondary or subsequent service after a different initial service [90760, 90765, 90774, 96409, 96413] is provided) 03/02/20 CPT Codes American Medic

al Association. All right 23 Code Descriptors 2006 Therapeutic, Prophylactic, and Diagnostic Injections and Infusions A therapeutic, prophylactic, or diagnostic IV infusion or injection (90765-90799) (other than hydration) is for the administration of substances/drugs. The fluid used to administer the drug(s) is incidental hydration and is not separately reportable. These services typically require direct physician supervision for any or all purposes of patient assessment, provision of consent, safety oversight, and intra-service supervision of staff. Typically, such infusions require special consideration to prepare, dose or dispose of, require practice training and competency for staff who administer the infusions, and require periodic patient assessment with vital sign monitoring during the infusion. Intravenous or intra-arterial push is defined as: a) an injection in which the health care 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.(Do not report 90765-90779 with codes for which IV push or infusion is an inherent part of the procedure (eg, administration of contrast material for a

diagnostic imaging study) 03/02/20 CPT Codes American Medic al Association. All right 24 Code Descriptors 2006 Therapeutic, Prophylactic, and Diagnostic Injections and Infusions 90765 Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour 90766 each additional hour, up to 8 hours (List separately in addition to code for primary procedure) (Report 90766 in conjunction with 90765, 90767) (Report 90766 for additional hour(s) of sequential infusion) (Report 90766 for infusion intervals of greater than 30 minutes

beyond 1 hour increments) 03/02/20 CPT Codes American Medic al Association. All right 25 New Codes 2006 Therapeutic, Prophylactic, and Diagnostic Injections and Infusions 90767 additional sequential infusion, up to 1 hour (List separately in addition to code for primary procedure) (Report 90767 in conjunction with 90765, 90774, 96409, 96413 if provided as a secondary or subsequent service after a different initial service. Report 90767 only once per sequential infusion of same infusate mix) 90768

concurrent infusion (List separately in addition to code for primary procedure) (Report 90768 only once per encounter) (Report 90768 in conjunction with 90765, 96413) 03/02/20 CPT Codes American Medic al Association. All right 26 Code Descriptors 2006 Therapeutic, Prophylactic, and Diagnostic Injections and Infusions 90772 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular (For administration of vaccines/toxoids, see 9046590466, 90471- 90472) (Report 90772 for non-antineoplastic hormonal therapy injections) (Report 96401 for anti-neoplastic nonhormonal injection therapy) (Report 96402 for anti-neoplastic hormonal injection

therapy) (Do not report 90772 for injections given without direct physician supervision. To report, use 99211) 90773 intra-arterial (90799 has been deleted. To report, use 90779) 03/02/20 CPT Codes American Medic al Association. All right 27 Code Descriptors 2006 Therapeutic, Prophylactic, and Diagnostic Injections and Infusions 90774 intravenous push, single or initial substance/drug (90772-90774 do not include injections for allergen immunotherapy. For allergen immunotherapy injections, see 95115-95117) 90775

each additional sequential intravenous push of a new substance/drug (List separately in addition to code for primary procedure) (Use 90775 in conjunction with 90765, 90774, 96409, 96413) (Report 90775 to identify intravenous push of a new substance/drug if provided as a secondary or subsequent service after a different initial service is provided) 90779 Unlisted therapeutic, prophylactic or diagnostic intravenous or intra-arterial injection or infusion (For allergy immunizations, see 95004 et seq) (90780 and 90781 have been deleted. To report, see 90760, 90761, 90765-90768) (90782 has been deleted. To report, use 90772) (90783 has been deleted. To report, use 90773) (90784 has been deleted. To report, use 90774) (90788 has been deleted. To report, use 03/02/20 CPT Codes American Medic al Association. All right

28 New Code Descriptors 2006 Chemotherapy Administration Chemotherapy administration codes 96401-96549 apply to parenteral administration of non-radionuclide anti-neoplastic drugs; and also to anti-neoplastic agents provided for treatment of non-cancer diagnoses (eg, cyclophosphamide for auto-immune conditions) or to substances such as monoclonal antibody agents, and other biologic response modifiers. These services can be provided by any physician. Chemotherapy services are typically highly complex and require direct physician supervision for any or all purposes of patient assessment, provision of consent, safety oversight and intra-service supervision of staff. Typically, such chemotherapy services require advanced practice training and competency for staff who provide these services; special considerations for preparation, dosage or disposal; and commonly, these services entail significant patient risk and frequent monitoring. Examples are frequent changes in the infusion rate, prolonged presence of nurse administering the solution for patient monitoring and infusion adjustments, and frequent conferring with the physician about these issues. 03/02/20

CPT Codes American Medic al Association. All right 29 New Code Descriptors 2006 Chemotherapy Administration If performed to facilitate the infusion or injection, the following services are included and are not reported separately: a. b. c. d. e. f. Use of local anesthesia IV start Access to indwelling IV, subcutaneous catheter or port Flush at conclusion of infusion Standard tubing, syringes and supplies Preparation of chemotherapy agent(s) (For declotting a catheter or port, use 36550)

03/02/20 CPT Codes American Medic al Association. All right 30 Code Descriptors 2006 Chemotherapy Administration Report separate codes for each parenteral method of administration employed when chemotherapy is administered by different techniques. The administration of medications (eg, antibiotics, steroidal agents, antiemetics, narcotics, analgesics) administered independently or sequentially as supportive management of chemotherapy administration, should be separately reported using 90760, 90761, 90765, 90779 as appropriate. Report both the specific service as well as code(s) for the specific substance(s) or drug(s) provided. The fluid used to administer the drug(s) is considered incidental hydration and is not separately reportable. When administering multiple infusions, injections or combinations, only one "initial" service code should be reported, unless protocol requires that two separate IV sites must be used. The initial code that best describes the key or primary reason for the encounter should always be reported irrespective of the order in which the infusions or injections occur. If an injection or infusion is of a subsequent or concurrent nature, even if it is the first such service within that group of services, then a subsequent or concurrent code

from the appropriate section should be reported (eg, the first IV push given subsequent to an initial one-hour infusion is reported using a subsequent IV push code). When reporting codes for which infusion time is a factor, use the actual time over which the infusion is administered 03/02/20 CPT Codes American Medic al Association. All right 31 Code Descriptors 2006 Injection and Intravenous Infusion Chemotherapy 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. 96401 Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic (96400 has been deleted. To report, see 96401, 96402)

96402 hormonal anti-neoplastic 96405 Chemotherapy administration, intralesional; intralesional, up to and including 7 lesions 96406 intralesional, more than 7 lesions 03/02/20 CPT Codes American Medic al Association. All right 32 Code Descriptors 2006 Injection and Intravenous Infusion Chemotherapy 96409 intravenous, push technique, single or initial substance/drug (96408 has been deleted. To report, use 96409) 96411 intravenous, push technique, each additional substance/drug (List separately in addition to code for primary procedure) (Use 96411 in conjunction with 96409, 96413) (96412 has been deleted. To report, use 96415) 03/02/20

CPT Codes American Medic al Association. All right 33 Code Descriptors 2006 Injection and Intravenous Infusion Chemotherapy 96413 Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug (96410 has been deleted. To report, use 96413) (96414 has been deleted. To report, use 96416) 96415 each additional hour, 1 to 8 hours (List separately in addition to code for primary procedure) (Use 96415 in conjunction with 96413) (Report 96415 for infusion intervals of greater than 30 minutes beyond 1-hour increments) (Report 90761 to identify hydration, or 90766, 90767, 90775 to identify

therapeutic, prophylactic, or diagnostic drug infusion or injection, if provided as a secondary or subsequent service in association with 96413) 03/02/20 CPT Codes American Medic al Association. All right 34 Code Descriptors 2006 Injection and Intravenous Infusion Chemotherapy Code 96523 does not require direct physician supervision. Codes 96521-96523 may be reported when these devices are used for therapeutic drugs other than chemotherapy 96521 Refilling and maintenance of portable pump (96520 has been deleted. To report, use 96521) 96522 Refilling and maintenance of implantable pump or reservoir for drug delivery, systemic (eg, intravenous, intra-arterial)

(For refilling and maintenance of an implantable infusion pump for spinal or brain drug infusion, use 95990-95991) 03/02/20 CPT Codes American Medic al Association. All right 35 Code Descriptors 2006 Injection and Intravenous Infusion Chemotherapy 96523 Irrigation of implanted venous access device for drug delivery systems (Do not report 96523 if an administration service is provided on the same day) or E& M (For collection of blood specimen from a completely implantable venous access device, use 36540) (96530 has been deleted. To report, use 96523)

96542 Chemotherapy injection, subarachnoid or intraventricular via subcutaneous reservoir, single or multiple agents (96545 has been deleted) (For radioactive isotope therapy, use 79005) (96545 has been deleted) (For radioactive isotope therapy, use 79005) 96549 03/02/20 Unlisted chemotherapy procedure CPT Codes American Medic al Association. All right 36 Probable EM Changes 2006 CPT at last has decided to entirely eliminate the problematic follow-up inpatient consult codes (99261-99263) and confirmatory consult codes (99271-99275). Starting Jan. 1, 2006, well be left with only the office/outpatient consults (99241-99245) and initial inpatient consults

(99251-99255), which remain unchanged. Will you still be allowed to use inpatient consult codes 9925x only once per admit? If so, will you be required to use the subsequent hospital care codes 99231-99233 for any follow-up visits? Remember that CPT and many payers have long said to use the subsequent care codes if the consultant takes over management of any part of the patients care. Source: Decision Health 03/02/20 CPT Codes American Medic al Association. All right 37 Probable EM Changes Nursing facility codes (99301-99313) and domiciliary/rest home codes (99321-99333) also have been deleted. Theyve been replaced with expanded code families that more clearly break out straightforward-, low-, moderate- and high-complexity medical decision-making. In CPT 2006 youll see: 3 codes for initial nursing facility care, per day (9930499306);

4 codes for subsequent nursing facility care, per day (9930799310); 1 code for E/M of a patient involving an annual nursing facility assessment (99318); 5 codes for domiciliary or rest home visit for the evaluation and management of a new patient (99324-99328) 4 codes for domiciliary or rest home visit for the evaluation and management of an established patient (99334-99337); and 2 monthly codes for individual physician supervision of a patient (patient not present) in home, domiciliary or rest home (99339-99340). Source: Decision Health 03/02/20 CPT Codes American Medic al Association. All right 38 Common Coding Errors & Omissions Using more than one initial

code per date of service Billing port flush with evaluation and management and/or administration codes Hydration infusion confusion Assorted administration code omissions 03/02/20 CPT Codes American Medic al Association. All right 39 Initial 2006 Administration Codes 90760 Hydration IV infusion, 1st h $62.86 90765 Therapeutic IV infusion, 1st h

$76.86 90744 Therapeutic IV injection $57.18 96409 Chemo IV push $121.92 96413 Chemo IV infusion, 1st h $172.27 03/02/20 CPT Codes American Medic al Association. All right

40 Billing Port Flush with Administration and/or E&M Service Pay for 96523, irrigation of implanted venous access device for drug delivery systems, 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 96523 is included in the payment for the other service. 03/02/20 CPT Codes American Medic al Association. All right 41 Port Flush Billing Procedures Check with your carrier to see if 96523 is payable with

lab Do not use 90774 for port access Schedule your patients for port flush on a separate day than physician visit 03/02/20 CPT Codes American Medic al Association. All right 42 Hydration Infusion Confusion Codes 90760-90761 are intended to report a hydration IV infusion to consist of a pre-packaged fluid and/or electrolyte solutions (eg, NS, D51/2NS + 30 meq KCL/ltr), but are not used to report infusion of drugs or other substances. 03/02/20

CPT Codes American Medic al Association. All right 43 Hydration Billing Procedures Use 90761 for hydration given sequential to either chemotherapy or therapeutic infusion with the -59 modifier Use 90761 if hydration is sequential and extends beyond 30 minutes or use multiples if hydration is only service of the day and extends over 1 hour and 30 minutes Do not bill for 90761 when hydration is concurrent with the chemotherapy or therapeutic infusion 03/02/20 CPT Codes American Medic al Association. All right 44

Commission of Omissions No initial code for date of service Omitted multiple hours for sequential infusions Omitted concurrent infusions Incorrect units for drugs with new HCPCS codes 03/02/20 CPT Codes American Medic al Association. All right 45 MMA Initiatives CAP (Competitive Acquisition Program) Part D Medicare Electronic Medical Record The Cancer Demonstration Project 03/02/20

CPT Codes American Medic al Association. All right 46 Part D Medicare Why should you care? Injectable drugs can be on multiple formularies--patients may see their obligation as being less under Part D, if they do not have Medigap. More patients will sign up for Medicare Advantage, which will not benefit physicians necessarily. Patients will ask you!!! 03/02/20 CPT Codes American Medic al Association. All right 47 Part D Medicare The Basics

Patients must enroll--not automatic! Coverage Deductible = $250 Premium (estimate)= $32.20 Up to $2250 with 25% Co-pay $2850 out of pocket Then, at $5100, Medicare kicks in at 95% or a low per prescription rate Differs for poor beneficiaries 03/02/20 CPT Codes American Medic al Association. All right 48 Compare Plans Assumptions Patients will pay the premiums anyway. These are not part of the analysis. Both drugs are counted against the deductible. Both drugs have allowables of $25,000

per year. Based on what we know about Part D, this is dubious. THERE IS NO SUCH THING AS A STANDARD PLAN!!! 03/02/20 CPT Codes American Medic al Association. All right 49 Compare Plans Part B Part D $124 deductible 20% of $24,876 = $4975 TOTAL OOP = $5099 03/02/20 $250 deductible $2000 with 25%

co-pay = $500.00 $2850 Donut Hole 5% of remaining $19,900 = $995 Total OOP = $4595 CPT Codes American Medic al Association. All right 50 Oral Cancer Drugs Part D Caveats Patients must ENROLL in Part D--it is not automatic. Premiums higher each year and will be variable by plan. But, premiums lower than Part B. Doughnut hole not covered by Medigap. Part B co-pay is! Poor patients considered differently by Part D (and for Part B premiums as well). Medicare Advantage and PDP Plans must be actuarially equivalent and this may mean

differing OOP for these plans and can include tiered pricing for drugs. 03/02/20 CPT Codes American Medic al Association. All right 51 The Demonstration Project 03/02/20 CPT Codes American Medic al Association. All right 52 The Demonstration Project 2006 The Cancer Demonstration Project Whats going to happen next year? As the data become more complete, CMS plans to analyze the relationships between the reported symptoms and hospitalizations and emergency

department visits for related conditions (such as intractable pain, dehydration, etc.). These analyses will inform us in any future efforts CMS undertakes to obtain patient reported data, as well as provide more insights about the use of Gcodes for data collection. Will continue to discuss the validity of this with oncology practices. What does your data say about you? 03/02/20 CPT Codes American Medic al Association. All right 53 The EMR Here is where we are (from CMS information):

The Veterans Health Information Systems and Technology Architecture (VISTA)is in 1300 sites in the VA system and is being adapted for small practice use. VISTA Office Electronic Health Record (VOE EHR) was to be offered free of charge through the Freedom of Information Act. This has been delayed. 10-15 practices can participate in a Beta test now.The Vista-Office evaluation software is not free software. There is a small fee for obtaining the software on computer disk, and there will be other fees an office will need to pay to use the software including licensing and support fees for the database program and CPT codes. The added office staff cost associated with the implementation of an EHR will also be a part of the total cost of ownership and will play a part in physicians' decisions to adopt and test Vista-Office. In addition, offices will generally need vendor support for installation, configuration, and maintenance, similar to support with any other electronic health record. To address this need, CMS has funded a VistaOffice Vendor Support Organization, WorldVistA, to provide training for vendors. The evaluation of these vendor services is an important objective of the initial VOE release. 03/02/20

CPT Codes American Medic al Association. All right 54 Pay for Performance Medicare Spending Facts Insurance for 42 million elderly and disabled In 2004, the largest component of the federal budget. In 2004, the largest component of national health spending. In 2006, the Prescription Drug Benefit will substantially increase benefits. 03/02/20 CPT Codes American Medic al Association. All right 55 Pay for Performance Medicare Modernization Act of

2003 New way to assess Medicare financial status Medicares future challenges Growth of beneficiaries Decline in worker/beneficiary ratio Increasing life expectancy 03/02/20 CPT Codes American Medic al Association. All right 56 Pay for Performance House Ways and Means Committee June letter requesting CMS provide information on quality indicators and the system for reporting them Seeking CMS recommendations on the financial incentives needed to ensure provider participation

Information on P4P demonstrations Lessons learned from P4P demonstrations Value-based purchasing 03/02/20 CPT Codes American Medic al Association. All right 57 Pay for Performance CMS demonstration initiatives Hospital Paid more to report 10 quality measures full market-basket update Hospital Top 10% performance additional 2% payment Next 10% performance additional 1% payment

Underway Nursing Homes Home Health 03/02/20 CPT Codes American Medic al Association. All right 58 Pay for Performance CMS Director Dr. Mark McClelland Linking a portion of Medicare payments to valid measures of quality and effective use of resources would give providers more direct incentives and financial support to implement innovative ideas and approaches that actually result in improvements in the value of care that our beneficiaries receive.

03/02/20 CPT Codes American Medic al Association. All right 59 Pay for Performance Committee Chairman William Thomas Today, Medicare pays providers the same whether they deliver excellent care or care that is ineffective, poor quality or out-of-date. Unfortunately, since Medicare pays for resource use, we pay for more and more services when providers deliver ineffective and inefficient care. 03/02/20 CPT Codes American Medic al Association. All right 60

Oncology ICD-9-CM Changes 10/1/2005 with no grace period Volume depletion: Three new codes, which can be used for patients who need volume replacement 276.50 for volume depletion, unspecified; 276.51 for dehydration; 276.52 for hypovolemia. 03/02/20 CPT Codes American Medic al Association. All right 61 Oncology ICD-9-CM Changes Hematology: New thrombocytopenia codes are here 287.30 is primary thrombocytopenia unspecified

287.31 is immune thrombocytopenic purpura 287.32 is for Evans Syndrome 287.33 for congenital and hereditary thrombocytopenic purpura 287.39 is for other primary thrombocytopenia 03/02/20 CPT Codes American Medic al Association. All right 62 Oncology ICD-9-CM Changes Kidney: For those of you who give ARANESP or PROCRIT to kidney disease patientslisten up! New codes are required as of October 1, 2005. 585.1 is for chronic kidney disease, Stage 1 585.2 is for Stage 2 585.3 is for Stage 3

585.4 is for Stage 4 585.5 is for Stage 5 585.6 is for End Stage Renal Disease (like when you are on dialysis) 585.9 is for unspecified chronic kidney disease. 03/02/20 CPT Codes American Medic al Association. All right 63 ICD-9-CM Chronic Kidney Disease 585.1 Stage I chronic kidney disease. Kidney damage with normal or increased glomerular filtration rate (GFR), greater than or equal to 90 ml/min/1.73m2

585.2 Stage II chronic kidney disease. Kidney damage with mild decrease in glomerular filtration rate (GFR), 60-89 ml/min/1.73m2 585.3 Stage III chronic kidney disease. Kidney damage with moderate decrease in glomerular filtration rate (GFR), 30-59 ml/min/1.73m2 585.4 Stage IV chronic kidney disease. Kidney damage with severe decrease in glomerular filtration rate (GFR), 15-29 ml/min/1.73m2 585.5 Stage V chronic kidney disease. Kidney damage with glomerular filtration rate (GFR) of less than 15 ml/min/1.73m not on dialysis New code 585.6 End stage renal disease. Stage V chronic kidney disease with patient on dialysis New code 585.9 Chronic kidney disease, unspecified chronic renal insufficiency Chronic renal failure NOS Genetic Counseling: V26.33 03/02/20 CPT Codes American Medic al Association. All right 64 ICD-9-CM Changes

One of them is for V58.1, which will be deleted 10/1/2005 and will now have a FIFTH DIGIT codes as of October 1. This change will impact the payment of your claims. Here is the scoop from the ICD-9-CM Maintenance Committee. V58.11 Encounter for antineoplastic chemotherapy V58.12 Encounter for immunotherapy for neoplastic condition Immunotherapy also called immune therapy and biologic therapy is a treatment that stimulates the bodys immune defense system to fight infection and disease. It is not classified as chemotherapy. Unlike traditional cytotoxic chemotherapies that attack cancer cells themselves, immunotherapy is designed to enhance the bodys defenses by mimicking the way natural substances activate the immune system. These can stimulate the growth and activity of cancer-killing cells, e.g.interleukin used in the treatment of malignant melanoma and renal cell carcinoma. We would guess that interferons now and future cancer vaccines in the pipeline would also be included in this definition. Check with your Carrier bulletin about interferon necessitating V58.12. 03/02/20

CPT Codes American Medic al Association. All right 65 Commercial Insurance Default Fee Schedule Changes- PPO Blue Cross of California Prudent Buyer PPO Fee Schedule changed July 1, 2005 Drugs paid at ASP + 25% E & M codes paid at 3% above Medicare 2005 fee schedule G-Codes paid at 90% of 2005 Medicare Allowable 2004 Administration CPT paid at 25-50% of 2004 Medicare Fee Schedule No Payment for Demonstration G-Codes 03/02/20 CPT Codes American Medic al Association. All right 66

Commercial Insurance Default Fee Schedule Changes- PPO Blue Shield of California PPO Fee Schedule Changed April 1, 2005 Drugs paid AWP 15% E& M codes paid at 4% above 2004 Medicare fee schedule. Administration CPT codes paid at 13-15% above 2004 Medicare fee schedule including transitional increase. No Payment for Demonstration Codes or Administration G-Codes 03/02/20 CPT Codes American Medic al Association. All right 67 Commercial Insurance Default Fee Schedule Changes- PPO Cigna PPO Default Fee Schedule Changed April 15, 2005

Drugs paid at AWP 15% E&M codes paid at 15% above 2005 Medicare fee schedule 2004 Administration CPT Codes paid at 91% Medicare 2004 fee schedule including transitional increase. No Payment for Demonstration Codes or G-Codes 03/02/20 CPT Codes American Medic al Association. All right 68 Commercial Insurance Default Fee Schedule Changes- PPO United Healthcare Options PPO Fee Schedule Changed September 1, 2005 Drugs paid AWP 15% E& M codes paid at 4% above 2004 Medicare fee schedule. Administration CPT codes paid at 1315% above 2004 Medicare fee schedule including transitional increase.

No Payment for Demonstration Codes or Administration G-Codes 03/02/20 CPT Codes American Medic al Association. All right 69 Commercial Insurance Fee Schedule Changes- HMO Fee Schedule Negotiated by IPAs Reimbursement for Drugs and Procedures Depends on Carve Out Most IPAs have transferred some if not most of the financial responsibility for drugs back to the health plan Tremendous Variability in physician payment structure 03/02/20 CPT Codes American Medic al Association. All right

70 Commercial Insurance Fee Schedule Changes- HMO IPA Example 1 Drugs paid at 100% of 2003 Medicare fee schedule E& M and Administration CPT codes paid at 95% 2003 Medicare fee schedule 03/02/20 CPT Codes American Medic al Association. All right 71 Commercial Insurance Fee Schedule Changes- HMO IPA Example 2 Drugs paid at 100% 2005 AWP updated quarterly E&M codes paid at 55% 2005 Medicare fee schedule

Administration CPT codes paid at 80% 2004 Medicare fee schedule without transitional increase 03/02/20 CPT Codes American Medic al Association. All right 72 Survival Strategies 03/02/20 CPT Codes American Medic al Association. All right 73 Do Not Underestimate Part D Medicare Advantage Plans will increase. This will create more complicated intake and more chaos for patients. MA Plans do not pay for the

Demo. MA plans or patients may switch drugs between Part B and Part D. Patients without Medigap may prefer to bring their drug in and get the injection. Get ready to answer lots of questions! 03/02/20 CPT Codes American Medic al Association. All right 74 Think Out of The Box Its Time to be Creative What new services can you do? Alternative therapies? Infusion Center? Rent-a-Nurse? Consolidation of Oncology Services and Offices Patient Payment Services? Pay for Performance? Pumps

03/02/20 CPT Codes American Medic al Association. All right 75 Pay Attention to Other Payers Understand how and when they will implement the new codes. It may be immediately or in three months. You need to know! Make sure your computer system can accommodate three different drug admin coding systems. Understand how and when they will calculate ASP, if they decide to use it as a payment system. Monitor EOBs to see if they are fluctuating on contract terms. 03/02/20 CPT Codes American Medic

al Association. All right 76 Manage Managed Care Contracts What can you negotiate? ASP + Conversion factor for fee schedule services Addition of E&M services to chemotherapy administration Following of CPT standards with grace period Daily or hourly facility/mixing/drug management fees Pay for performance---can you start this? Pharmacy fees Negotiated AWP amount Claim administration Patient counseling 03/02/20 CPT Codes American Medic al Association. All right 77

Coping with Change Your check list Be sure you really understand what your cash needs are now. They have changed over the last six months. Be prepared for coding anarchy on January 1, 2006. There is no grace period for Medicare and we will have three coding systems to deal with. Be sure to schedule coding education for the end of the year. You do not want to be scrambling on 1/1/2006. What will happen if there is a 20+% decrease in your professional service profitability for Medicare patients? How will this impact your operation and MD bonus structure? Prepare to answer questions about Part D next year for your patients. They will be very confused. Make sure you have the electronic systems to support Pay for Performance. How would you track patient outcomes? Participate in the struggle! 03/02/20 CPT Codes American Medic al Association. All right

78 Contact Information Here is our contact information: Bobbi Buell [email protected] 800-795-2633 415-332-2793 650-618-8621 (FAX) Patty Falconer [email protected] 650-949-2526 650-745-1122 (FAX) 03/02/20 CPT Codes American Medic al Association. All right 79

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