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Practice Management Series 2005

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    1. Practice Management Series 2005 ASCO Clinical Practice Series 5/6/05

    2. 2 Practice Management Curriculum

    3. 3 Medicare Coding and Billing Update Overview of new drug administration and demonstration project codes including recent Medicare clarifications Review of coding for common clinical scenarios Updates on carrier implementation of G codes ASP updates Frequently Asked Questions

    4. 4 MMA 2005 Administration Codes Established 3 categories of infusion/injection administration codes for office-based practices Infusion for hydration Non-chemotherapy therapeutic/diagnostic injections and infusions other than hydration Chemotherapy administration (other than hydration) which includes infusions/injections Temporary G codes developed for use by Medicare in 2005, will change to CPT codes in 2006

    5. 5 Drugs and Administration Codes Effective for services 1/1/05, use of chemotherapy administration codes was expanded to include parenteral administration of nonradionuclide anti-neoplastic drugs, monoclonal antibodies and other biologic response modifiers for non-cancer diagnoses, and to anti-neoplastic agents provided for the treatment of non-cancer diagnoses 4/14/05: CMS will continue to defer to local carriers to decide which drugs may be billed under the chemotherapy administration codes

    6. 6 Initial Code The initial code is the code that best describes the key or primary reason for the encounter and should always be reported irrespective of the order in which the infusions or injections occur; additional codes are secondary to the initial code 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 comes back for a separately identifiable service on the same day, or has two IV lines per protocol, these services are separately payable and reported with modifier -59 (distinct procedural service) Initial = primary Initial service = the most resource consumptive service provided on a date of serviceInitial = primary Initial service = the most resource consumptive service provided on a date of service

    7. 7 Initial Code Patient presents for the principal service of injection of a chemotherapy drug (not described as an initial service). If, in addition to the chemotherapy injection, the patient receives hydration or non-chemotherapy infusions, can an initial hydration or non-chemotherapy code be billed? CMS 4/14/05: 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. The biller may report the chemotherapy injection code as the initial service code. No other initial service code should be billed with this code.

    8. 8 Push/Short Duration Infusion CMS published the following coding guideline on 4/15/05: An intravenous or intra-arterial push is now defined as an injection in which the healthcare professional who administers the substance/drug is continuously present to administer the injection and observe the patient; or an infusion of 15 minutes or less. Use codes G0353, G0354 for push or short duration infusion (15 minutes or less) of non-chemotherapy agents; use codes G0357, G0358 for push or short duration infusion of chemotherapy agents Effective for dates of service on or after March 15, 2005 although carriers may not implement this change until May 16, 2005

    9. 9 Multiple Injections When using code G0351 for non-chemotherapy injections (therapeutic or diagnostic injection, SC or IM), should a modifier be used or can multiple units be indicated on the claim form? And if a patient received one drug more than once in a day by the same method of administration, can more than one administration be billed? CMS 4/14/05: Payment may be made for medically necessary multiple injections to the beneficiary. We defer to the carriers on whether these services are reported through the use of a modifier or a numerical entry in the units field.

    10. 10 Hydration 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 with ASCO that electrolytes that are prepackaged or mixed are reported using the hydration codes Separate payment is allowed for hydration therapy and chemotherapy infusion if they are provided sequentially on the same day but not at the same time; use -59 modifier to indicate that hydration is performed before or after the chemotherapy infusion Ex: chemotherapy agent requires pre- or post-treatment hydration (ex. cis-plat based regimens) OR patient comes in for fluid 2-3 day post-chemotherapy Ex: chemotherapy agent requires pre- or post-treatment hydration (ex. cis-plat based regimens) OR patient comes in for fluid 2-3 day post-chemotherapy

    11. 11 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 G0346-59 for hydration of >30 minutes following chemotherapy infusion using G0359

    12. 12 Concurrent Infusion G0350 Intravenous infusion, for therapy/diagnosis (specify substance/drug); concurrent infusion Cannot bill for multiple hours of concurrent infusion No concurrent infusion code for chemotherapy drugs Beginning 3/15/05, Medicare carriers will allow payment for only one concurrent infusion per patient per encounter Medicare will not pay for G0350 if it is billed with modifier -59 unless this procedure is provided during a second encounter on the same day and is accompanied by supporting medical documentation G0350 NON-CHEMOTHERAPY only - assumes that chemo drugs are given sequentionally, not concurrently What about leucovorin given concurrently? Carrier discretion on whether Leucovrin is chemo or non-chemo. If treated as non-chemo, use chemo admin codes for other drugs, use G0350 for leucovorinG0350 NON-CHEMOTHERAPY only - assumes that chemo drugs are given sequentionally, not concurrently What about leucovorin given concurrently? Carrier discretion on whether Leucovrin is chemo or non-chemo. If treated as non-chemo, use chemo admin codes for other drugs, use G0350 for leucovorin

    13. 13 Concurrent Infusion Do drugs have to be administered in separate bags to constitute a concurrent infusion? 4/14/05 CMS is continuing to review what constitutes a concurrent infusion. In the meantime, carriers may develop definitions. On 1/1/05, Wisconsin Physician Services 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. Other carriers may have similar policies.

    14. 14 Concurrent Infusion If the initial service for a patient is chemotherapy infusion (G0359) and the patient also receives the concurrent infusion of two non-chemotherapy drugs prior to chemotherapy, which drug administration codes are used for the concurrent infusion? CMS 4/14/05: payment could be made for the concurrent infusion code (G0350) and for each of the drugs concurrently infused. Remember concurrent infusion can be billed only once per patient per encounter

    15. 15 Infusion Times For each additional hour hydration, non-chemotherapy infusions, and chemotherapy infusions: After the first hour of infusion, round infusion times to the nearest 30 minutes. If 30 minutes or less, round down. If greater than 30 minutes, round up.

    16. 16 CCI Edits April 1 version of CCI edits (version 11.1), AdminaStar included an edit on G0354 (each additional sequential intravenous push) when used with five codes G0345, G0347, G0357, G0359, G0361 AdminaStar is aware of the error; however it will not be corrected until version 11.2 is released, scheduled for July 1, 2005 Until correction is issued on July 1, edits may be bypassed using modifier -59. Modifier will not be needed for claims processed after July 1, 2005

    17. 17

    18. 18

    19. 19 Demonstration Project 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 has stated We expect that the patients responses will be recorded and included as part of the patients medical records. Physician signature?? No formal requirement but good practice to show that the practitioner has reviewed the dataPhysician signature?? No formal requirement but good practice to show that the practitioner has reviewed the data

    20. 20 Demonstration Project How is the assessment performed? Patients 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

    21. 21 Demonstration Project Assessment is to be performed at the time of a patient chemotherapy encounter which is defined as chemotherapy administered through intravenous infusion (G0359) or push (G0357), limited to once per day Chemotherapy injections (G0355, G0356) are not included Initiation of prolonged infusion requiring use of a portable or implantable pump (G0361) is not included Refill and maintenance of portable pump (96520) is not included

    22. 22 Demonstration Project CMS will pay based on the lesser of 80% of the actual charge or the allowance by code: Nausea/Vomiting G9021 G9024 $43.34 Pain G9025 G9028 $43.33 Fatigue G9029 G9032 $43.33 These services are paid on an assignment basis and the usual Part B coinsurance and deductible apply. N/V G9021-G9024 Pain G9025-G9028 Fatigue G9029-G9032 Medicare will pay 80% of $130 or $104.00 2nd ins or patient responsible for 20% - $26.00 N/V G9021-G9024 Pain G9025-G9028 Fatigue G9029-G9032 Medicare will pay 80% of $130 or $104.00 2nd ins or patient responsible for 20% - $26.00

    23. 23 Demonstration Project Billing Requirements 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. Office-based oncology practices only - place of service must be office (11). Medicare beneficiaries who are enrolled in a Medicare Advantage plan are not included in the demonstration project.

    24. 24 Demonstration Project Physician Sign-Off Is the physician required to sign off on the symptom assessment prepared by a nurse (incident to the physician) before the demonstration codes can be billed? CMS response 4/14/05: While it would be preferable for this requirement to be completed before the claim is submitted, there is no requirement that it must.

    25. 25 Demonstration Project Initiation of Chemo Can payment be made under the chemotherapy demonstration project on the day that chemotherapy is initiated? CMS response 4/14/05: Assuming other requirements have been met under the demonstration project, payment can be made under the demonstration project for the day that chemotherapy is initiated.

    26. 26 Demonstration Project Non-covered Drugs Can payment be made under the chemotherapy demonstration project if the chemotherapeutic drug is non-covered (e.g. self-administered drug or a drug used for a non-approved indication)? CMS response 4/14/05: In order for the demonstration fee to be paid, the underlying chemotherapy drug or biologic response modifier billed that day must be covered and the diagnosis must be for cancer.

    27. 27 Medigap Coverage Medicare Supplement (Medigap) insurance policies are required to pay 20% of the Medicare allowed amount for all claims Currently, there are ten standardized Medigap plans called A through J. Medigap policies must follow Federal and State laws. Not all secondary plans are Medigap policies. New drug administration codes (G codes) and demonstration project codes should be paid by Medigap plans

    28. 28 MMA 2005 Drug Reimbursement Reimbursement is now based on Average Sales Price (ASP) Effective 1/1/05 drugs furnished incident to a physicians service are paid at ASP + 6% ASP data is updated quarterly with a two quarter lag (ex. 4/1/05 payments based on 4th qtr 2004 data) Next update is due July 1, 2005

    29. 29 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 $38.74 Q9942 IVIG lyophilized 10 mg. $0.39 Q9943 IVIG non-lyophil. 1 gram $56.22 Q9944 IVIG non-lyophil. 10 mg. $0.56

    30. 30 ASP Update - April 1, 2005 Revisions to first quarter payment rates Previously paid claims must be resubmitted to be reprocessed

    31. 31 ASP Update - April 1, 2005 More revisions

    32. 32 Putting the Pieces Together Clinical Coding Examples

    33. 33 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

    34. 34

    35. 35 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

    36. 36

    37. 37

    38. 38 Looking Ahead Competitive Acquisition Program (CAP) is planned for 1/1/06 Proposed rule published on 3/4/05 Physicians will choose ASP + 6% or CAP Proposed rule discusses phase-in period beginning 1/1/06; details of phase-in still to be determined Significant paperwork requirements for physician practices as outlined in proposed rule ASCOs summary of the rule and comments provided to CMS can be accessed at www.asco.org/MMA under Regulations and Resources

    39. 39 How to Prepare Still many unanswered questions, but now is the time to start to prepare Do you understand your costs? What does it cost to run your current pharmacy service? Are you managing inventory, controlling shrinkage, purchasing aggressively, collecting co-pays on all drugs? What will it cost to manage the administrative challenges of the CAP program?

    40. 40 Looking Ahead G codes will transition to CPT codes New codes and definitions will be published in CPT Private payers will convert to the new codes at this time

    41. 41 How to Prepare G codes will change to CPT codes in the 2006 CPT book Contact your major commercial payers now and discuss their implementation plans new codes, possible changes in drug reimbursement Purchase your 2006 CPT book as soon as it is available (~November 2005) Start planning now to update your office tools (charge ticket, fee schedules) with the new CPT codes

    42. 42 For More InformationCMS Policy Revisions and Clarifications For Transmittal 148 (4/15/05): http://www.cms.hhs.gov/manuals/pm_trans/R148OTN.pdf For CMS Frequently Asked Questions: Go to www.cms.hhs.gov and click on FAQs. On the FAQ page, select Physicians as the category and Drug Administration Services as the subcategory.

    43. 43 ASCO Resources Practical Tips for the Practicing Oncologist 3rd edition Practical Tips for the Practicing Oncologist Supplement for 2005 Available online at www.asco.org/practicaltips

    44. 44 ASCO Resources www.asco.org/MMA Full set of FAQs are available and are updated as new information is available Ask a Coding Question: Call 703-299-1054 or Email practice@asco.org