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Implementing Medicare and Commercial Insurance Coding Changes in 2006. Patricia Falconer, MBA President, Health Options 650-949-2526 phone 650-745-1122 fax Healthoptions@worldnet.att.net. Strategies For 2006. Financial Issues Medicare Demonstration Project Fee Schedule Management
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Implementing Medicare and Commercial Insurance Coding Changes in 2006 Patricia Falconer, MBA President, Health Options 650-949-2526 phone 650-745-1122 fax Healthoptions@worldnet.att.net
Strategies For 2006 • Financial Issues • Medicare Demonstration Project • Fee Schedule Management • Operations
Financial Issues • Plan for Reduced Cash Flow • Medicare Revenue Loss from Elimination of 2005 Demonstration Project • Medicare Revenue Loss from 3% Reduction in Administration CPT Codes • Delays in Medicare payments due to 1/17/06 implementation date for Demonstration codes • Fee Schedule Reductions from Commercial PPO Insurance Plans
Medicare Demonstration Project 2006 • Should you participate? • How to facilitate the billing process • Documentation Requirements
Demonstration Project Philosophy • “The project builds on the use of G-codes to gather more specific information about patients with particular types of cancer, including information about the primary focus of the visit and the spectrum of care that you provide. It will emphasize practice guidelines as the source for standards of care, permitting CMS to monitor and encourage quality care to cancer patients, and to identify and promote best cancer care practices that should lead to improved patient outcomes”. MediLearn Matters Number SE0589 Effective Date 1/1/06
Demonstration Project Revenue Projection • Calculate the total Number of 99212-99215 visits in 2005. • Estimate the percentage of Medicare patients in the practice. • Estimate the percentage of visits representing the 13 major diagnostic categories. • Multiply each element above and then multiply the number by $23.00
Implement A New Superbill • Add all Codes on Superbill. • This will require a two page superbill. • First page: E & M codes, Procedure Codes, G-Codes, and Lab • Second page: 2006 Administration CPT codes, supplies, and J-Codes for drugs. G-Codes and 2004 CPT codes may be required for specific contracts. • Patient insurance must be on the superbill • Update all new CPT and J-Codes
Educate Providers • Physicians and Nurse Practitioners who bill as “incident to” • Use Resources • Educate Billing Staff • Set up Charge Entry and Documentation Audit System
Documentation RequirementsPrimary Focus of VisitG9050 – G9055 • Progress note section, chief complaint or primary reason for visit, should match G-Code • Work-Up Evaluation • Treatment Decision/Management • Surveillance for Disease • Expectant Management of Patient • Supervision Palliative • Other- Visit Unspecified
Documentation RequirementsFor Guideline Adherence Codes (G9056 – G9062) • Must Document Source of Guideline • ASCO • NCCN • Both • No Guideline Available or None • Clinical Trials
Documentation Guidelines Current Disease StateG9063- G9130 • Choose the single G-Code that best represents the disease status based on the best available data at the time of service • G-Code selected must match ICD-9 code • Staging should be documented in progress note
2006 Fee Schedule- Medicare • US House of Representatives passed a federal budget package that stopped the 4.4% Medicare cut in December 2005 but could not obtain final approval before the holiday break. CMA and AMA are now working with congress to pass the payment “freeze”. • Practices should use billed charges or the 2005 Medicare fee schedule for dates of service in 2006 except with the new administration CPT codes. • The new administration CPT codes will be paid using the 2006 fee schedule. These codes are not part of the “freeze”.
If Congress Freezes 2006 Medicare Payments at 2005 Rates... • Medicare carrier will have 2 business days to begin to automatically reprocess claims that were paid under the 4.5 % conversion reduction. • Payments will be issued in one lump sum by July 2006 • Additional Medicare payments will increase patients co-payments if they do not have secondary insurance • Decision to recover co-payments from patients is up to the individual practice • Waiving co-payments due to the change in conversion factor would not be viewed as an “inducement”
Fee Schedule- PPO Commercial • Lower Contracted Reimbursement Rates for 2006 Administration CPT Codes • Blue Shield of California PPO Default Fee Schedule • Average of 30% Reduction • Blue Cross Prudent Buyer PPO Default Fee Schedule • Average of 33% Reduction • Monitor PPO Plans rate changes through their websites • Electronic Claim Clearing House Edits • Can you submit 2004 CPT codes or 2005 G-codes if your payer contracts require them?
Fee Schedule - HMO Commercial • HMO Plans • Take this opportunity to renegotiate your IPA HMO contracts to include 2006 CPT codes. • Find out if your IPAs carved out the financial responsibility for drug reimbursement for 2006 • Who pays you for drugs and procedures for each health plan? • What rate? • Any other changes?
Managing Drug Purchasing • Compare Quarter 1 2006 ASP with your current practice acquisition costs • Manage your drug distributors • Use Distributors Website for Drug Purchasing • Monitor price changes with each order • Order from multiple distributors • Review drugs within therapeutic classes to maximize purchase power • Growth Factors • Antiemetics • Bisphosphonates
Operations • Implement Automated Functions wherever possible • Electronic Claim Submission for all payers that will accept them. Can your software submit three digit units? • Electronic Remittance • Electronic Patient Statements • Reduce Accounts Receivable days to match or beat drug distributor payment terms
Resources • www.anco-online.org • www.asco.org • www.nccn.org • www.medicarenhic.com • www.bluecrossca.com • www.mylifepath.com • www.cigna.com • www.aetna.com • www.unitedhealthcareonline.com • www.practicemanagerinsider.com • www.caring4cancer.com
