Whitewater Management Successfully Navigating Oncology ...

Whitewater Management

Successfully Navigating Oncology Management in

Turbulent Times

04/10/23 CPT Codes ©American Medical Association. All rights reserved.

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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 Carrier’s 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.


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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!

Medicare Regulations 2005-2006

Office Based Oncology


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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


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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


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Medicare Physician Fee Schedule

• Medicare Conversion Factor Bumped Up $37.8975 is the CF—published 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.


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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.


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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


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• 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.


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• 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)


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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


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Coding for Cancer Services 2005


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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 infusion’s 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)


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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?


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Coding for Therapeutic Infusions

2005 Code

2006Code

Description 2005 Transitional 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 infusion, up to one hour

$43.72

G0350 90768 IV infusion, concurrent infusion

$25.37


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Therapeutic Injections/Pushes

2005 Code

2006Code


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


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Chemotherapy Injections/Pushes

2005 Code

2006Code


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


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Chemotherapy Infusions

2005 Code 2006 Code Description 2005 Transitional 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 Each additional sequential infusion, up to one hour

$86.66


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Miscellaneous Chemo Procedures

2005 Code 2006 Code


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 implanted pump

$113.59


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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 anesthesiab. IV startc. Access to indwelling IV, subcutaneous catheter or portd. Flush at conclusion of infusione. Standard tubing, syringes, and supplies

(For declotting a catheter or port, see 36550)


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2006 Code Descriptors

• Hydration, Therapeutic Injections and InfusionsWhen 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.


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2006 Code Descriptors

• HydrationCodes 90760-90761 are intended to report a hydration IV infusion to consist of a pre-packaged fluid and electrolytes (eg, normal saline, D5-½ 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)


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Code Descriptors 2006

Therapeutic, Prophylactic, and Diagnostic Injections and InfusionsA 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)


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• 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)


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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)


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90772 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular

(For administration of vaccines/toxoids, see 90465-90466, 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)


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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


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New Code Descriptors 2006

• Chemotherapy AdministrationChemotherapy 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.


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New Code Descriptors 2006

• Chemotherapy AdministrationIf performed to facilitate the infusion or injection, the

following services are included and are not reported separately:

a. Use of local anesthesiab. IV startc. Access to indwelling IV, subcutaneous catheter or portd. Flush at conclusion of infusione. Standard tubing, syringes and suppliesf. Preparation of chemotherapy agent(s)

(For declotting a catheter or port, use 36550)


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• Chemotherapy AdministrationReport separate codes for each parenteral method of administration employed when chemotherapy is administered by different techniques. The administration of medications (eg, antibiotics, steroidal agents, anti-emetics, 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


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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


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• 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)



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• Injection and Intravenous Infusion Chemotherapy

96413 Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug



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)


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Injection and Intravenous Infusion ChemotherapyCode 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


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)


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Injection and Intravenous Infusion Chemotherapy96523 Irrigation of implanted venous access device

for drug delivery systems

(Do not report 96523 if an administration or E& M service is provided on the same day)

(For collection of blood specimen from a completely implantable venous access device, use 36540)


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 Unlisted chemotherapy procedure


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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, we’ll 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 patient’s care.

Source: Decision Health


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Probable EM Changes

• Nursing facility codes (99301-99313) and domiciliary/rest home codes (99321-99333) also have been deleted. They’ve been replaced with expanded code families that more clearly break out straightforward-, low-, moderate- and high-complexity medical decision-making. In CPT 2006 you’ll see:

• 3 codes for “initial nursing facility care, per day” (99304-99306);

• 4 codes for “subsequent nursing facility care, per day” (99307-99310);

• 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


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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


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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


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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.”


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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


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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.”


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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


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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


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MMA Initiatives

• CAP (Competitive Acquisition Program)

• Part D Medicare• Electronic Medical Record• The Cancer Demonstration Project


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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!!!


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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


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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!!!


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Compare Plans

• Part B $124 deductible 20% of $24,876 = $4975

TOTAL OOP = $5099

• Part D $250 deductible $2000 with 25% co-pay = $500.00

$2850 Donut Hole

5% of remaining $19,900 = $995

Total OOP = $4595


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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.


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The Demonstration Project


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The Demonstration Project 2006

• The Cancer Demonstration Project

• What’s 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 G-codes for data collection. “

Will continue to discuss the validity of this with oncology practices.

What does your data say about you?


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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 Vista-Office Vendor Support Organization, WorldVistA, to provide training for vendors. The evaluation of these vendor services is an important objective of the initial VOE release.


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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.


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Pay for Performance

• Medicare Modernization Act of 2003 New way to assess Medicare financial status

• Medicare’s future challenges Growth of beneficiaries Decline in worker/beneficiary ratio

Increasing life expectancy


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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


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Pay for Performance

• CMS demonstration initiativesHospital

• 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


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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.”


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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.”


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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.


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•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


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•Kidney: For those of you who give ARANESP or PROCRIT to kidney disease patients—listen 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.


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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


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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 chemotherapyV58.12 Encounter for immunotherapy for neoplastic condition“ Immunotherapy also called immune therapy and biologic therapy is a treatment that stimulates the body’s 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 body’s 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.


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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


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• 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


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• 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


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• 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 13-15% above 2004 Medicare fee schedule including transitional increase.

No Payment for Demonstration Codes or Administration G-Codes


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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


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• 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


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• 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


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Survival Strategies


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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!


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Think Out of The Box

• It’s 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


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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.


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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


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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!


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Contact Information

• Here is our contact information:

Bobbi [email protected] (FAX)

Patty [email protected] (FAX)

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