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GASCO Seminar September 11, 2010.  What’s Going On Right Now  What Might Happen In 2011: MPFS Proposed  PQRI and E-Prescribing 2010-2011  Meaningful.

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Presentation on theme: "GASCO Seminar September 11, 2010.  What’s Going On Right Now  What Might Happen In 2011: MPFS Proposed  PQRI and E-Prescribing 2010-2011  Meaningful."— Presentation transcript:

1 GASCO Seminar September 11, 2010

2  What’s Going On Right Now  What Might Happen In 2011: MPFS Proposed  PQRI and E-Prescribing  Meaningful Use Final Rule  ICD-9-CM for  Follow Up Items For Practices 2onPoint Oncology LLC

3 3  Much is not known about Health Reform and The Final Rule for Physician Services in This is what we know right now.  Payers differ on their guidelines. Please verify coding for each payer and claim.  All Medicare and RAC information is literally changing on a daily basis. What is presented herein may or may not be valid for  This is not legal or payment advice.  This content is abbreviated for Medical Oncology. It does not substitute for a thorough review of code books, regulations, and Carrier guidance.  This information is good for the date of the information and may contain typographical errors.  CPT is the trademark for the American Medical Association. All Rights Reserved. onPoint Oncology LLC

4 4  Payments are based on RVUs for each code (WRVUs+PERVUs+MalRVUs)  RVUs are multiplied times GPCIs for your area. There is a work GPCI floor in some areas of (W*WGPCI+PE*PEGPCI+Mal*MalGPCI)  The Medicare conversion factor determines the overall level of Medicare payments (W*WGPCI+PE*PEGPCI+Mal*MalGPCI) times CF = $Your Total Allowable for your area  A formula spelled out in the Medicare statute determines the annual update to the conversion factor and that has been a disaster. onPoint Oncology LLC

5 5 schedule.shtml

6  We have had 4 different conversion factors this year! ◦ Started off with last year’s conversion factor-- $ ◦ Went to $ in January ◦ Went to $ when Congress was deliberating and then will be (?) paid back—Could return December 1. ◦ Went to $ June 1  We have a new fee schedule starting July 1…yikes! 6onPoint Oncology LLC

7 Procedure2009 RVUs2010 RVUs Procedure2010 $ 96365$ $ $ $ $ $ $ $ $ $ $ onPoint Oncology LLC

8 8  To assist providers in their quest to get physicians enrolled in PECOS, the Part B MACs will be sending revalidation letters to all physicians who have not updated their Medicare enrollment in over 6 years. (Medicare contractors first began updating the PECOS database with physician enrollments in November of 2003; therefore, physicians enrolled prior to this date will not be in the database.). The letter will instruct the physician to submit either an updated paper enrollment form or to enroll online via PECOS.  Need to update any changes within 30 days ◦ Address, phone, suite ◦ New members in group ◦ Other changes  If no claims to Medicare in one year—physician is disenrolled in Medicare  REFERRING PHYSICIAN WITH NO NPI REGISTERED THROUGH PECOS CAN BE REJECTED! onPoint Oncology LLC

9 9 ◦ Claims ordered / referred must:  NPI of ordering provider  Name in PECOS or MAC system  Specialty as listed ◦ Grace Period (??)  Phase 1: 10/5/09 to 7/6/10 warning message on remittance  Phase 2: 7/6/10 and after: claim rejected if referring individual not in Pecos or MAC list  JULY 1, 2010: CMS SAID THEY WOULD HOLD OFF ON REJECTING CLAIMS. onPoint Oncology LLC

10  Transmittal 762, Change Request 6711, effective July 30, 2010 ◦ Use of –JW still optional at discretion of Carrier ◦ Depends upon J-code. Let’s say J-code is 1 mg. You use 9 mg and waste 1 mg. You would bill 2 lines  9 units on one line  1 unit with –JW on another line ◦ But, if the J-code is 10 mg, you would just bill the one line. ◦ Must document waste in either case. 10onPoint Oncology LLC

11  Transmittal 694, CR 6965, effective July 1 and implemented July 6, 2019 ◦ Implements Health Reform Provision ◦ Reduction of –TC increased from 25% to 50% for additional procedures done in the same session on the same day.  Many experts thought this would not happen until onPoint Oncology LLC

12  Transmittal 697, CR 6960, effective January 1, 2010 and implemented October 4, 2010  Claims must be filed within one calendar year. Implementation will be according to this schedule: ◦ 1) claims with dates of service prior to October 1, 2009 will be subject to pre-PPACA timely filing rules and associated edits; ◦ 2) claims with dates of service October 1, 2009 through December 31, 2009 received after December 31, 2010 will be denied as being past the timely filing statute and; ◦ 3) claims with dates of service on or after January 1, 2010 received more than 1 calendar year beyond the date of service will be denied as being past the timely filing statute (ex: claim DOS = 3/15/10, claim must be received by COB 3/15/11). ◦ One exception is a mistake by CMS or agents thereof. 12onPoint Oncology LLC

13  Auditors: MACs, CERTs, and RACs, just to name a few. CMS requires that orders for healthcare services and the services that were provided be authenticated by the author using either a handwritten or electronic signature. CMS has made it clear that stamped signatures are not an acceptable form of authentication.  The previous language in the CMS Program Integrity Manual required a “legible identifier”. The recent CMS Transmittal 327 has added additional clarification and signature assessment requirements.CMS Transmittal 327  Any auditor can use this rule, unless other laws or regulations supersede this rule. 13onPoint Oncology LLC

14  If the signature is missing from any other medical documentation, excluding the order, the reviewer should accept a signature attestation from the author of the medical record entry. Providers should not add late signatures to the medical record “beyond the short delay that occurs during the transcription process” and should instead use the signature attestation process. Other providers in the same group may not attest to the original author’s signature.  In addition, if the Medicare policy is “silent” on whether a signature must be dated, the reviewer has been instructed to ensure that the rest of the documentation contains enough information to determine the date when the service was ordered and/or performed. For example, the reviewer finds that the first and third order on a page have a specific date; however, the second order on the same page is not dated. It could be assumed that the second order occurred on the same date.  All providers should be reviewing all documentation for dates and signatures in a timely manner and prior to considering the medical record complete. If a signature is not legible or is missing, the providers should take the appropriate steps to comply with the requirement in advance to prevent delays regarding the outcome of the review.  Also, review all request letters for any additional language the reviewer might add reminding you that a signature log or attestation can be submitted with the copies as part of the Additional Documentation Request (ADR). 14onPoint Oncology LLC

15  Retro changes in fee schedule means that patient portions will need to be changed or secondaries need to be re-billed. ◦ Routine waiver of patient portions implicated Anti- Kickback statute. ◦ Patient portions in this instance may be waived under these conditions:  If they fall within the Retroactive period of claims adjustment.  Once the actual adjusted fee schedules is paying, beneficiary portions must be collected as usual.  Waivers must be made without regard to beneficiary, item or service, AND there is no advertising or solicitation to patients.  Waivers are not conditional in any way. 15onPoint Oncology LLC

16 ESAs in Chronic and End-Stage Renal Disease  CMS received a formal request for a national coverage determination (NCD) for recombinant human erythropoietin (ESAs) for treatment of chronic kidney disease (CKD) and dialysis-related anemia.  Medicare has historically made payment for ESAs for particular indications with specific conditions. Erythropoiesis Stimulating Agents (ESAs) are drugs or biologic agents which interact with the erythropoietin receptor or its pathway.  Anemia, which has multiple causes, is not uncommon in some patient populations, such as those with chronic renal disease. Emerging data have suggested that ESA use may be associated with decreased survival and increased morbidity in both renal and non-renal patient populations.  ESAs have FDA approved labeling that includes boxed warnings citing greater risks for death, serious cardiovascular events, and stroke in some chronic renal failure populations. The requestor points to recent clinical studies that have shown significant ESA-related adverse safety signals and asks CMS to establish coverage limitations for ESA use in both pre-dialysis and dialysis renal disease patient populations.  Some parties have suggested that prior ESA use may predict the long term success of subsequent kidney transplantation in patients with chronic kidney disease. We are commissioning a technology assessment from an outside entity.  Comment Period 6/16/10-7/16/10; Decision due 3/ onPoint Oncology LLC

17  CMS received informal inquiries for a national coverage determination (NCD) for autologous cellular immunotherapy treatment of prostate cancer. This interest arose upon the recent FDA approval of the Sipuleucel T treatment regimen, marketed as Provenge®.  As described on the FDA website at edProducts/ucm htm, "PROVENGE® (Sipuleucel T, APC8015) is an autologous cellular immunotherapy product consisting of peripheral blood mononuclear cells (PBMCs) obtained from patients by leukapheresis and activated in vitro with a recombinant fusion protein (prostatic acid phosphatase fused with GM-CSF)…FDA will require the sponsor to complete a post marketing study to evaluate the risk of stroke in patients who receive sipuleucel-T." edProducts/ucm htm  Provenge® has FDA approved labeling for the treatment of asymptomatic or minimally symptomatic metastatic castrate resistant (hormone refractory) prostate cancer.  We are opening this national coverage analysis to determine whether or not autologous cellular immunotherapy is reasonable and necessary under sections 1862(a)(1)(A) and/or 1862(a)(1)(E) of the Social Security Act.  Comment Period: 6/30/10-7/30/10, with decision due by 3/30/11 17onPoint Oncology LLC

18  Tobacco Cessation (8/25/2010) ◦ The Centers for Medicare and Medicaid Services (CMS) has determined that the evidence is adequate to conclude that counseling to prevent tobacco use, which is recommended with a grade of A by the U.S. Preventive Services Task Force (USPSTF) for all adults and pregnant women who use tobacco, is reasonable and necessary for prevention of illness or disability and is appropriate for individuals entitled to benefits under Part A or enrolled under Part B. ◦ Therefore CMS will cover tobacco cessation counseling for outpatient and hospitalized Medicare beneficiaries:  Who use tobacco, regardless of whether the patient has signs or symptoms of tobacco-related disease;  Who are competent and alert at the time that counseling is provided; and  Whose counseling is furnished by a qualified physician or other Medicare-recognized practitioner.  CMS will cover two individual tobacco cessation counseling attempts per year. Each attempt may include a maximum of four intermediate or intensive sessions, with the total annual benefit thus covering up to eight sessions per Medicare beneficiary who uses tobacco. The practitioner and patient have the flexibility to choose between intermediate (more than three minutes) or intensive (more than ten minutes) cessation counseling sessions for each attempt.  This decision memorandum does not modify existing coverage for minimal individual cessation counseling (three minutes or less), which is already covered as part of each Evaluation and Management (E&M) visit and is not separately billable. onPoint Oncology LLC18

19  The new statute clarifies that the term “other services related to the admission” includes “all services that are not diagnostic services (other than ambulance and maintenance renal dialysis services) for which payment may be made by” Medicare that are provided by a hospital to a patient: (1) on the date of the patient’s inpatient admission, or (2) during the 3 days (or in the case of a hospital that is not a subsection (d) hospital, during the 1 day) immediately preceding the date of admission unless “the hospital demonstrates (in a form and manner, and at a time, specified by the Secretary) that such services are not related to such admission.” The statute makes no changes to the billing of diagnostic services.  The provision is effective for services furnished on or after June 25, 2010, the date of enactment of the Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of The provision also prohibits Medicare from reopening, adjusting or making payments when hospitals submit new claims or adjustment claims for services that were provided prior to the date of enactment in order to separately bill outpatient non-diagnostic services.  Will this ever cross over to Part B?? 19onPoint Oncology LLC

20  Part B Offices ◦ Dose versus billed  Fulvestrant  Palonosetron  Filgrastim 480 mcg  Dolasetron  Rituximab  Leuprolide  Paclitaxel  Cetuximab  Abraxane onPoint Oncology LLC20

21  Hospital Outpatient ◦ Units Billed versus Dose  Tenecteplase  Pamidronate sodium  Adenosine  Zoledronic Acid  Irinotecan  Docetaxel  Carboplatin  Bevacizumab  Darbepoetin onPoint Oncology LLC21

22  Both Settings ◦ CSW During Hospital Stay ◦ Admit Order for Admission ◦ Blood Transfusions ◦ IV Hydration ◦ Pegfilgrastim Units of Service  Other Issues ◦ Medical Necessity Inpatient ◦ DRGs Reviewed onPoint Oncology LLC22

23 Connolly: Medical Record Submission  We will accept paper medical records, but we suggest submitting medical records via CD/DVD  Adhere to the provider medical record submission requirements ◦ See Handout Instructions  Make sure all medical record images are sent in a tamper-proof package  Strongly suggest that all medical records be sent on CD/DVD via trackable carriers ◦ FedEx, UPS, DHL, registered USPS mail, etc.

24 Connolly Key RAC Personnel  Dr. James Lee, D.O. ◦ Medical Director and Registered Pharmacist  Thomas Gallo, Principal ◦ Operations  Christine Castelli, Principal ◦ Client Relations / Quality Assurance

25 Connolly Resources  Connolly RAC toll free phone number ◦  Connolly RAC fax number ◦  Connolly website & address ◦ ◦  Connolly RAC office address ◦ The Navy Yard Corporate Center One Crescent Drive, Suite 300-A Philadelphia, PA  Christine Castelli ◦

26 June 25, 2010

27  On June 25, 2010, the Centers for Medicare & Medicaid Services (CMS) posted a proposed notice for Medicare payments in the physician fee schedule for calendar year (CY)  Many of these provisions were specified in Health Reform (“ACA”). The final rule (CMS-1502-P) affects physicians and office payment for services paid under the resource-based relative value scale/system (RBRVS), also known as, the Medicare Physician Fee Schedule.  Here are the highlights of the PROPOSED RULE. Remember that this is a proposal, not the law. https://www.cms.gov/PhysicianFeeSched/PFSFRN/list.asp#TopOfPage 27onPoint Oncology LLC

28  SGR: The current conversion factor is $ with the recent 2.2% increase, effective June 1. The Medicare law includes the standard statutory formula that will require (absent Congressional intervention) CMS to implement a minus 6.1 percent update in payment rates for physician- related services. This cut will be on top of the percent reduction, now delayed until December 1,  Practice Expense: CMS continues for the second year (at a 50/50 blend), the phasing-in over four years the implementation of the American Medical Association (AMA) Physician Practice Information Survey (PPIS) data administered in 2007/08 for practice expense (PE) indirect per hour rate. Oncology is still using the AMA SMS data series. Of interest is this year's calculation of practice expense for drug administration because many of our codes were bumped up slightly to include some supplies. https://www.cms.gov/PhysicianFeeSched/PFSFRN/list.asp#TopOfPage 28onPoint Oncology LLC

29  The Medicare Economic Index: You may ask yourself why this is being discussed. Because, if you just look at the RVUs, you’d think we’re getting a big, huge increase in almost all of our services. But, in order to re- base this silly update factor called the MEI: ◦ CMS added a factor of to ALL practice expense RVUs and a factor of to all malpractice RVUs. ◦ CMS rebased the conversion factor using.921, yielding a -1% change for hematology-oncology. 29onPoint Oncology LLC

30 Impact of the MEI (No conversion factor impact noted) 30onPoint Oncology LLC

31  Related –TC of Imaging Codes Get Cuts: Well, of course, this is happening in July But, what it means is that, as of July 6, you will get a cut of 50% for secondary –TCs of related procedures in the same family of imaging procedures. This was codified in the proposed rule, but it is happening THIS WEEK.  GPCIs: For several years, including 2010, there was a 1.00 ‘floor’ on GPCIs in places where the work GPCI fell further than that. Upholding 1.00 was a really cool for some folks. It will not be upheld next year with the following exceptions. Alaska will have a GPCI floor of 1.5. The “frontier states” will have a practice expense GPCI floor of 1.00 as well as a work GPCI of Frontier states include: Montana, Wyoming, North Dakota, Nevada, South Dakota. Additionally, Medicare used housing data to change everybody’s GPCIs.  Telehealth Services: To perform telehealth services, there must be two- way communication between provider and patient, plus you must be in HPSA (Health Provider Shortage) area or outside an MSA. Additional services proposed as allowable in 2011 are (every three days) and every 30 days. 31onPoint Oncology LLC

32  Physician Extenders: They are sometimes known as NPs and PAs. It is proposed that they can now perform certification and periodic re-certification for SNF patients.  Bone density payment: The proposal calls for these to be paid 70% of the 2006 RVUs at the 2006 conversion factor with this year’s GPCIs for codes This is retroactive to January 1,  Payment for Biosimilars: Here is the payment formula for drugs that are ‘similar’ to today’s biologics. Down the road, we will see lots of these in cancer treatment for sure… ◦ A biosimilar is a product approved under an abbreviated application for a license of a biological product that relies on a license of another biologic. ◦ The payment for these biosimilar products will be the sum of all ASPs assigned to a biosimilar products divided by all applicable units plus six percent. 32onPoint Oncology LLC

33  Waiver of Cost Sharing for Preventive Services: The ACA requires that CMS establish regulations that will waive the deductible and coinsurance requirements for some preventive services, including the following (there are others that would not be performed by most cancer practices): ◦ Annual wellness visits, ◦ Initial preventive physician examination, depending upon CMS feed- back, ◦ Screening mammography, ◦ Pneumococcal, influenza, hepatitis B vaccinations, ◦ PAPs/pelvics, ◦ Prostate screening, ◦ Colorectal screening, even if a screening exam becomes therapeutic (e.g. removal of polyps), ◦ Bone mass measurement, ◦ And, maybe, smoking screening and cessation, if this gets good comments. https://www.cms.gov/PhysicianFeeSched/PFSFRN/list.asp#TopOfPage 33onPoint Oncology LLC

34  Primary Care Bonus Payments: Primary Care in certain areas is getting a bonus under certain conditions. The ACA (Health Reform) requires that CMS implement a 10% bonus for providers designated as family medicine, internal medicine, geriatrics, or pediatrics that furnish primary care services effective January 1, The ACA limits the bonus payments to practitioners whose allowed charges consist of 60% or more of primary care services (codes , , and ). Providers may get this bonus in addition to a HPSA bonus, which we call the “Boonie Bonus”. There is also a 10% bonus for surgeons performing procedures in a HPSA area https://www.cms.gov/PhysicianFeeSched/PFSFRN/list.asp#TopOfPage 34onPoint Oncology LLC

35  Self-Referral Disclosure Law: The good news is that, while the law said it was retro to January 1, this is not effective right now, and so you can stop doing it. The Affordable Care Act (ACA) amends the in-office ancillary services exception to the self-referral law as applied to magnetic resonance imaging, computed tomography, and positron emission tomography, to require a physician to disclose to a patient in writing at the time of the referral a list of other suppliers who perform the same services in the area in which the patient resides. Here’s the bad news: CMS is proposing to require that the referring physician follow the following guidelines: ◦ A list of ten alternative ‘suppliers’ (not a hospital) within a 25-mile radius of the physician’s office who provide the same imaging services. The list must include no less than 10 suppliers. ◦ The list must include, name, address, phone number and distance from the physician’s office at the time of the referral. If there is no one they can go to, tell the patient they can get these tests in other facilities. ◦ The list is to be given to the patient at the time of referral. ◦ A signature on the disclosure is required and must be maintained in the medical record. CMS is currently not proposing to expand the list of procedures affected by this policy. ◦ Emergency situations are not an exception. ◦ Exceptions include patients who are not on Medicare at the time of the referral.  Equipment Utilization Rate: Medicare law requires CMS to implement a 75 percent equipment utilization rate assumption to expensive diagnostic imaging equipment in a non-budget neutral manner for CY 2011, and the changes to PE RVUs will not be transitioned over a period of years. All other codes will remain at the 50 percent equipment assumption rate. In general, the codes affected by the 75 percent utilization rate are PET, CT and MRI codes. 35onPoint Oncology LLC

36  Drugs: The proposed rule maintains the current average sales price (ASP) + 6% reimbursement for Part B drugs; however, it includes proposed changes to ASP reporting, thresholds, and vial amounts. ◦ Among other provisions, if the manufacturer is late with quarterly reporting, the CMS proposes to update ASPs by carrying over the previously reported manufacturer ASP for applicable national drug code(s) (NDC(s)). This is called the “carry over” methodology, not to be confused with “the hang-over” methodology, which is when ASPs are calculated after a night in Vegas. This method will not be implemented if there are not a significant number of involved NDCs. But, manufacturers are still subject to Civil Monetary Penalties, if they make a habit of not submitting ASPs. ◦ CMS also proposes to update the regulations to clearly state that Medicare will not pay for amounts of “overfill”, i.e. product in excess of the amount reflected on the FDA-approved label. The ASP plus 6% will be paid for FDA-approved amounts in the vial, but practices may not bill for and/or pool their overfill. ◦ Partial quarter ASPs for new drugs were also discussed in the proposed rule. Single- source drugs will be priced at WAC, plus 6% for that quarter and multisource and line extension drugs will be added to the weighted average of applicable NDCs. ◦ CMS also proposes to maintain the applicable threshold percentage for price substitution of WAMP or AMP for two consecutive quarters at 5%, and outlines a new proposal for price substitution at 103% of average manufacturer price (AMP) in certain circumstances when the ASP exceeds the AMP by 5% or more. WAMP will not be used in price substitution, according to the proposal. Any ASP substitutions would have to be reviewed on a quarterly basis. 36onPoint Oncology LLC

37  Signature on Requisition: CMS proposes to require a physician’s or a non-physician practitioner’s signature on requisitions for clinical diagnostic laboratory tests paid under the Clinical Lab Fee Schedule. This has gotten very negative comments in the past. ◦ CMS believes that signatures are already required on orders for clinical diagnostic laboratory tests paid under the Clinical Lab Fee Schedule and there is confusion about the difference between an order and a requisition. ◦ The proposed policy will also be consistent with the requirement that orders for diagnostic tests paid under the MPFS must be signed by a physician or appropriate non- physician practitioner.  One-year filing for Part B claims: There has already been a transmittal about this. But, starting January 1, 2010, there will be a one-year filing deadline for claims. 37onPoint Oncology LLC

38  PQRI for 2011: This year, there are 198 proposed measures. Like last year, there are 2 reporting periods: 6 months and 12 months. Other proposed changes to PQRI applicable to office-based cancer practices include: ◦ Registries: CMS once again emphasized that Registries are the way to go for more accuracy in PQRI data submission. CMS wants to get away from claims submissions ASAP. New cancer registry: ◦ Success Criteria: It is PROPOSED for claims ONLY that you report on at least 3 measures (if applicable) AND you report on at least 50% of applicable patients, instead of 80%---which would still be the rate for EMR/EHR or Registry submission. ◦ Measures Groups: There are still no Measures Groups in cancer. There are some that apply if you perform screening procedures or if you are multi-specialty. You must report consecutive Medicare patients in 2011, not all patients. There is no EHR submission for Measures Groups. ◦ Group Practices: Two types of group practices are proposed to report in First are practices over 200 eligible providers called GPROI. Then there are groups eligible providers called GPROII. To report as a GPROII, you must self-nominate; be in the first 500 practices to do so after the beginning of the year 2011; and, you must report at least one of GPROII groups, which do not apply to many cancer practices. CMS is looking for specialty measures groups for GPROII. ◦ Deleted Measures: These measures used by cancer folks are leaving (maybe) in 2011:  Measures 114 and 115 for Tobacco Use (more later about this);  Measure 136 for Melanoma ◦ Measures Reportable by Registry Only: These are the same as last year:  : Melanoma  : Pain In Cancer Measures 38onPoint Oncology LLC

39  PQRI 2011 ◦ New Measures: Remember that more can be added in the final rule!  Melanoma: Overuse of Radiation in Stages 0-1A  Mammography: Reminder System  Tobacco: Screening/ Cessation/ Interventions ◦ EHR Reporting: If you have a certified (by CMS) EHR/EMR that can submit data to CMS for you, you can report using your EMR. Here are some :  Immunizations: Influenza and pneumonia  Screening Mammography  Therapy or screening for osteoporosis  Colorectal screening  EHR Use (duh—obvious if you are submitting by EHR)  Tobacco use and cessation  Advance care plan  Alcohol screening (on the patients, not the staff) 39onPoint Oncology LLC

40  PQRI Proposed 2011 ◦ MOCP (Maintenance of Certification) Adjustment: Certain certifying agencies board- certify physicians and their facilities. If you meet these criteria. This is a health reform provision. Beginning in 2011, provides an additional 0.5% PQRI bonus for 3 years ( ) if physicians and other eligible professionals report quality data to the PQRI through a maintenance of certification (MOC) process, and after 2014, the Secretary could require participation in an MOC as part of the physician cost/quality index under section 3007 of ACA. ◦ Public Reporting: the “Medicare Compare” web site was supposed to be up and running 1/1/2011 with all the PQRI and E-Rx success stats for providers. That deadline will now be Um, whoops… ◦ Integration of PQRI and “Meaningful Use” ARRA incentive: It is proposed that, in 2012, there will be measures that obviate use of EHR, plus quality of care. This reportedly is to avoid duplication, as you will not be able to get ARRA incentives along with e- prescribing. ◦ Appeals: For the first time in 2011, it is proposed that the determination of whether or not EPs qualify for the incentive may be appealed through an ‘informal’ appeal through ever-popular ◦ Interim Feedback: CMS proposes to provide feedback to participating providers in June 2011 about their PQRI incentive status. Maybe, they should have done this when the incentive was 2%. https://www.cms.gov/PhysicianFeeSched/PFSFRN/list.asp#TopOfPage 40onPoint Oncology LLC

41  E-Prescribing: E-prescribing will pay 1% of the providers’ billed and allowed fee schedule services (all services paid by RVUs) in is the last year where you will not be penalized, if you do not participate if you qualify is the year that those that should be penalized will be identified. The penalty only exists for those who do not have at least 100 cases in the denominator codes (mostly E/M); who do not report at least 10 encounters in 2012 or, do not qualify as a physician or physician extender who has at least 10% of fee schedule revenue in the denominator codes. ◦ Measures: Exactly the same as in 2010, unless you are reporting under GPROI or GPROII, i.e. as a group practice. Then, the number depends entirely upon your group’s size. ◦ Reporting period: Calendar year, but data 1/1/2011-6/30/2011 will be used to identify those who should be penalized. So, you must report at least 50% before 6/30/11. ◦ Reporting mechanisms: Registries, claims, or EHR (if you are reporting PQRI this way) ◦ Hardship exceptions—there will be new G-codes for these:  Rural practices with no high speed internet OR  Providers near pharmacies that do not process e-rx. https://www.cms.gov/PhysicianFeeSched/PFSFRN/list.asp#TopOfPage 41onPoint Oncology LLC

42 Implementing the American Reinvestment & Recovery Act of 2009

43 American Reinvestment & Recovery Act – February 2009 EHR Incentive NPRM on Display – December 30, 2009; published January 13, 2010 NPRM Comment Period Closes – March 15, 2010 Final Rule Published 7/13/ onPoint Oncology LLC

44  Definition ◦ To be determined by Secretary ◦ Must include quality reporting, electronic prescribing, information exchange  Process of defining ◦ NCVHS Hearings ◦ HIT Policy Committee recommendations ◦ Listening Sessions with providers/organizations ◦ Public Comments on the HIT Policy Committee recommendations ◦ NPRM comments received from the Department and OMB 44onPoint Oncology LLC

45 Data capture and sharing Advanced clinical processes Improved outcomes 45onPoint Oncology LLC

46 Meaningful Use will be defined in 3 stages through rulemaking ◦ Stage 1 – 2011 ◦ Stage 2 – 2013 * ◦ Stage 3 – 2015 * *Stages 2 and 3 will be defined in future CMS rulemaking. 46onPoint Oncology LLC

47 MedicareMedicaid Feds will implement (will be an option nationally) Voluntary for States to implement (may not be an option in every State) Fee schedule reductions begin in 2015 for providers that are not Meaningful Users No Medicaid fee schedule reductions Must be a meaningful user in Year 1Adopt/Implement/Upgrade option for 1 st participation year Maximum incentive is $44,000 for EPsMaximum incentive is $63,750 for EPs MU definition will be common for MedicareStates can adopt a more rigorous definition (based on common definition) Medicare Advantage EPs have special eligibility accommodations Medicaid managed care providers must meet regular eligibility requirements Last year an EP may initiate program is 2014; Last payment in program is Payment adjustments begin in 2015 Last year an EP may initiate program is 2016; Last payment in program is 2021 Only physicians, subsection (d) hospitals and CAHs 5 types of EPs, 3 types of hospitals 47onPoint Oncology LLC

48 YearIncentivesPenalties for Non-Compliance 2011$18,000, $12,000, $8,000, $4,000, $2,000 $0 2012$18,000, $12,000, $8,000, $4,000, $2,000 $0 2013$15,000, $12,000, $8,000, $4,000$0 2014$12,000, $8,000, $4,000$0 2015$0-1% in Medicare Fee Schedule 2016$0-2% in Medicare Fee Schedule 2017 & beyond$0-3% in Medicare Fee Schedule

49 TOTAL Adopt 2011 $18,000$12,000$8,000$4,000$2,000$0 $44,000 Adopt $18,000$12,000$8,000$4,000$2,000$0$44,000 Adopt $15,000$12,000$8,000$4,000$0$39,000 Adopt $12,000$8,000$4,000$0$24,000 Adopt $0

50  Incentives will start in 2011 for adoption, implementation, upgrade, maintenance, and operation of a certified EHR ◦ Up to $63,750  No Medicaid payment reductions if a provider does not adopt certified EHR technology  To be eligible for Medicaid providers are required to waive Medicare EHR incentive payments  Incentives for up to 85% of costs for EHR ◦ Caps: 1 st year payment at $25,000 ◦ Caps: following years at $10,000/year  1 st yr cost no later than 2016  No payments made after 2021 or more than 5 years 50onPoint Oncology LLC

51 ProvidersMedicaid Patient Volume Non-hospital based providers≥ 30% Non-hospital based pediatrician≥ 20% Physician who practices in federally qualified health center or rural health clinic ≥ 30% attributable to needy individuals Children’s hospitalsNo requirement needed Acute-Care hospitals≥ 10%

52 * Hospital-based professionals excluded from incentives

53 80%-Objective part of standard practice-e.g.- maintain active medication list Others-defined on a case-by-case basis based on commenter or clearance feedback Example-e-prescribing set at 40% lowered from 75% to address concerns by commenters regarding non-participation by pharmacies and patient preference. 53

54 Health Outcomes Policy Priority Stage 1 ObjectiveStage 1 Measure Improving quality, safety, efficiency, and reducing health disparities Use CPOE for medication orders directly entered by any licensed healthcare professional who can enter orders into the medical record per state, local, and professional guidelines More than 30% of unique patients with at least one medication in their medication list seen by the EP or admitted to the eligible hospital or CAH have at least one medication entered using CPOE Implement drug-drug and drug-allergy interaction checks The EP/eligible hospital/CAH has enabled this functionality for the entire EHR reporting period EP Only: Generate and transmit permissible prescriptions electronically (eRx) More than 40% of all permissible prescriptions written by the EP are transmitted electronically using certified EHR technology Record demographics: preferred language, gender, race, ethnicity, date of birth, and date and preliminary cause of death in the event of mortality in the eligible hospital or CAH More than 50% of all unique patients seen by the EP or admitted to the eligible hospital or CAH have demographics as recorded structured data Maintain up-to-date problem list of current and active diagnoses More than 80% of all unique patients seen by the EP or admitted to the eligible hospital or CAH have at least one entry or an indication that no problems are known for the patient recorded as structured data

55 Health Outcomes Policy Priority Stage 1 ObjectiveStage 1 Measure Improving quality, safety, efficiency, and reducing health disparities Maintain active medication listMore than 80% of all unique patents seen by the EP or admitted to the eligible hospital or CAH have at least one entry (or an indication that the patient is not currently prescribed any medication) recorded as structured data Maintain active medication allergy listMore than 80% of all unique patents seen by the EP or admitted to the eligible hospital or CAH have at least one entry (or an indication that the patient has no known medication allergies) recorded as structured data Record and chart vital signs: height, weight, blood pressure, calculate and display BMI, plot and display growth charts for children 2-20 years, including BMI For more than 50% of all unique patients age 2 and over seen by the EP or admitted to the eligible hospital or CAH, height, weight, and blood pressure are recorded as structured data Record smoking status for patients 13 years old or older More than 50% of all unique patients 13 years or older seen by the EP or admitted to the eligible hospital or CAH have smoking status recorded as structured data Implement one clinical decision support rule and the ability to track compliance with the rule Implement one clinical decision support rule Report clinical quality measures to CMS or the StatesFor 2011, provide aggregate numerator, denominator, and exclusions through attestation; For 2012, electronically submit clinical quality measures

56 Health Outcomes Policy Priority Stage 1 ObjectiveStage 1 Measure Engage patients and families in their healthcare Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, medication allergies, discharge summary, procedures), upon request More than 50% of all unique patients of the EP, eligible hospital or CAH who request an electronic copy of their health information are provided it within 3 business days Hospitals Only: Provide patients with an electronic copy of their discharge instructions at time of discharge, upon request More than 50% of all patients who are discharged from an eligible hospital or CAH who request an electronic copy of their discharge instructions are provided it EPs Only: Provide clinical summaries for each office visitClinical summaries provided to patients for more than 50% of all office visits within 3 business days Improve care coordination Capability to exchange key clinical information (ex: problem list, medication list, medication allergies, diagnostic test results), among providers of care and patient authorized entities electronically Performed at least one test of the certified EHR technology’s capacity to electronically exchange key clinical information Ensure adequate privacy and security protections for personal health information Protect electronic health information created or maintained by certified EHR technology through the implementation of appropriate technical capabilities Conduct or review a security risk analysis per 45 CFR (a)(1) and implement updates as necessary and correct identified security deficiencies as part of the EP’s, eligible hospital’s or CAH’s risk management process

57 Health Outcomes Policy Priority Stage 1 ObjectiveStage 1 Measure Improving quality, safety, efficiency, and reducing health disparities Implement drug-formulary checksThe EP/eligible hospital/CAH has enabled this functionality and has access to at least one internal or external drug formulary for the entire EHR reporting period Hospitals Only: Record advance directives for patients 65 years old or older More than 50% of all unique patients 65 years old or older admitted to the eligible hospital or CAH have an indication of an advance directive status recorded Incorporate clinical lab-test results into certified EHR technology as structured data More than 40% of all clinical lab test results ordered by the EP, or an authorized provider of the eligible hospital or CAH, for patients admitted during the EHR reporting period whose results are either in a positive/negative or numerical format are incorporated in certified EHR technology as structured data Generate lists of patients by specific conditions to use for quality improvement, reduction of disparities, research or outreach Generate at least one report listing patients of the EP, eligible hospital or CAH with a specific condition EPs Only: Send reminders to patients per patient preference for preventive/follow-up care More than 20% of all unique patients 65 years or older or 5 years old or younger were sent an appropriate reminder during the EHR reporting period

58 Health Outcomes Policy Priority Stage 1 ObjectiveStage 1 Measure Engage patients and families in their health care EPs Only: Provide patients with timely electronic access to their health information (including lab results, problem list, medication lists, medication allergies) within 4 business days of the information being available to the EP More than 10% of all unique patients seen by the EP are provided timely (available to the patient within 4 business days of being updated in the certified EHR technology) electronic access to their health information subject to the EP’s discretion to withhold certain information Use certified EHR technology to identify patient- specific education resources and provide those resources to the patient, if appropriate More than 10% of all unique patients seen by the EP or admitted to the eligible hospital or CAH are provided patient-specific education resources Improve care coordination The EP, eligible hospital or CAH who receives a patient from another setting of care or provider of care or believes an encounter is relevant should perform medication reconciliation The EP, eligible hospital or CAH performs medication reconciliation for more than 50% of transitions of care in which the patient is transitioned into the care of the EP or admitted to the eligible hospital or CAH The EP, eligible hospital or CAH who receives a patient from another setting of care or provider of care or refers their patient to another provider of care should provide a summary of care record for each transition of care or referral The EP, eligible hospital or CAH who transitions or refers their patient to another setting of care or provider of care provides a summary of care record for more than 50% of transitions of care and referrals

59 Health Outcomes Policy Priority Stage 1 ObjectiveStage 1 Measure Improve population and public health 1 Capability to submit electronic data to immunization registries or Immunization Information Systems and actual submission in accordance with applicable law and practice Performed at least one test of the certified EHR technology’s capacity to submit electronic data to immunization registries and follow-up submission if the test is successful (unless none of the immunization registries to which the EP, eligible hospital or CAH submits such information have the capacity to receive such information electronically) Hospitals Only: Capability to submit electronic data on reportable (as required by state or local law) lab results to public health agencies and actual submission in accordance with applicable law and practice Performed at least one test of certified EHR technology’s capacity to provide submission of reportable lab results to public health agencies and follow-up submission if the test is successful (unless none of the public health agencies to which the EP, eligible hospital or CAH submits such information have the capacity to receive such information electronically) Capability to submit electronic syndromic surveillance data to public health agencies and actual submission in accordance with applicable law and practice Performed at least one test of certified EHR technology’s capacity to provide electronic syndromic surveillance data to public health agencies and follow- up submission if the test is successful (unless none of the public health agencies to which the EP, eligible hospital or CAH submits such information have the capacity to receive such information electronically) 1 Unless an EP, eligible hospital or CAH has an exception for all of these objectives and measures they must complete at least one as part of their demonstration of the menu set in order to be a meaningful EHR user.

60 Registration for the EHR Incentive Programs will begin in January 2011 For Medicare providers, attestation for the EHR Incentive Programs will begin in April 2011 EHR incentive payments will be made 11 months after the rule is published* For Medicaid providers, States may launch their programs in January 2011 and thereafter November 30, 2011 – Last day for eligible hospitals and CAHs to register and attest to receive an incentive payment for FFY 2011 (Medicare providers) February 29, 2012 – Last day for EPs to register and attest to receive an incentive payment for CY 2011 (Medicare providers) 2015 – Medicare payment adjustments begin for EPs and eligible hospitals that are not meaningful users of EHR technology** 2016 – Last year to receive a Medicare EHR incentive payment; Last year to initiate participation in Medicaid EHR Incentive Program** 2021 – Last year to receive Medicaid EHR incentive payment**  **Statutory 60

61 61

62  New Hem-Onc Codes ◦ Red blood cell disorders (275.0_) ◦ Transfusion circulatory overload (276.61) ◦ Post-transfusion purpura (287.41) ◦ Other secondary thrombocytopenia (287.49) ◦ Febrile non-hemolytic transfusion reaction (780.66) ◦ Jaw pain (784.92) ◦ Hemoptysis, unspecified (786.30) ◦ Feces disorders (787.6_) ◦ Transfusion reactions (999.6_-999.8_) ◦ Do not resuscitate status (V49.86) 62onPoint Oncology LLC

63  Iron Disorders (275)  Fluid disorders (276.6)  Secondary thrombocytopenia (287.4)  Hemoptysis (786.3)  Incontinence of feces (787.6) 63onPoint Oncology LLC

64  Make sure you have gotten correct payments from Medicare.  Understand Medicare fee schedule impact on private insurance company contracts.  Ascertain your vendor’s plan for Meaningful Use in 2010 for implementation in  Start planning for PQRI and E-Rx or ARRA in  Check to make sure you are NOT billing overfill in your facility.  Think about alternative revenue streams—oral drugs, trials, etc.  Participate in the struggle—2011 is a false positive. 64onPoint Oncology LLC

65  CAN Web Site ◦ The latest news ◦ Forms ◦ Regulations ◦ Newsletters ◦ Presentations ◦ 65onPoint Oncology LLC

66 66  Contact ◦ ◦ ◦  Newsletter is free!  Send all RAC information to me at the ABOVE s or FAX to  Go to our website: onPoint Oncology LLC

67 67 onPoint Oncology LLC


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