Presentation on theme: "Bobbi Buell MBA 800-795-2633 Reimbursement 2012. Agenda onPoint Oncology LLC 2 What’s Going On Right Now Medicare PFS Final Rule 11-1-2011 PQRS and E-Prescribing."— Presentation transcript:
Agenda onPoint Oncology LLC 2 What’s Going On Right Now Medicare PFS Final Rule 11-1-2011 PQRS and E-Prescribing 2012 Meaningful Use/ HIT 2012 Hospital Outpatient Prospective Payment System Final Rule New Payment Models Coding 2012 Your To Do List
onPoint Oncology LLC 3 Disclaimer 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 for 2012 is still being evaluated. 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. ICD-9-CM information is abbreviated and coders are urged to check the tabular lists of code books for correct coding. 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 Medicare Physician Payment Basics 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 1.00. (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.
SGR Update onPoint Oncology LLC 5 SGR is frozen for two months. With no fix, a 27.4% decline. GPCI floor is frozen for two months. The fee schedule CF has been adjusted for ‘budget neutrality’. So, the new allowables have nothing to do with the original one. But, RVUs are the same. Congress has looked at a longer fix, but expect a fight. Probable case = 1-2 year fix.
A Little History… 6 YearMedicare ActsConversion1st Hour $DrugsOther 1991Proposed MPFS$30.00$58.7885% of AWPDrugs now paid at 2-3 times AWP 1993Final MPFS$31.00N/A100% of AWP 99213 = $31.00 1994Cancer Coverage Improvement Act $33.72 and $32.90 N/A100% of AWP Off-label use approved; oral cancer drugs Part B 1996HIPAA passed$35.42 and $34.63 N/A100% of AWP False Claims Act for Medicare 1997BBA of 1997$36.69N/A95% of AWPOral anti- emetics passed (c) onPoint Oncology LLC
A Little History 7 Year Medicare Acts Conversion1st Hour $ DrugsOther 1998None of Note$36.69N/A95% of AWP or inherent reasonableness LCA for LUPRON 1999None of Note$34.73N/A95% of AWP26 states have off label laws 2000None of Note$36.61$61.9095% of AWPDrug pricing investigated 2001None of Note$38.26$62.0095% of AWPAredia goes generic 2002Single Drug Pricer $36.20N/A95% of AWP under SDP Taxol goes generic (c) onPoint Oncology LLC
A Little History 8 Year Medicare Acts Conversion1st Hour $DrugsOther 2003Passed MMA for 2004 $36.79$59.2295% of AWPRACs approved 2004MMA$37.34$217.3585% of AWP for some drugs 99211 denied with drugs 2005Demo Project$37.90$177.61ASP, plus 6%$130 per visit for demo 2006Demo Project$37.90$172.81ASP, plus 6%$26 per visit for demo 2007PQRI$37.90$165.99ASP, plus 6%IVIG in shortage 2008ESAs limited$38.09$161.49ASP, plus 6%40% denial rate on ESAs beginning of the year (c) onPoint Oncology LLC
A Little History 9 Year Medicare Acts Conversion1st Hour $DrugsOther 2009ARRA, MIPPA $36.07$147.51 (- 32.1% since 2004) ASP, plus 6% 2010None of NoteMany$140.72ASP, plus 6%PQRS/ ERx = 4% incentive 2011None of Note$33.98$146.44ASP, plus 6%MUEs, Drug Shortages (c) onPoint Oncology LLC
11/1/2011 Medicare Physician Fee Schedule PFS Final Rule 2012
MPFS 2012 onPoint Oncology LLC 11 On November 1, 2011, the Centers for Medicare & Medicaid Services (CMS) posted a proposed notice for Medicare payments in the physician fee schedule for calendar year (CY) 2012. Here are the highlights of Rule which becomes effective for dates of service on or after 1-1-2012. https://www.cms.gov/PhysicianFeeSched/PFSFRN/list.asp#TopOfPage
Reductions Will Occur for Most Chemotherapy Administration Codes (1 of 2) CPT CodeDescriptor Final 2011Final 2012 Difference in RVUs Difference in Payment* Total RVUs MPFS PaymentTotal RVUs MPFS Payment* 96401Chemo anti- neopl sq/im 2.14$72.712.15$53.040.47%-27.05% 96402Chemo hormon antineopl sq/im 1.03$35.000.99$24.42-3.88%-30.21% 96405Chemo intralesional up to 7 2.53$85.962.49$61.43-1.58%-28.54% 96406Chemo intralesional over 7 3.48$118.243.55$87.582.01%-25.93% 96409Chemo iv push sngl drug 3.32$112.803.26$80.43-1.81%-28.70% 96411Chemo iv push addl drug 1.86$63.201.83$45.15-1.61%-28.56% 96413Chemo iv infusion 1 hr 4.31$146.444.07$100.41-5.57%-31.43% 96415Chemo iv infusion addl hr 0.92$31.260.90$22.20-2.17%-28.97% 96416Chemo prolong infuse w/pump 4.75$161.394.06$100.17-14.53%-37.94% Source: Centers for Medicare & Medicaid Services (CMS). Calendar Year 2012 Medicare Physician Fee Schedule Final Rule (CMS-1524-FC). Released November 1, 2011. *These payment rates reflect the 27.4% across-the-board cut that will occur if Congress does not pass an SGR fix. Assuming Congress acts to avoid the SGR cuts, the changes in RVUs are more reflective of the actual changes in payment rates for these codes in CY 2012.
Reductions Will Occur for Most Chemotherapy Administration Codes (2 of 2) CPT CodeDescriptor Final 2011Final 2012 Difference in RVUs Difference in Payment Total RVUs MPFS PaymentTotal RVUs MPFS Payment 96417Chemo iv infus each addl seq 2.13$72.372.09$51.56-1.88%-28.75% 96420Chemo ia push tecnique 3.21$109.063.15$77.71-1.87%-28.74% 96422Chemo ia infusion up to 1 hr 5.16$175.324.99$119.58-3.29%-31.79% 96423Chemo ia infuse each addl hr 2.35$79.842.29$54.88-2.55%-31.26% 96425Chemotherapy infusion method 5.29$179.745.23$125.33-1.13%-30.27% 96440Chemotherapy intracavitary 21.45$728.7924.31$599.7613.33%-17.71% 96446Chemotx admn prtl cavity 5.21$177.025.58$137.676.63%-28.58% 96450Chemotherapy into cns 5.85$198.765.50$135.69-5.98%-31.73% 96542Chemotherapy injection 3.74$127.073.61$89.06-3.48%-29.91% Source: Centers for Medicare & Medicaid Services (CMS). Calendar Year 2012 Medicare Physician Fee Schedule Final Rule (CMS-1524-FC). Released November 1, 2011. *These payment rates reflect the 27.4% across-the-board cut that will occur if Congress does not pass an SGR fix. Assuming Congress acts to avoid the SGR cuts, the changes in RVUs are more reflective of the actual changes in payment rates for these codes in CY 2012
Multiple Procedure Payment Reduction (MPPR) Expansion to Include Physician Interpretation CMS finalized its proposal to expand the MPPR, which reduces payment by 25 percent for each second and subsequent advanced imaging service furnished during the same session to the “PC” of advanced imaging services, which represents the physician interpretation of the image Applies to CT, MR, and ultrasound CMS currently applies the MPPR to the TC of the same services CMS will consider the following MPPR policies in CY 2013 and beyond: Apply the MPPR to the TC and PC of all imaging services (e.g., PET) Apply the MPPR to the TC of all diagnostic tests CPTModifierDescription Physician Work RVUs CY 2012 Transitional NF PE RVUs Malpractice RVUs Total NF RVUs CF 1\ NF Payment Current payment Methodology Final Payment Methodology 71250 Global Ct thorax w/o dye 1.025.840.066.92$24.6712$170.72 TC0.005.440.015.45$24.6712$134.461 x $134.46 261.020.400.051.47$24.6712$36.271 x $36.27 72192 Global Ct pelvis w/o dye 1.095.540.066.69$24.6712$165.05 TC0.005.130.015.14$24.6712$126.810.5 x $126.81 261.090.410.051.55$24.6712$38.241 x $38.240.75 x $38.24 Total$322.55$272.38$262.82 Source: Centers for Medicare & Medicaid Services (CMS). Calendar Year 2012 Medicare Physician Fee Schedule Final Rule (CMS-1524-FC). Released November 1, 2011. 1 CF = The final CY 2012 CF is $24.6712 PC = Professional Component TC = Technical Component
MPFS 2012 onPoint Oncology LLC 15 Practice Expense: CMS continues for the third year (at a 50/50 blend), the four-year phase-in of 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. Net year, this process of 5-year review will end and CMS will focus on mis-valued codes. These include 96413, 96367, and 96365. https://www.cms.gov/PhysicianFeeSched/PFSFRN/list.asp#TopOfPage
MPFS 2012 onPoint Oncology LLC 16 Drugs Average Manufacturers’ Price will be price substitution for drugs where AMP is 5% or more below ASP for 2 consecutive quarters prior to the current quarter or for 3 out of the preceding 4 quarters. This match-up will apply to BIOSIMILARS once they are approved. CMS emphasized that 103% of AMP will be the price substitute if the threshold is exceeded per the guidelines. Before implementation, 103% of AMP and 106% of ASP will be compared. The spreadsheet used by Manufacturers will change in 2012. https://www.cms.gov/PhysicianFeeSched/PFSFRN/list.asp#TopOfPage
MPFS 2012 onPoint Oncology LLC 17 The 72-Hour Rule (7/1/2012) One of the most horrible parts of hospital reimbursement is that all “related” services within 72 hours before are bundled into the hospital per discharge payment (MS-DRG). CMS now proposes that, for any physician practice that is totally owned by the hospital or wholly-operated by the hospital, their diagnostic procedures or related therapeutic procedures will be impacted by the 72 hour rule. Professional components will be paid at the facility (not non-facility) rate. –TC will be denied. All other codes will be paid at the facility rate. Practices are responsible for billing with a – PD Modifier, when the patient is admitted, but this is not final until 7/1/2012. Hospitals must notify the practice,
Medicare Physician Fee Schedule PQRS and E-Prescribing 2012
PQRS 2012 onPoint Oncology LLC 19 The PQRS will pay bonuses equal to a 0.5% bonus for reporting years in 2012 through 2014. This is for all fee schedule services, excludes drugs, labs, and DME. In 2015, providers who don't participate in PQRS will suffer a payment decrease. Beginning in 2015, EPs who do not satisfactorily report Physician Quality Reporting System measures will be subject to payment adjustments 2015: -1.5% payment adjustment 2016 and beyond: -2% payment adjustment
MPFS 2012 onPoint Oncology LLC 20 PQRS Changes (Proposed) CMS is making an effort to consolidate PQRS reporting with ARRA HIT incentives for Quality Indicator Reporting. Time frame—a six month reporting period (7/1/2012- 12/31/2012) will only be available for Measures Groups through a Registry. All other reporting must be for the full twelve-month period. Consolidates current Group Practice options to one Group Practice Reporting Option (GPRO) that is defined as 25 or more eligible professionals. 18 measures may be reported under this option. CMS will ‘suggest’ appropriate beneficiaries for reporting. Practices must go through a self-nomination process.
PQRS Changes 2012 onPoint Oncology LLC 21 Measures 26 additional new measures, including 6 for cancer 44 CQM measures that are now reportable to get the ARRA HIT incentive (“Meaningful Use”) 10 measures groups for reporting, none of which are related to cancer Reporting/HIT EHR submission of PQRS data either through a submission vendor or through a qualified EHR system. These must be certified by PQRS.. Can report your CQMs for MU either by attestation or by EHR through a portal or direct from your EHR.
New Cancer Measures 2012 Measure Title Measure DeveloperConsensus StatusReporting Mechanism Immunohistochemical (IHC) Evaluation of HER2 for Breast Cancer Patients CAPN/AClaims, Registry Image Confirmation of Successful Excision of Image–Localized Breast Lesion ASBSN/AClaims, Registry Preoperative Diagnosis of Breast Cancer ASBSN/AClaims, Registry Sentinel Lymph Node Biopsy for Invasive Breast Cancer ASBSN/ARegistry Biopsy Follow-upAADN/ARegistry New Individual Measures for 2012 PQRS Source: Centers for Medicare & Medicaid Services (CMS). Calendar Year 2012 Medicare Physician Fee Schedule Final Rule (CMS-1524-FC). Released November 1, 2011. PQRS = Physician Quality Reporting System CAP = College of American Pathologists ASBS= American Society of Breast Surgeons AAD= American Academy of Dermatology
Why Participate? onPoint Oncology LLC 23 Performance will be the basis for payment in the near future Physician Compare beginning in 2013 http://www.medicare.gov/find-a-doctor/provider- search.aspx
Physician Compare Website onPoint Oncology LLC 24 “Physician Compare for 2011 includes information about physicians and other professionals who participated in the Physician Quality Reporting System. It does not yet contain physician and eligible professional performance information. We expect to have performance information on Physician Compare starting in 2013. This will be for services those providers furnished to Medicare beneficiaries during 2012.”
PQRS Resources onPoint Oncology LLC 26 See on CMS Web Site Frequently Asked Questions Supplemental education materials National Provider Calls Special Open Door Forums QualityNet Help Desk http://www.cms.hhs.gov/PQRI/36_HelpDeskSupport.asp#TopOfPage http://www.cms.hhs.gov/PQRI/36_HelpDeskSupport.asp#TopOfPage 7:00 a.m. - 7:00 p.m. CST at 866-288-8912 or firstname.lastname@example.org
E-Prescribing – Penalties 2012 – 1% reduction 2013 – 1.5% reduction 2014 – 2% reduction 2011 Individual EPs must have : report at least 10 electronic prescriptions to avoid penalty for 2012. Reporting period 1/1/11 – 6/30/11 (processed by 7/31); report at least 25 electronic prescriptions to avoid penalty for 2013. Reporting period 1/1/11 – 12/31/11. 27
E-Prescribing 2012 onPoint Oncology LLC 28 Reporting YearReport 10 Encounters Report 25 Encounters 2011No penalty in 2012No penalty in 2013 2012No penalty in 2013No penalty in 2014 2013No penalty in 2014No penalty in 2015 https://www.cms.gov/PhysicianFeeSched/PFSFRN/list.asp#TopOfPage
E-Rx Reporting onPoint Oncology LLC 29 For successful claims-based reporting in 2012, a single code should be reported (numerator) G8553 – At least one prescription created during the encounter was generated and transmitted electronically using a qualified e-Rx system Must be on the same claim (denominator)–90801, 90802, 90804, 90805, 90806, 90807, 90808, 90809, 90862, 92002, 92004, 92012, 92014, 96150, 96151, 96152, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0101, G0108, G0109
eRx Incentive Payment eRx incentive is percentage of all Medicare fee schedule charges (not including drugs) based on EP’s TIN/NPI. 2011, 2012 – 1% 2013 – 0.5% EPs have until February 28, 2012 to submit CY 2011 claims to show they qualify. 30
eRx Incentive Payment May report through: Claims submissions. Qualified Registry – (Some registries qualify for both PQRS and eRx). Check CMS website for list of registries. Currently 2010 list available: http://www.cms.gov/PQRI/Downloads/Qualified_Registries_Ph ase4_eRxPQRI_06282010_FINAL.pdf http://www.cms.gov/PQRI/Downloads/Qualified_Registries_Ph ase4_eRxPQRI_06282010_FINAL.pdf Qualified EHR – Check CMS website for list. http://www.cms.gov/PQRI/Downloads/QualifiedEHRVendorsfor the2011PhysicianQualityReportingandeRx121310.pdf http://www.cms.gov/PQRI/Downloads/QualifiedEHRVendorsfor the2011PhysicianQualityReportingandeRx121310.pdf 31
eRx – Penalties Penalty Exceptions: Individual EPs EP who is not a physician, NP or PA as of June 30, 2012 EP who does not have 100 cases in applicable codes through 6/30/2012 Physician is unable to electronically prescribe due to local, state, or federal law or regulation (e.g., state law prohibits e-Prescribing of controlled substances) Hardship Exception: Hardship Exception Codes: Use G8642 (practice in rural area without high speed internet access) or G8643 (practice in area without available pharmacies for e- prescribing). Groups Third and fourth exceptions above also apply to GPRO Must go to the CMS web site to register exceptions by 6/30/2012 32
EHR and eRx: Integration & Penalties If an EP gets an EHR incentive in 2011 and 2012, can still get eRx 2012 penalty E-prescribing measures are different E-prescribing system requirements are different If an EP gets an eRx incentive in 2011 and 2012, can still get eRx penalty Reporting periods for incentive and penalty are different For individual EPs (not groups) reporting requirements are different. 33
E-Prescribing MPFS 2012 onPoint Oncology LLC 34 Changes include: Use same coding requirements for the program in 2012. Establish GPRO reporting requirements to be the same as PQRS—25 or more eligible professionals. Modifies the requirements of the program to allow usage of either a qualified e-prescribing system or using a certified EHR system to prescribe. Reporting choices—only one per year-- include: EHR (2 submissions per year) Registry (2 submissions per year) Claims
How Much Are the Incentives? onPoint Oncology LLC 36 Medicare Incentive Payments Detail Columns = first calendar year EP receives a payment Rows = Amount of payment each year if continue to meet requirements CY 2011CY 2012CY 2013CY2014CY 2015 and later CY 2011$18,000 CY 2012$12,000$18,000 CY 2013$8,000$12,000$15,000 CY 2014$4,000$8,000$12,000 CY 2015$2,000$4,000$8,000 $0 CY 2016$2,000$4,000 $0 TOTAL$44,000 $39,000$24,000$0
How Much Are the Incentives? onPoint Oncology LLC 37 Medicaid Incentive Payments Detail Columns = first calendar year EP receives a payment Rows = Amount of payment each year if continue to meet requirements CY 2011CY 2012CY 2013CY 2014CY 2015CY 2016 CY 2011$21,250 CY 2012$8,500$21,250 CY 2013$8,500 $21,250 CY 2014$8,500 $21,250 CY 2015$8,500 $21,250 CY 2016$8,500 $21,250 CY 2017$8,500 CY 2018$8,500 CY 2019$8,500 CY 2020$8,500 CY 2021$8,500 TOTAL$63,750
What is Meaningful Use? onPoint Oncology LLC 38 Meaningful Use is using certified EHR technology to Improve quality, safety, efficiency and reduce health disparities Engage patients and families in their health care Improve care coordination Improve population and public health All the while maintaining privacy and security Meaningful Use mandated in law to receive incentives
A Conceptual Approach to Meaningful Use onPoint Oncology LLC 39 Data capture and sharing Advanced clinical processes Improved outcomes
What You Need to Participate onPoint Oncology LLC 40 All providers must: Register via the EHR Incentive Program website---you need to do this to be exempt from E-prescribing penalties, if the EP did not report. Be enrolled in Medicare FFS, MA, or Medicaid (FFS or managed care) Have a National Provider Identifier (NPI) Use certified EHR technology http://healthit.hhs.gov/certification http://healthit.hhs.gov/certification Medicaid providers may adopt, implement, or upgrade in their first year All Medicare providers and Medicaid eligible hospitals must be enrolled in PECOS, when this is required.
Websites onPoint Oncology LLC 41 Get information, tip sheets and more at CMS’ official website for the EHR incentive programs: http://www.cms.gov/EHRIncentivePrograms http://www.cms.gov/EHRIncentivePrograms Eligibility Meaningful Use Medicaid State Information Educational Materials National CMS Listserv: http://www.cms.gov/EHRIncentivePrograms/65_CMS_EHR_Listserv. asp http://www.cms.gov/EHRIncentivePrograms/65_CMS_EHR_Listserv. asp Frequently Asked Questions: http://www.cms.gov/EHRIncentivePrograms/95_FAQ.asp http://www.cms.gov/EHRIncentivePrograms/95_FAQ.asp Registration for the EHR Incentive Programs: http://www.cms.gov/EHRIncentivePrograms/20_RegistrationandAttes tation.asp http://www.cms.gov/EHRIncentivePrograms/20_RegistrationandAttes tation.asp
Educational Materials onPoint Oncology LLC 42 www.cms.gov/EHRIncentivePrograms/55_EducationalMaterials.asp Resources Available: Meaningful Use Calculator, Incentive Program Timelines, Webinars, Eligibility Flow Chart and Interactive Tool, CMS ListServe, and more
Fee Schedule Changes to MU Incentive onPoint Oncology LLC 43 For 2012 Reporting of Clinical Quality Measures (CQMs): Attestation as it is today Overlap PQRS with HIT Incentives oCan delay your HIT incentive oYou may submit two ways: Through a portal Directly from an approved (by PQRS) EHR
Final Rule 2012 Medicare Hospital Outpatient Prospective Payment System (OPPS):
Increase in Threshold to Determine Whether Drugs are Paid Separately Medicare uses two methods to pay for drugs and biologicals in the hospital outpatient setting: Bundled: Payment for products with a per dose cost under a specified threshold are included in payment for administration or associated services Separately Paid: Payment for products with a per dose cost above the specified threshold are paid separately CMS increased the packaging threshold for CY 2012 from $70 to $75 Products with estimated per day costs at or below the threshold are bundled, while those with estimated costs above the threshold are separately paid This is less than the $80 threshold CMS proposed The packaging threshold for CY 2012 is $75 per day (an increase of $5 per day from the CY 2011 threshold) Source: Source: Centers for Medicare & Medicaid Services (CMS). Calendar Year 2012 Outpatient Prospective Payment System Final Rule (CMS- 1525 FC). Released November 1, 2011.
Payment for Most Drugs and Biologics at ASP + 4, a Decrease from ASP + 5 For CY 2012, CMS will reimburse drugs and biologics as follows: Drugs and biologics eligible for pass-through* payment: ASP + 6 percent Non-pass-through specified covered outpatient drugs (SCOD): ASP + 4 percent Source: Source: Centers for Medicare & Medicaid Services (CMS). Calendar Year 2012 Outpatient Prospective Payment System Final Rule (CMS-1525 FC). Released November 1, 2011. ASP = Average Sales Price * Pass-through status is assigned to new products with costs that are “not insignificant” and stays in effect for at least 2 years but no more than 3 years
Payment Increase for Qualifying Cancer Hospitals Cancer hospitals receive: The full difference for covered outpatient services under the OPPS and the pre-BBA amount – in other words, they are “held harmless” A transitional outpatient payment (TOP) to ensure that their payment under the OPPS is not less than it was prior to BBA implementation Per ACA, CMS will increase in payments to the 11 qualifying cancer hospitals in CY2012 CMS will examine each cancer hospital’s data at cost report settlement to determine its payment-to-cost ratio (PCR) and, if it is below the weighted average PCR for other OPPS hospitals (target PCR; 0.91 for CY 2012), it will receive a payment adjustment to make the hospital’s PCR equal the target PCR Most cancer hospitals will no longer qualify for Transitional Outpatient Payments (TOPs) as a result of the increased payments received under the proposed cancer hospital payment adjustment CMS estimates an overall 9.5 percent increase in payments for these hospitals as a result of these changes Source: Source: Centers for Medicare & Medicaid Services (CMS). Calendar Year 2012 Outpatient Prospective Payment System Final Rule (CMS-1525 FC). Released November 1, 2011. ACA = Affordable Care Act
Key Highlights of CY 2012 Quality Measures CMS did not add any new measures to the Hospital Outpatient Quality Data Reporting Program (HOP QDRP) program for CY 2012 Providers that do not satisfactorily report quality data during CY 2012 will continue to incur a two percent reduction in their annual payment update for CY 2013: The agency will continue its established process of adding measures to the HOP QDRP program for three years of payment determinations, rather than one In 2013, CMS will retain the 15 existing HOP QDRP measures from CY 2012 In 2014,CMS will retain all measures from CY 2013 and finalized three of the nine proposed measures for CY 2014 Additional oncology-specific measures are being considered for 2015 and subsequent years: Cancer Care (hormonal therapy, biopsies) Chemotherapy Colonoscopy and endoscopy Reduced conversion factor $68.62 Full, proposed conversion factor $70.02 Source: Source: Centers for Medicare & Medicaid Services (CMS). Calendar Year 2012 Outpatient Prospective Payment System Final Rule (CMS-1525 FC). Released November 1, 2011.
A Number of Factors Have Led to a Need for Payment Reform Misaligned Payment: Based on Volume Lack of Information: Few Incentives for Care Coordination Variable Treatment: Patients Receive Sub- optimal Care Rising Costs: Increased Burden on Purchasers
Current EffortsFuture Efforts Pay-for-Reporting and Pay-for-Performance Incentives, in addition to fee- for-service payments, for reporting performance measures or achieving specified quality standards Payment Reform Introduction of new payment models, including bundled and global payments CMS = Centers for Medicare and Medicaid Services FFS = Fee-for-service CMS physician and hospital quality pay-for- reporting programs Private payer pay-for-reporting programs (e.g., Aetna, BlueCross BlueShield, United) Current Efforts to Improve Quality and Reduce Costs Focus Primarily on Enhancing the FFS Model
Payment reform paradigms need to be developed, tested, and analyzed on a case-by-case basis, as their effects can vary significantly across provider organizations, conditions, and settings Several variables must be considered when instituting a new payment policy: Settings of care (full vs. partial bundle) Delivery system infrastructure Market (e.g., numerous integrated delivery systems) Provider organization type Existing payment infrastructure Disease condition (chronic vs. acute) Associated area of medicine Payment Reform Is Unlikely to Be a “One-Size- Fits-All” Approach: Market Variables Acute Episode Payment Examples: Hip Fractures, Labor & Delivery Fee for Service Examples: Immunizations, Simple Injuries Year-Long Episode Payment + Acute Episode Payment Examples: Heart Disease, Back Pain Year-Long Episode Payment Examples: COPD, CHF Low High Amount of Variation in Cost Per Episode Variation in Frequency of Episodes Per Condition Different Payment Systems Are Appropriate for Certain Conditions and Address Unique Cost and Quality Issues COPD = Chronic Obstructive Pulmonary Disease CHF = Congestive heart failure Source: Center for Healthcare Quality and Payment Reform. “Which Healthcare Payment System is Best?”. Available at http://www.chqpr.org/downloads/WhichPaymentSystemisBest.pdf / http://www.chqpr.org/downloads/WhichPaymentSystemisBest.pdf /
BundledEpisodeGlobal Scope of payment Payment for a tightly- linked set of services provided by one or a small number of providers (e.g., Medicare’s hospital inpatient DRG system) Payment for all/most services delivered by related providers for a time-delimited “episode- of-care” (e.g., hip replacement surgery and rehab) Payment for all/most services delivered by related providers to a heterogeneous population (e.g., Medicare’s Medicare Advantage program) DrugsNo universal approach to including drugs in the payment amount Potential Value/Cost Savings Focuses on improving efficiency and not exceeding budgeted payment amount Promotes provider collaboration to better coordinate care and reduces duplication of services Makes spending more predictable and allows for implementation of population health- optimizing interventions As an Alternative to Fee-for-Service, Payers Use a Variety of Payment Reform Approaches DRG = Diagnosis-related group
Public Programs Have Demonstrated Interest in New Payment Models Bundled Payment Bundled Payments for Care Improvement Initiative 1 Medicare ESRD Bundled Payment 2 Medicare Acute Care Episode Demonstration 3 Payment Model Design of the Payment 4 payment model options: 1) Retrospective Acute Care Hospital Stay Only; 2) Retrospective Acute Care Hospital Stay plus Post-Acute Care; 3) Retrospective Post-Acute Care Only ; 4) Prospective Acute Care Hospital Stay Only Single unit of payment for most services and drugs in dialysis facilities; physician services excluded Episode of care payment for physician services pertaining to the inpatient stay for Medicare fee-for- service beneficiaries Disease Areas of Focus Proposed by applicantsESRDSpecified cardiovascular and/or orthopedic procedures ImplementationModel 1 could start as early as 1 st quarter 2012. The other models do not have start dates yet Began January 1, 2011, with full implementation by January 1, 2014 Began in 2009 and will end in 2012 Quality Incentives Proposed by applicants and to be approved by CMS 2% payment reduction for facilities that do not meet quality standards Exact payment incentive amounts vary by site and demo agreement with CMS CMS = Centers for Medicaid and Medicare Services ESRD = End-stage renal disease 1) Centers for Medicare & Medicaid Innovation, Bundled Payments for Care Improvement Initiative. Available at: http://www.innovations.cms.gov/documents/payment-care/Request_for_Applications.pdfhttp://www.innovations.cms.gov/documents/payment-care/Request_for_Applications.pdf 2) CMS, ESRD proposed rule, Available at: http://www.gpo.gov/fdsys/pkg/FR-2010-08-12/pdf/2010-18466.pdfhttp://www.gpo.gov/fdsys/pkg/FR-2010-08-12/pdf/2010-18466.pdf 3) CMS. Medicare Acute Care Episode Demonstration, Available at: http://www.cms.gov/DemoProjectsEvalRpts/downloads/ACE_web_page.pdf.http://www.cms.gov/DemoProjectsEvalRpts/downloads/ACE_web_page.pdf CMS has not yet developed an oncology-focused payment model, but may consider looking into this in the future, as cancer is a high cost disease area for the Medicare program Bundled Payment
PCMHs Could Be a Potential New Payment and Delivery Model for Oncology Services and Drugs Model Description PCMHs focus on integrated care delivery for patients and serve to improve communication between various care providers Care management, use of evidence-based care guidelines, and patient engagement and education are hallmarks of the PCMH model While there are many PCMHs in existence, their role and structure continue to evolve 1) American College of Physicians, Payment Methods for the PCMH, Available at: http://www.acponline.org/about_acp/chapters/ri/pch09_houy.pdf.http://www.acponline.org/about_acp/chapters/ri/pch09_houy.pdf PCMH = Patient-Centered Medical Home Role of Oncologist Few PCMHs are specialty-focused and, only one that is oncology-focused has received recognition 1 In most PCMHs, the oncologist serves as a “neighbor to the PCMH” and is an external, contracted entity The oncologist may develop a care plan for the patient with the providers within the PCMH Disease Management and Care Coordination Continuity of Care Services “Whole” Patient Care Evidence- based Medicine Health Information Technology Healthcare Team Patient
ACOs Could Be a Potential New Payment and Delivery Model for Oncology Services and Drugs Model Description An ACO is an entity and a related set of providers that agree jointly to be held accountable for the cost and quality of care delivered to a defined patient population ACOs must have a formal legal structure with a governing board responsible for measuring and improving performance Role of Oncologist Oncologists are likely to be formal ACO participants because of their close relationship with patients Oncologists also may play a role in ACO governance ACO Model 1 IPA or Primary Care Physician Groups Specialty Groups Hospital ACO Model 2 Multi- Specialty Group Hospital ACO Model 3 Hospital Medical Staff Organization (MSO) or Physician Hospital Organization (PHO) ACO Model 4 Integrated Delivery System Different Structures ACO = Accountable Care Organization IPA = Independent Practice Association
Medicare Shared Savings Program Final Rule Snapshot Program Design: FFS + Shared Savings Sector: Public/Private Size: CMS expects 50-270 ACOs to participate Start Date: Will begin accepting applications January 1, 2012 Status: Final Rule Released October 20, 2011 Program Overview Sponsor: CMS Design: The Medicare Shared Savings Program, which promotes the formation and operation of ACOs, is projected to begin January 1, 2012 »CMS finalized 33 quality measures for the first year; providers must meet performance standards to be eligible for savings »CMS will assign beneficiaries to an ACO based on where the patient receives a plurality of primary care services from primary or non-primary care physicians –This change from the proposed rule allows the inclusion of specialists in the assignment of beneficiaries to an ACO Payment for Drugs and Services Providers continue to receive FFS payments and are eligible to receive payments for shared savings if the ACO meets certain performance standards and cost savings; ACOs may choose between two tracks: »An upside-only ACO model that will be eligible to share up to 50% of any Medicare savings below its benchmark »A two-sided ACO model that will be eligible to share up to 60% of any Medicare savings below its benchmark or be required to repay any spending above its benchmark Drug reimbursement does not change; however cost shifting to drugs covered under the pharmacy benefit or therapeutic substitution might occur Source: Centers for Medicare and Medicaid, Medicare Shared Savings Program Final Rule Available at: http://www.ofr.gov/OFRUpload/OFRData/2011-27461_PI.pdf http://www.ofr.gov/OFRUpload/OFRData/2011-27461_PI.pdf
Multiple Layers of Audits – Federal Medicare Incorrectly Billed Claims Processing Errors Medical Necessity Incorrect Payment Amounts Non-covered Services Incorrectly Coded Services Duplicate Services RAC XXXXXXX MAC XXXXXXX PSC/ZPIC XXXXX CERT XXXXX MAC Billing Audits XXXXXX Office of Audit Services Audits XXXX Annual Work Plan Projects XXXXXX Large $ Items X XX onPoint Oncology LLC 59
Don’t Be Caught Unaware……... Be Prepared! onPoint Oncology LLC 60
ICD-9-CM 10/1/2011 For more see…http://www.cdc.gov/nchs/icd/icd9cm_addenda_guidelines.htm This for Cancer Practices and Clinics only onPoint Oncology LLC 61
ICD-9-CM New Codes 10/1/2011 onPoint Oncology LLC 62 154.2 Malignant neoplasm of anal canal 173.10 Unspecified malignant neoplasm of the skin of the lip 173.01 Basal cell carcinoma of the skin of the lip 173.02 Squamous cell carcinoma of skin of the lip 173.09 Other specified malignant neoplasm of the skin of the lip
ICD-9-CM New Codes 10/1/2011 onPoint Oncology LLC 63 173.10 Unspecified malignant neoplasm of the eyelid, including the canthus 173.11 Basal cell carcinoma of the eyelid, including the canthus 173.12 Squamous cell carcinoma of skin of the eyelid, including the canthus 173.19 Other specified malignant neoplasm of the eyelid, including the canthus
ICD-9-CM New Codes 10/1/2011 onPoint Oncology LLC 64 173.20 Unspecified malignant neoplasm of the skin of the ear and the external auditory canal 173.21 Basal cell carcinoma of the skin of the ear and the external auditory canal 173.22 Squamous cell carcinoma of skin of the ear and the external auditory canal 173.29 Other specified malignant neoplasm of the skin of the ear and the external auditory canal
ICD-9-CM New Codes 10/1/2011 onPoint Oncology LLC 65 173.30 Unspecified malignant neoplasm of the skin of other and other unspecified parts of the face 173.31 Basal cell carcinoma of the skin of other and other unspecified parts of the face 173.32 Squamous cell carcinoma of skin of other and other unspecified parts of the face 173.39 Other specified malignant neoplasm of other and other unspecified parts of the face
ICD-9-CM New Codes 10/1/2011 onPoint Oncology LLC 66 173.40 Unspecified malignant neoplasm of the scalp and skin of neck 173.41 Basal cell carcinoma of the skin of the scalp and skin of neck 173.42 Squamous cell carcinoma of skin of the scalp and skin of neck 173.49 Other specified malignant neoplasm of the scalp and skin of neck
ICD-9-CM New Codes 10/1/2011 onPoint Oncology LLC 67 173.50 Unspecified malignant neoplasm of skin of trunk, except scrotum 173.51 Basal cell carcinoma of skin of trunk, except scrotum 173.52 Squamous cell carcinoma of skin of trunk, except scrotum 173.59 Other specified malignant neoplasm of skin of trunk, except scrotum
ICD-9-CM New Codes 10/1/2011 onPoint Oncology LLC 68 173.60 Unspecified malignant neoplasm of skin of the upper limb, including shoulder 173.61 Basal cell carcinoma of skin of the upper limb, including shoulder 173.62 Squamous cell carcinoma of skin of the upper limb, including shoulder 173.69 Other specified malignant neoplasm skin of the upper limb, including shoulder
ICD-9-CM New Codes 10/1/2011 onPoint Oncology LLC 69 173.70 Unspecified malignant neoplasm of skin of lower limb, including hip 173.71 Basal cell carcinoma of skin of lower limb, including hip 173.72 Squamous cell carcinoma of skin of lower limb, including hip 173.79 Other specified malignant neoplasm skin of lower limb, including hip
ICD-9-CM New Codes 10/1/2011 onPoint Oncology LLC 70 173.80 Unspecified malignant neoplasm of other specified sites of the skin 173.81 Basal cell carcinoma of other specified sites of the skin 173.82 Squamous cell carcinoma of other specified sites of the skin 173.89 Other specified malignant neoplasm of other specified sites of the skin
ICD-9-CM New Codes 10/1/2011 onPoint Oncology LLC 71 173.90 Unspecified malignant neoplasm of unspecified sites of the skin Malignant neoplasm of the skin, NOS 173.91 Basal cell carcinoma of skin, site unspecified 173.92 Squamous cell carcinoma of skin, site unspecified 173.99 Other specified malignant neoplasm of skin, site unspecified
ICD-9-CM New Codes 10/1/2011 onPoint Oncology LLC 72 284.11 Antineoplastic chemotherapy induced pancytopenia 284.12 Other drug induced pancytopenia 284.19 Other pancytopenia 286.52 Acquired hemophilia 286.53 Antiphospholipid antibody with hemorrhagic disorder 286.59 Other hemorrhagic disorder due to intrinsic circulating anticoagulants, antibodies, or inhibitors Antithrombinemia Antithromboplatinemia Etc.
ICD-9-CM New Codes 10/1/2011 onPoint Oncology LLC 73 996.88 Complications of stem cell transplant 999.32 Bloodstream infection due to Central Venous Catheter 999.33 Local infection due to Central Venous Catheter 999.34 Acute infection following transfusion, infusion, or injection of blood and blood products
ICD-9-CM New Codes 10/1/2011 onPoint Oncology LLC 74 999.41 Anaphylactic reaction due to administration of blood and blood products 999.42 Anaphylactic reaction due to vaccination 999.49 Anaphylactic reaction due to other serum 999.51 Other serum reaction due to administration of blood and blood products 999.52 Other serum reaction due to vaccination 999.59 Other serum reaction due to other serum V58.68 Long-term (current) use of biphosphonates
CPT Changes 2012 onPoint Oncology LLC 75 Changes to Observation Codes (99218-99220) for time. 38232: Bone marrow harvesting for transplantation: autologous 77424-77425: Intra-operative radiation treatments
CPT Changes—Infusion Coding onPoint Oncology LLC 76 Changes to Preamble—not much of it is new, but just further explained. 96360-96379, 96401-96402, 96409-96425, 96521- 96523 are not to be reported by a PHYSICIAN in a facility setting. EM should be appended with -25 with 96360- 96549, if separately identifiable office or other outpatient EM is performed.
CPT Changes-Infusion Coding onPoint Oncology LLC 77 INITIAL INFUSION Do not report an initial infusion due to a re-start of an intravenous line, an IV rate requiring 2 lines for implementation, or for accessing the port of a multiple lumen catheter. The difference in time and effort in providing this second IV is using an initial code with -59. Example 96365, 96365-59.
CPT Changes—Infusion Coding onPoint Oncology LLC 78 SEQUENTIAL INFUSIONS All sequential infusions need to those of a new substance/drug. The one exception is that facilities (HOSPITALS) may report sequential infusions of the same drug using 96376, if infusions are more than 30 minutes apart. CONCURRENT INFUSIONS Clarified better that 96368 is not time-based and can only be reported once per day. Clarified that it is the infusion of a NEW substance/ drug.
CPT Changes—Infusion Coding onPoint Oncology LLC 79 Multiple Infusions of the SAME DRUG Must be over 30 minutes as has been true since 2006 (2005 for Medicare) The sequential or subsequent infusions of the SAME drug should be reported based on the time of the infusion using the applicable add-on code. Example—A hospital patient is given a one-hour infusion every eight hours in 24 hours. 96365 is used for the initial infusion with 96366 is reported twice for the second and third infusions. HYDRATION codes should not be used in a ‘keep open’ situation or as a free flowing IV during a chemotherapeutic or therapeutic infusion.
CPT Changes-New Patient onPoint Oncology LLC 80 More clarification of what a new patient is A new patient is one who has not received professional services from the same EXACT specialty and subspecialty in the same group practice in the last three years. Professional services are face-to-face services.
HCPCS 2012--Changes onPoint Oncology LLC 83 S0353Cancer treatment plan initial TREATMENT PLANNING AND CARE COORDINATION MANAGEMENT FOR CANCER INITIAL TREATMENTADDI4/1/12 S0354Cancer treatment plan change TREATMENT PLANNING AND CARE COORDINATION MANAGEMENT FOR CANCER ESTABLISHED PATIENT WITH A CHANGE OF REGIMENADDI4/1/12 S-codes are Not paid by Medicare Usually used by the Blues Check with your payer before using
Other Important Deadlines onPoint Oncology LLC 84 HIPAA 5010 1/1/2012 Advanced Imaging Accreditation 1/1/2012 ICD-10-CM 10/1/2013
Medicare Implementation of 5010 – Common Edits and Enhancement Module (CEM) Standardized Claim Editing One set of edits per line of business Consistent editing Consistent results Standardized Error Handling TA1 999 277CA Receipt, Control and Balancing Claim Number Assignment
Medicare Implementation 5010 Changes to core processing system Increase quantity from 999.9 to 9999.9 NPI validation NDC detail Room for ICD-10 Medicare Secondary Payer (MSP) balancing edits 90 day compliance extension, but does not mean you do not have to be on board
Pharmacy billing for drugs provided “incident to” a physician service MM 7397, revised 12/16/11 “Pharmacies, suppliers and providers may not bill Medicare Part B for drugs dispensed directly to a beneficiary for administration “incident to” a physician service…. These claims will be denied.” "Pharmacies may not bill Medicare Part B for drugs furnished to a physician for administration to a Medicare beneficiary. When these drugs are administered in the physician's office to a beneficiary, the only way these drugs can be billed to Medicare is if the physician purchases the drugs from the pharmacy.”
Pharmacy billing for drugs provided “incident to” a physician service Effective and implementation dates have been changed from January 1, 2012 to January 1, 2013 http://www.cms.gov/Transmittals/downloads/R2368 CP.pdf http://www.cms.gov/Transmittals/downloads/R2368 CP.pdf
Your To Do List… Right Now onPoint Oncology LLC 89 Notice all 5010 problems and get them fixed. Ascertain your vendor’s plan for Meaningful Use for implementation in 2012. Understand the PQRS and EHR relationship in 2012. Make sure have a compliance plan in place. Audits are one way health reform is financed!!! Don’t think you do not have to prepare for ICD- 10…it will be here before you know it… Participate in the struggle—can you afford another cut or even a hold?
onPoint Oncology LLC 90 CAN Web Site The latest news Forms Regulations Newsletters Presentations http://can.communityoncology.org
onPoint Oncology LLC 91 Contact email@example.com firstname.lastname@example.org 800-795-2633 Newsletter is free! Go to our website: http://www.onpointoncology.com