1. Presented by: Roberta L. Buell, MBA, principal, onPoint Oncology LLC, Sausalito, California 800-795-2633 bbuell@covad.net Updated March 30, 2010 1

2. 2 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 2010. 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.

3. 3 Discuss Fee Schedule for 2010 Discuss Consults Discuss Coding/Options for PQRI 2010 Discuss Coding for E-Prescribing 2010 Outline “Meaningful Use” Incentives Discuss the Status of RACs Discuss PECOS Discuss Signatures Know What You Need to Do Next

4. 4 Payments are based on RVUs for each code (WRVUs+PERVUs+MalRVUs) The pool of RVUs is fixed – any changes must be budget neutral--we had one of the few exceptions in 2004-2005. RVUs are multiplied times GPCIs for your area. The 1.00 GPCI Floor has been eliminated. The Medicare conversion factor determines the overall level of Medicare payments A formula spelled out in the Medicare statute determines the annual update to the conversion factor and that has been a disaster.

5. 5 On March 4 th, the president signed H.R. 4691, the Temporary Extension Act of 2010 into law. This legislation includes a provision that freezes Medicare physician payments at their current level until March 31, 2010. The legislation also extends the therapy cap exception process through until March 31, 2010. The bill passed the Senate by a vote of 78 – 19. The House of Representatives had unanimously approved a companion bill by voice vote on Feb. 25. H.R. 4691 The Senate debated H.R. 4213 the American Workers, State, and Business Relief Act of 2010. This legislation extends the freeze on Medicare physician payments until Sept. 30, 2010. It also provides an extension to the therapy cap exception process through Dec. 31, 2010 and an extension of the geographic practice cost index floor through Dec. 31, 2010. Never approved by the Senate.H.R. 4213 We are now on hold again…

6. 6 The SGR formula which has been flawed for years signals that we will have a 21.2% DECREASE in the conversion factor after 4/1/10. Physician drugs are now included in the SGR formula, allegedly skewing it upwards. CMS has eliminated Part B drugs from the SGR meaning lower future reductions. But, for right now, we are stuck with a conversion factor of $28.3895 down from $36.0666 after the 2 month hold. For 3 months, CF = $36.0846

7. 7

8. 8 CMS has long had confusing rules relative to consults. So, the easiest way to deal with the problem is to eliminate them altogether. What this means is: New consults in the office will be coded as New Patients (99201- 99205). This means that no one in practice of your specialty has seen the patient at all for 36 months. Established consults in the office will be coded as Established Patients (99212-99215)…this is not an exact match with consultation criteria. Hospital consults will be coded as Admissions (99221-99223) with a new modifier (“AI”) signifying who was the admitting physician. There is no exact crosswalk of five levels to three. TeleHealth consults are the exception. They have special G-codes.

9. Why? Link to the Final Rule The section showing the consultation changes can begins on page 61767 http://edocket.access.gpo.gov/2009/pdf/E9-26502.pdf 9 9

10. New Patients Service Performed CPT Code Documentation required History/Exam/MDM Problem SeverityMedicare Consult level 1 99241(1 5 min) PF/PF/Straightforward Self limited or minor 99201 (10 min) Consult level 2 99242 (30 min) EPF/EPF/Straightforward Low severity 99202 (20 min) Consult level 3 99243 (40 min) Detailed/Detailed/Low Moderate severity 99203 (30 min) Consult level 4 99244 (60 min) Comp./Comp./Moderate Moderate to high severity 99204 (45 min) Consult level 5 99245 (80 min) Comp./Comp./High Moderate to high severity 99205 (60 min) 10

11. Established Patients Service Performed CPT CodeDocumentation required (All 3 to 2 out of 3) History/Exam/MDM Problem SeverityMedicare Consult level 199241 (15 min) PF/PF/StraightforwardSelf limited or minor99212 (10 min) Consult level 299242 (30 min) EPF/EPF/Straightforward or Low for 99213 Low severity99213 (15 min) Consult level 399243 (40 min) Detailed/Detailed/Low or Moderate for 99214 Moderate severity99213 or 99214 (15-25 min) Consult level 499244 (60 min) Comp./Comp./Moderate or High for 99215 Moderate to high severity99214 or 99215 (25-40 min) Consult level 599245 (80 min) Comp./Comp./HighModerate to high severity99215 (40 min) 11

12. Inpatient Consults CPT CodeHistoryExamMDM Traditional Medicare 99251 (20 min) PF HxPF ExamSF MDM 99252 (40 min) EPF HXEPF ExamSF MDM 99253 (55 min) Det HxDet ExamLow MDM99221 (30 min) 99254 (80 min) Comp HxComp ExamModerate MDM 99222 (50 min) 99255 (110 min) Comp HxComp ExamHigh MDM99223 (70 min) 12

13. Medicare Q&A Is CMS going to crosswalk the CPT consultation codes that are no longer recognized to the E/M codes for each setting in which an E/M service that could be described by a CPT consultation code can be furnished? No, providers must bill the E/M code (other than a CPT consultation code) that describes the service they provide in order to be paid for the E/M service furnished. The general guideline is that the provider should report the most appropriate available code to bill Medicare for services that were previously billed using the CPT consultation codes. For services that could be described by inpatient consultation CPT codes, CMS has stated that providers may bill the initial hospital care service CPT codes and the initial nursing facility care CPT codes, where those codes appropriately describe the level of service provided. When those codes do not apply, providers should bill the E/M code that most closely describes the service provided. 13 MLN Matters® Number: SE1010

14. Medicare Q&A How should providers bill for services that could be described by CPT inpatient consultation codes 99251 or 99252, the lowest two of five levels of the inpatient consultation CPT codes, when the minimum key component work and/or medical necessity requirements for the initial hospital care codes 99221 through 99223 are not met? There is not an exact match of the code descriptors of the low level inpatient consultation CPT codes to those of the initial hospital care CPT codes. For example, one element of inpatient consultation CPT codes 99251 and 99252, respectively, requires “a problem focused history” and “an expanded problem focused history.” In contrast, initial hospital care CPT code 99221 requires “a detailed or comprehensive history.” Providers should consider the following two points in reporting these services. First, CMS reminds providers that CPT code 99221 may be reported for an E/M service if the requirements for billing that code, which are greater than CPT consultation codes 99251 and 99252, are met by the service furnished to the patient. Second, CMS notes that subsequent hospital care CPT codes 99231 and 99232, respectively, require a “problem-focused interval history” and “an expanded problem focused interval history” and could potentially meet the component work and medical necessity requirements to be reported for an E/M service that could be described by CPT consultation code 99251 or 99252. 14 MLN Matters® Number: SE1010

15. Medicare Q&A How will more reporting of initial hospital care CPT codes instead of CPT consultation codes affect the review of claims by Medicare contractors? CMS has alerted MAC audit staff as well as Medicare Recovery Audit Contractors of its expectation that physicians may bill more E/M codes for initial hospital care in place of billing inpatient CPT consultation codes. CMS has also alerted contractors to expect a different proportion of various initial hospital care CPT codes under the new policy. CMS expects contractors to consider that these may be appropriate changes when making decisions about whether to pursue medical review and other types of claims review. 15 MLN Matters® Number: SE1010

16. Medicare Q&A Because CPT consultation codes are no longer recognized by CMS for payment, is the definition of transfer of care no longer relevant? Yes, CMS agrees that discontinuing recognition of the CPT consultation codes for payment renders the issues regarding the definition of what constitutes a transfer of care no longer relevant. 16 MLN Matters® Number: SE1010

17. Medicare Q&A Can a provider provide an advance beneficiary notice (ABN) to the beneficiary and then bill his or her charge for the consultation after the consultation is billed and denied by Medicare? No, when a CPT consultation code is reported to Medicare, the claim is not denied. Instead, the claim is returned to the provider for a different CPT code because Medicare recognizes another code for payment of E/M services that may be described by CPT consultation codes. Once the claim is resubmitted to report an appropriate, payable E/M code (other than a CPT consultation code) for a medically reasonable and necessary E/M service, the beneficiary can only be billed any applicable Medicare deductible and coinsurance amounts that apply to the covered E/M service. 17 MLN Matters® Number: SE1010

18. Medicare Q&A How should E/M services previously reported by CPT consultation codes and provided in a split/shared manner be billed? The split/shared rules applying to E/M services remain in effect, including those cases where services would previously have been reported by CPT consultation codes. Huh? 18 MLN Matters® Number: SE1010

19. Medicare Q&A Do admitting physicians still get paid if they do not report the modifier “-AI?” Yes, the use of the modifier is for informational purposes only. 19 MLN Matters® Number: SE1010

20. 20 Consult CodeMaps toPercentage Mapped 2010 Price 99241 ($48.69) 99201 99211 50% $38.95 $19.12 99242 ($91.61) 99202 99212 50% $67.44 $38.95 99243 ($125.15) 99203 99213 50% $97.74 $65.54 99244 ($185.38) 992o4 99214 50% $151.48 $98.46 99245 ($226.50) 99205 99215 50% $190.43 $132.73 Source: CMS Website from Frank Cohen; 2010 NF RVUs; 2009 CF and GPCIs =1

21. 21 Concurrent Care “Concurrent care is provision of similar services (e.g. hospital visits) to the same patient by more than one physician on the same day. When concurrent care is provided, no special reporting is required. ” Transfer of Care “Transfer of care is the process whereby a physician who is providing management for all or some of a patient’s problems relinquishes this responsibility to another physician who EXPLICITLY agrees to accept this responsibility and, who from the initial encounter is not providing consultative services.” “Consultation codes should not be reported by the physician who has agreed to accept the transfer of care before the initial evaluation, but are appropriate to report if the decision to accept the transfer of care cannot be made until after the initial consultation…”

22. 22 “A consultation is a type of evaluation and management service provided by a physician at the request of another physician or appropriate source to either recommend care for a specific condition or problem or determine whether to accept responsibility for ongoing management of the patient’s entire care or for the care of a specific condition or problem.”

23. 23 Evaluation and Management (E/M): Consultations: To clarify the two situations under which consultations may be reported, the Evaluation and Management (E/M) section subheading, "Consultations" has been revised. These situations are: 1) to provide opinion/services for a specific condition or problem, or 2) to allow a determination to be made on whether to accept the ongoing management of the patient's entire care or for the care of a specific condition or problem (i.e. transfer of care AFTER an evaluation of the patient's problem). CPT outlined that documentation of the written or verbal request for a consultation can be done by either the consultant or by the requesting physician or other appropriate source. You may remember that Medicare requires (until January 1) that BOTH the requesting and consulting physicians document the request. But, the request DOES need to be documented.

24. 24 Patients and/or families cannot initiate consultations. Transfer of care definition in both office and hospital consults. All admitting E/M services are bundled into an inpatient consultation on the date of admission. Only one consult in the hospital or nursing facility stay. This includes inpatient and outpatient consultations. Documentation: Request Opinion Written report

25. 25 Key mechanism for transforming Medicare from passive payer to active purchaser. Current Medicare Physician Fee Schedule is based on quantity and resources consumed, NOT quality or value of services. Value = Quality / Cost Incentives can encourage higher quality and avoidance of unnecessary costs to enhance the value of care.

26. 26 TRHCA – Tax Relief & Health Care Act, 2006 Established 2007 PQRI, 7/1-12/31/07, authorized 1.5% incentive subject to a cap, claims- based reporting by eligible professionals (EPs) of up to 3 individual applicable measures for 80% of eligible cases MMSEA - Medicare, Medicaid, and SCHIP Extension Act of 2007 Authorized 2008 PQRI, 1.5% incentive, eliminated cap Incentive Required alternative reporting periods and alternative reporting criteria for 2008 and 2009 Requires alternative reporting for measures groups and for registry-based reporting MIPPA - Medicare Improvements for Patients and Providers Act Section 131 : 2009 PQRI Authorized PQRI 2009 raised incentive to 2%, adds qualified audiologists as eligible professionals, no effect on 2007 or 2008 incentive payments FR requires CMS to post on our web site names of EPs who satisfactorily report quality measures for 2009 PQRI Section 132 : e-Prescribing Incentive Program Authorized separate 2% incentive payment to EPs who successfully use a qualified eprescribing system eRx measure removed from 2009 PQRI --separately posted measure specifications. The Secretary has the authority to update the codes of the electronic prescribing measure in the future. FR requires names of eligible professionals who are successful e-prescribers be posted on the CMS web site

27. 27 Physicians MD/DO Podiatrist Optometrist Oral Surgeon Dentist Chiropractor Therapists Physical Therapist Occupational Therapist Qualified Speech- Language Pathologist Practitioners Physician Assistant Nurse Practitioner Clinical Nurse Specialist Certified Registered Nurse Anesthetist Certified Nurse Midwife Clinical Social Worker Clinical Psychologist Registered Dietician Nutrition Professional Audiologist

28. 28 153 PQRI quality measures for 2009 179 PQRI quality measures proposed so far for 2010; this includes all ways of reporting. Coding and measure specifications are available at: http://www.cms.hhs.gov/pqri Read all measures before choosing.

29. 29 The Oncology Pain Measures (#143 and 144) will be reportable ONLY by registries. The Melanoma measures (#136-138) will only be reportable by Registry in 2010. CMS is moving toward Registry reporting and away from claims-based reporting. There is a new measure, “Cancer Stage Documented”-- Measure #194 for colon, breast, rectal, etc. cancer. Check it out!!!

30. 30 Measure Groups Report on one or more measure groups---13 measure groups Diabetes mellitus, chronic kidney disease, preventive care, coronary artery bypass graft, rheumatoid arthritis, peri-operative care, back pain, hepatitis C, heart failure, coronary artery disease, ischemic vascular disease, HIV/AIDS, community-acquired pneumonia Choose a measure group only if ALL the measures within the group are applicable to services provided to Medicare patients by the reporting provider. Review the 2010 PQRI Measures Group Specifications Manual to determine if a particular measures group is applicable for your practice http://www.cms.hhs.gov/PQRI/15_MeasureCodes.asp#TopOfPage

31. 31 Reporting period: January 1, 2009 – December 31, 2009 2 reporting periods for reporting measures groups and registry-based reporting: January 1, 2009 – December 31, 2009 July 1, 2009 – December 31, 2009 In 2010, 2 reporting periods apply to claims, registries, and measures groups.

32. 32 Criteria for claims-based submission of individual measures (1 option): 3 PQRI measures or 1-2 measures if < 3 apply* 80% of applicable Medicare Part B FFS patient claims for 1-3 measures If < 3 measures, measures are subject to measure applicability validation (MAV) Criteria proposed for 2010 annual reporting also includes that each measure must have a minimum of 15 patients for each measure. THIS WAS NOT APPROVED IN THE FINAL RULE!

33. Should You Use A Registry?? Registries are trained to process and submit data. 96% of EPs reporting by registry in 2008 were successful, which accounted for 17% of all payments. Registries save you from having to submit at the time of service by claim. Registries do cost $$$, but your time is worth $$$. This is not to represent that registries will take all of the work out of PQRI, but you will have a better handle on getting paid. It’s not too late!! Get the list--- http://communityoncology.info/pqri-e-prescribing- folder/ 33

34. Registries: Oncology Measures CECity, http://pqrinet.com, Simone Karp 888-669- 7444 x311http://pqrinet.com DocSite, http://docsite.com/pqri, 919-856-9500http://docsite.com/pqri Patient360, http://www.patient360.comhttp://www.patient360.com Wellcentive LLC, http://www.wellcentive.com, PQRI@wellcentive.com, 877-692-6180 x702http://www.wellcentive.com PQRI@wellcentive.com 34

35. 35 EHR/EMR Reporting 10 specific individual measures, but none in Oncology Must meet these criteria if Oncology does get EMR/ EHR reporting including Be able to transmit data elements per specific CMS criteria Be able to separate out and report on CMS FFS patients only Be able to transmit TIN/NPI information Be able to transmit in approved formats Be able to transmit in a HIPAA secure format Enter into legal arrangements that permit receipt of and transmission of patient-specific data Obtain permission by NPI number Must pass CMS test. “Group Practices” may report, but only if they have 200 providers.

36. 36 Patient must have the right diagnosis and that must be linked to the PQRI codes. Codes must be arrayed per measure specifications. Patient must meet the age requirement. Codes must be reported with the denominator CPT or HCPCS codes. Claims must have an NPI. 80% is calculated by NPI. http://www.ama- assn.org/ama/pub/category/17432.html Get forms at http://www.ama- assn.org/ama/pub/category/17432.html

37. The Future of PQRI Health Reform reinforced PQRI for the foreseeable future. 1% in 2011 0.5% in 2012-2014; still voluntary 2015: -1.5% for non-participation After 2015: -2.0% 37

38. 38 YearSuccessful**Not 20092%0% 20102%0% 20111%0% 20121%-1% 20130.5%-1.5% 2014+0%-2% In 2009 and 2010, physicians who successfully e-prescribe may receive a bonus payment of 2 percent of their overall Medicare reimbursement in addition to a potential 2 percent incentive related to PQRI for a potential bonus of 4 percent in Medicare reimbursement. ***No double incentives for those participating in the ARRA EMR incentive program.

39. 39 E-prescribing measure is reportable only through claims in 2009; in 2010, CMS proposes three methods—claims, registries, and EHRs. Limitation to applicability of incentive payment Denominator codes (E/M etc) for the e-prescribing measure must comprise at least 10% of an EP’s total allowed charges for all covered services furnished by the EP during the reporting period

40. 40 Visit Documented in Medical Record & Rx Generated Encounter Form Coding & Billing Carrier/MAC Analysis Contractor NCH National Claims History File Incentive Payment Confidential Report Critical Step Rx Trans- mitted to Pharmacy N-365 PBM

41. 41 Numerator: eRx Quality-Data Code for Successful Reporting: Prescription(s) Generated and Transmitted via Qualified eRx System G8553: At least one prescription created during the encounter was generated and transmitted electronically using a qualified eRx system REPORTING DENOMINATOR: Any patient visit for which one (or more) of the following denominator codes applies and is included on the claim Denominator Criteria (Eligible Cases): Patient visit during the reporting period (CPT or HCPCS): 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 To figure out if you are eligible: Put the allowed reimbursement of the above codes OVER Your total allowed revenue for MPFS services (EXCLUDES DRUGS AND LAB) 25 Encounters with G8553 per Eligible Provider

42. 42 That’s right! Just for cancer practices! www.oncologyerx.com www.oncologyerx.com www.oncologyerx.com For more information, contact me! New final rule for e- prescribing controlled substances

43. Redundancy of CMS Auditors Roles of Medicare Improper Payment Review Entities 43

44. Source: American Hospital Association 44

45. 45 Where Did RACs Find Overpayments? Most overpayments were collected from inpatient hospital services for medical necessity and coding SNF 2% Doc/Ambulance/ Lab/DME/Other 4% Inpatient Hospital 85% 95% from Hospitals

46. 46 D C B A RAC Jurisdictions March 1, 2009 August 1, 2009

47. 47 RAC CMS Contact Person Phone AEbony Brandon410-786-1585 BScott Wakefield410-786-4301 CAmy Reese410-786-8627 DKathleen Wallace410-786-1534

48. 48 Region A (Northeast states) Diversified Collection Services, www.dcsrac.com/issues.html www.dcsrac.com/issues.html Region B (Great Lakes states) CGI, http://racb.cgi.com http://racb.cgi.com Region C (Mid Atlantic, South and Southeast states) Connolly Healthcare, http:// www.connellyhealthcare.com/RAC Region D (Midwest, West Coast, Southwest states) HealthDataInsights www.healthdatainsights.com/RAC.aspx www.healthdatainsights.com/RAC.aspx

49. Oncology Issues Blood Transfusion Units of Service IV Hydration Units of Service Neulasta Units of Service Pump/Pump Supplies Facility versus Non-Facility SNF Billing A4221 Units of Service Global versus –TC, -TC in facility CSW During Inpatient Services to Hospice Patients “New” versus Established patients DME Charged After date of Death MUEs 49 These are changing daily—Check the Web Site often

50. 50 Look to see what improper payments were found by the RACs: Demonstration findings: www.cms.hhs.gov/racwww.cms.hhs.gov/rac Permanent RAC findings: will be listed on the RACs’ websites Look to see what improper payments have been found in OIG and CERT reports OIG reports: www.oig.hhs.gov/reports.htmlwww.oig.hhs.gov/reports.html CERT reports: www.cms.hhs.gov/certwww.cms.hhs.gov/cert

51. Meaningful USE--Qualifying Criteria Meeting specified HIT standards, policies, implementation specifications, timeframes, and certification requirements. CMS generally expects that under Medicare, “meaningful EHR users” would demonstrate each of the following: meaningful use of a certified EHR, the electronic exchange of health information to improve the quality of health care, and reporting on clinical quality and other measures using certified EHR technology, integrated decision support, and computerized provider order entry. Must meet 24 points before 7/1/11…many EMRs or EHRs do not meet these today. BUT, the proposal may be amended. There are three phases to this. 51

52. Ambulatory Incentive Opportunities 52

53. Meaningful Use Incentives for meaningful use in one of two programs (not both) Two programs proposed rules on 12/30/09 Proposed Rule: "Meaningful Use" Standards http://www.federalregister.gov/OFRUpload/OFRData/20 09-31216_PI.pdf Proposed Rule: Incentive Program http://www.federalregister.gov/OFRUpload/OFRData/20 09-31217_PI.pdf http://www.federalregister.gov/OFRUpload/OFRData/20 09-31216_PI.pdf http://www.federalregister.gov/OFRUpload/OFRData/20 09-31217_PI.pdf Medicaid or Medicare Penalty if not doing meaningful use by 2015 53

54. Incentives Proposed Rule 12/30/09 For the first year an EP applies for and receives an incentive payment, CMS proposes that an EHR Reporting Period is 90 days for any continuous period beginning and ending within the year. For every year after the first payment year, CMS proposes that the EHR reporting period is the entire year. A Payment Year equals a Calendar Year (CY). Incentive payments for meaningful EHR use end after 2016. A qualifying EP will receive an incentive payment equal to 75 percent of Medicare allowable charges for covered professional services furnished by the EP in a payment year, subject to maximum payments. In general, a qualifying EP can receive an annual incentive payment as high as $18,000 if their first payment year is 2011 or 2012. Otherwise, the annual incentive payment limits in the first, second, third, fourth, and fifth years are $15,000, $12,000, $8,000, $4000, and $2,000 respectively. In general, the maximum amount of total incentive payments that an EP can receive under the Medicare program is $44,000. An EP who predominantly furnishes services in a geographic Health Professional Shortage Area is eligible for a 10 percent increase in the maximum incentive payment amount. The maximum amount of total incentive payments that such an EP can receive under the Medicare program is $48,400. For EPs who begin to be meaningful EHR users in 2014, their payment calculations will be made as if they began meaningful use in 2013. (That is, if an EP were to begin meaningful use in 2014, the EP would receive $12,000 for that year, the second year’s amount as if they had begun in 2013). 2014 is the last year for which an EP can begin receiving incentive payments for meaningful use. Incentive payments for meaningful HER use ends after 2016. Maximum Total Amount of EHR Incentive Payments for a Medicare EP is outlined in the table below 54

55. Year2011 Is First Year2012 Is First year2013 Is First Year2014 Is First Year2015 Is First Year 2011 $18,000 2012 $12,000 $18,000 2013 $8,000 $12,000$15,000 2014 $4,000 $8,000$12,000$15,000 2015 $2,000 $4,000$8,000$12,0000 2016 $0 $2,000$4,000$8,0000 TOTAL$44,000 $42,000$35,0000 Medicare ARRA Physician Payment Maximum Incentives – Must have already implemented “certified” EHR meeting “meaningful use” criteria to qualify. 55 10% more for HPSA areas

56. Meaningful Use Timeline Requirements for meeting Meaningful Use will increase over time Incentives run 2011-2015 and penalties begin in 2016

57. 57 PECOS 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 1/2/11 warning message on remittance Phase 2: 1/3/11 and after: claim rejected if referring individual not in Pecos or MAC list

58. 58 PECOS 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. Revalidation of some labs 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

59. Consignment Closets Rescinded!!! CMS has issued Compliance Standards for Consignment Closets and Stock and Bill Arrangements. The purpose of Change Request 6528 was to define and prohibit certain arrangements where an enrolled supplier of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) maintains inventory at a practice location which is not owned by the enrolled DMEPOS supplier, but rather owned by a physician, non-physician practitioner or other healthcare professional, which arrangements are sometimes referred to as "consignment closets" or "stock and bill arrangements.” The CMS announcement does not prohibit these arrangements, but indicates that they must comply with the following requirements: 1.The title to the DMEPOS shall be transferred to the enrolled physician, non-physician practitioner or practice at the time the DMEPOS is furnished to the beneficiaries; 2.The physician or non-physician practitioner shall bill for the DMEPOS supplies and services using their own enrolled DMEPOS billing number; 3.All services provided to a Medicare beneficiary concerning fitting or use of the DMEPOS shall be performed by individuals being paid by the physician or non-physician practitioner's practice, and not by any other DMEPOS supplier; 4. The beneficiary shall be advised that if he or she has a problem or question regarding the DMEPOS, then the beneficiary should contact the physician or non-physician practitioner and not the DMEPOS supplier who placed the DMEPOS at the physician or non-physician practitioner's practice; and 5. The National Supplier Clearinghouse Medicare Administrative Contractor (NSC-MAC) shall verify that two or more enrolled DMEPOS suppliers shall not be enrolled and/or located at the same practice location and that each practice location shall have a separate entrance and separate post office address. 59 Should infusion pumps be an exception to this?

60. Signatures: Review Criteria 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 If the reason for a pre- or post-payment denial is unrelated to the signature requirement, the contracted reviewer can disregard the signature authentication process. However, if the criteria in the specific Medicare policy cannot be met because the documentation is missing a signature or it is not legible, the reviewer is instructed to proceed to the signature assessment procedure. If the signature is missing from an order, the reviewer has been instructed to disregard the order during the review of the claim. If the signature is illegible, the reviewer can request a signature log or attestation statement to determine the identity of the author of a medical record entry. Although there is not a specific attestation form at this time, the transmittal does provide specific language that should be considered if the provider is using this process. 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. Providers should also be reviewing all documentation prior to sending medical record copies to contractors for review. 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). 60

61. 61 Cash is the practice’s most vital resource. Make sure you have your cash requirements in mind with every decision you make. Do not live beyond your means. Remember that collections start with the referral and ends with payment. Collections also start at the top with the physicians. Patients should pay balances with every encounter. Do not get behind in your payments to distributors. This is the beginning of the end of your survival. Nobody is your friend if you owe them money. Ensure that your billing system is sophisticated enough to meet your needs. You need to keep close tabs on your production by code, your DSO, and your Accounts Receivable. This system is your lifeline. Make sure physicians are re-educated regarding the proper coding and documentation for consults and lack thereof. Check the signatures in your records for compliance. If you haven’t participated in PQRI, use a REGISTRY. Start getting prepared for “meaningful use” HIT incentives and direct submission of PQRI data. Get with your EMR vendor! Make sure you are prepared for more cash flow interruptions. Participate in the struggle! The fight is not over yet!

62. CAN Web Site The latest news Forms Regulations Newsletters Presentations http://communityoncology.info 62

63. 63 Contact bbuell@covad.net bobbibuell1@yahoo.com 800-795-2633 Newsletter is free! Send all RAC information to me at the ABOVE E-mails or FAX to 650-618-8621 Go to our website: http://www.onpointoncology.com

64. 64