Practice Management Series

ASCOClinical Practice

Series

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Practice Management Curriculum

Adapting to Changes in Medicare

Generating Practice Efficiencies

Health Information Technology in Practice

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Adapting to Changes in Medicare…2006

Topics for today: The 2006 Oncology Demonstration Project Physician fee schedule changes Drug administration coding Part D

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2006 Oncology Demonstration Project

A one-year demonstration project, effective 1/1/06

Purpose is to identify and assess, in office-based oncology practices, certain oncology services that positively affect outcomes in the Medicare population. Capture the spectrum of services oncologists provide to

Medicare beneficiaries with certain cancer diagnoses Determine the extent to which practice guidelines

parallel care that hematologists/oncologists provide

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2006 Oncology Demonstration Project

Replaces the 2005 chemotherapy demonstration project

Calendar year 2005 G-codes (G0921 – G0932) have been eliminated, effective 12/31/05

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G-Codes

CMS has established 81 new G-codes in three reporting categories1. Primary focus of the E & M visit (G9050 – G9055)2. Whether current patient management adheres to

clinical practice guidelines (G9056 – G9062)3. Current disease state (G9063 – G9130)

Reporting is no longer specific to chemotherapy administration services; now associated with E & M services for established patients with cancer

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Who Can Participate?Office-based hematologists and oncologists

Medicare-designated physician specialties hematology (specialty code 82), medical oncology (specialty 83), and hematology/oncology (specialty 90) Check with your carrier to be sure your

physicians are identified with the correct specialty designation

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Who Can Participate?

Midlevel providers (NPs, PAs) who may bill independently for Medicare services are not eligible to participate in the demonstration

ASCO’s interpretation of the carrier instructions is that visits performed in compliance with Medicare’s incident-to rules may be billed under the demonstration

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How Does it Work?

Office-based hematologists and oncologists can participate for services furnished in 2006 when … E & M services level 2 thru 5 (99212 – 99215) are

provided to established patients with a primary diagnosis of cancer in one of 13 major diagnostic categories

Participation is voluntary and the physician participates by filing a claim for services with their Medicare carrier

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13 Diagnostic CategoriesHead & Neck Cancer (140.0 – 149.9, 161.0 – 161.9)Esophageal Cancer (150.0 – 150.9)Gastric Cancer (151.0 – 151.9)Colon Cancer (153.0 – 153.9)Rectal Cancer (154.0, 154.1)Pancreatic Cancer (157.0, 157.1, 157.3, 157.8, 157.9)Lung Cancer (both non-small cell and small cell) (162.2 – 162.9) Female breast cancer (invasive) (174.0 – 174.9)Ovarian Cancer (183.0)Prostate cancer (185)Non-Hodgkin’s Lymphoma (202.00 – 202.08, 202.80 – 202.98)Multiple Myeloma (203.00, 203.01)Chronic myelogenous leukemia (205.10, 205.11)

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Payment Requirements

To qualify for payment, providers must submit one G-code from each of the three reporting categories when billing for an E & M service for established patients, 99212 – 99215

Claims must be assigned

Place of service must be “office” (place of service code 11)

Patients enrolled in Medicare Advantage plans are not eligible

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Payment Requirements

Providers reporting data for all three categories with a qualifying visit will receive demonstration payment of $23

Allowances are as follows: G9050 – G9055 $7.67 G9056 – G9062 $7.67 G9063 – G9130 $7.66

The usual Part B coinsurance and deductible apply

Effective date is 1/1/06; carrier implementation date is 1/17/06; carriers will hold claims until 1/17/06

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E & M VisitsThe demonstration applies to E & M visits with patients who have a diagnosis in one of the 13 listed categories where the primary focus of the visit is management of the cancer, its complications, and the complications of its treatment

Eligible visits should have an ICD-9 code on the claim for one of the included cancers; that cancer should be the first listed cancer diagnosis on the claim form The cancer does not need to be the first list

diagnosis of any kind

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E & M Visits

The E & M service may be furnished on the same day that chemotherapy is provided to a patient or it may be the only service a patient receives on that day

If a medically necessary E & M service is provided on the same day as chemotherapy administration, attach modifier -25 to the E & M service

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E & M Visits

As always, the physician should appropriately document the patient’s record to support the level of E & M service billed

E & M visits should not be “upcoded” because of the additional documentation required by the demonstration project

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Documentation Requirements

For each qualifying visit, physicians must identify three appropriate G-codes, one from each category:

Primary focus of visit (G9050 – G9055) Adherence to guidelines (G9056 – G9062) Current disease state (G9063 – G9130)

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Documentation Requirements

Physician must also supply documentation in the patient chart to support billing for the demonstration project

The primary requirement is to identify the source of the guideline consulted

The title of the specific guideline that was consulted is not required

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Documentation Requirements

Suggested phrases for documentation:

Demonstration project – ASCO Demonstration project – NCCN Demonstration project – ASCO & NCCN, or Both Demonstration project – No guideline available,

or None Demonstration project – Clinical trial, or CT

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Documentation RequirementsPhysicians do not have to provide additional documentation in the patient chart beyond these elements

Local Medicare carriers have been advised that further documentation requirements are not to be imposed

Notify ASCO if your carrier adds documentation requirements

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An Alternative Approach

CMS has also suggested using a documentation template, or flowsheet, designed to fulfill all requirements under the demonstration project http://www.asco.org/asco/downloads/Medlearn_Article_D

emo_Documentation_and_Reporting.pdfIf such a template is used, physicians do not have to provide any additional documentation in the patient recordAgain, local carriers are instructed not to impose additional documentation requirements

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Documentation Templates from ASCO

ASCO has prepared 13 diagnosis-specific templates for use with the Demonstration Project

In addition to the codes, each template includes a list of appropriate practice guidelines (both ASCO and NCCN)

To access the ASCO templates, go to www.asco.org/2006demo

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Coding Guidance: Primary Focus of the Visit

Physician should determine the single code that best identifies the primary focus of the E & M visit on that particular day

CMS recognizes that many different issues are addressed in most E & M visits; physicians should make what to them seems the best choice for that day

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Primary Focus of the Visit

G9050 Oncology Work-up Evaluation G9051 Oncology Treatment Decision/Treatment Management G9052 Oncology Surveillance for DiseaseG9053 Oncology Expectant Management of PatientG9054 Oncology Supervision PalliativeG9055 Oncology Visit Unspecified

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Coding Guidance: Guideline Adherence

Treating physician should choose the single code that best reflects whether or not patient management adheres to practice guidelines, and if not, the best listed reason why not

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Oncology Practice GuidelinesG9056 Management Adheres to GuidelinesG9057 Management Differs from Guidelines as a Result of Enrollment in Clinical TrialG9058 Management Differs from Guidelines because the Physician Disagrees with the GuidelinesG9059 Management Differs from the Guidelines because the Patient Opts for Different TreatmentG9060 Management Differs from Guidelines for Reasons Associated with Patient IllnessG9061 Patient’s Condition Not Addressed by GuidelinesG9062 Management Differs from Guidelines for Other Reasons

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G9056 Management Adheres to Guidelines

Focus of the Visit What to Look ForG9050 Oncology work-up evaluation

Compare tests obtained to those recommended in guidelines

G9051 Oncology treatment decision/treatment management

Compare chemotherapy, hormonal therapy, immunotherapy, and radiotherapy treatments offered or provided to those recommended in guidelines

G9052 Oncology surveillance for disease

Compare surveillance approach, such as tests and frequency of tests, to that recommended in guidelines

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G9056

Focus of the Visit What to Look ForG9053 Oncology expectant management of patient

Compare expectant management approach, such as tests and frequency of tests, to that recommended in guidelines

G9054 Oncology supervision of palliative therapies

Compare management of patient’s primary symptom, complaint, or complication in that visit to that recommended in guidelines

G9055 Oncology visit unspecified

Compare relevant management to relevant guidelines

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G9057 Management Differs from Guidelines as a Result of Enrollment in Clinical Trial

Code is reserved for patients who are on an IRB-approved clinical trial that dictates the care being provided in that visit

Will most often be relevant to visits in which the primary focus is treatment but may also include clinical trials focused on evaluation, surveillance, expectant management or palliation

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G9057

If the primary focus of the visit is the subject of the clinical trial, this code should be submitted; if the primary focus of the visit is other than that being evaluated in the clinical trial, the treating physician should determine if that management adheres to guidelines.

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G9057

NOTE: NCCN guidelines specify participation in a clinical trial as a recommended management strategy. For the purposes of this demonstration, if management differs from that specified in guidelines due to the patient’s enrollment on an IRB-approved clinical trial, G9057 should be reported as described above.

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Coding Guidance: Disease StatusPhysician providing the E & M service on that day should determine the single code that best represents the disease status of the patient’s cancer.

Disease status code should be relevant to the cancer that is the first listed cancer diagnosis on the claim form.

Disease status should be based on the best available data at the time of the visit. No additional diagnostic tests or evaluations should be performed for the purpose of further determining disease status for the purposes of this demonstration project.

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Disease Status Codes

Lung cancer, non-small cell, small cell (162.2 – 162.9)

G9063 – G9070

Female breast cancer (174.0 – 174.9)

G9071 – G9076

Prostate cancer (185) G9077 – G9083

Colon cancer (153.0 – 153.9) G9084 – G9089

Rectal cancer (154.0, 154.1) G9090 – G9095

Esophageal cancer (150.0 – 150.9)

G9096 – G9099

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Disease Status CodesGastric cancer (151.0 – 151.9)

G9100 – G9104

Pancreatic cancer (157.0 – 157.3, 157.8, 157.9)

G9105 – G9108

Head and neck cancer (140.0 – 149.9, 161.0 – 161.9)

G9109 – G9112

Ovarian cancer (183.0) G9113 – G9117Non-Hodgkin’s lymphoma (202.00 – 202.08, 202.80 – 202.98)

G9118 – G9122

Chronic myelogenous leukemia (205.10, 205.11)

G9123 – G9127

Multiple myeloma (203.00, 203.01)

G9128 – G9130

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Demo Project FAQsHow do I enroll in the demonstration project? There is no separate enrollment process.

Reporting one G-code form each category for an E & M visit for a patient with a qualifying diagnosis will automatically enroll you in the demonstration project. Participation is voluntary.

Can I bill for the demonstration project in the hospital outpatient department? No. CMS has stated that the demonstration can

only be billed in the office setting (place of service 11).

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Demo Project FAQs

Will the patient be responsible for a 20% Medicare co-pay? Yes.

Will non-Medicare secondary payers recognize the demonstration project and cover the 20% co-pay? All official Medigap plans will cover the 20% co-

pay. Other secondary insurers may cover the co-pay. Check with individual payers.

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Demo Project FAQs

Is patient consent required for the demonstration project?

No. Physicians are not required to obtain patient consent to participate in the demonstration project. However, physicians may choose to provide some explanation of the additional co-pay to their patients.

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Demo Project FAQsIs a physician required to select the G-codes for the demonstration or can this be done by a nurse reviewing the patient’s chart?

CMS has clearly noted its intent to tie the demonstration project to a physician service and has designed reporting requirements around the physicians evaluation and management of the patient. Therefore, ASCO recommends that the physician take primary responsibility for selecting and reporting the appropriate demonstration codes, based on his/her evaluation of the patient. Physicians also need to continue to comply with the E & M documentation requirements for their level 2 – 5 office visits.

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2006 Physician Fee Schedule

Conversion factorPayment for covered outpatient drugs and biologicalsDiagnostic imagingPhysician self-referral prohibitionHCPCS changes

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Conversion FactorCF was scheduled to decrease 4.4% on 1/1/06Before the holiday break, the House and Senate both approved a conference report to freeze the conversion factor at 2005 levels BUT the Senate struck three unrelated provisions on a point of order and now the House must re-pass the reportHouse is expected to re-pass the report, but this is not guaranteedTiming is unclear, probably late January or FebruaryFreeze on CF will likely be retroactive to 1/1/06; impact on claims processing unclear at this time

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Payment for Covered Outpatient Drugs and Biologicals

Average Sales Price (ASP) ASP calculation methodology remains

unchanged ASP updates continue to be provided

quarterly, generally about 15 days before the beginning of the quarter

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Payment for Covered Outpatient Drugs and Biologicals

Intravenous infusion of immunoglobulin Temporary code (G0332) established to describe

additional pre-administration services related to IVIG administration

Intended to cover “substantial additional resources that are associated with locating and acquiring adequate IVIG product and preparing for an office infusion of IVIG in the current environment.”

G0332 may be billed once per day in association with a patient encounter for administration of IVIG.

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Payment for Covered Outpatient Drugs and Biologicals

New J-codes for IVIG J1566 Injection, immune globulin, intravenous,

lyophilized (powder), 500 mg. J1567 Injection, immune globluin, intravenous,

non-lyophilized (liquid), 500 mg.

Codes Q9941, Q9942, Q9943, Q9944 have been deleted

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Diagnostic ImagingMultiple procedure payment reduction CMS finalized a proposal to reduce payment for the

2nd and subsequent imaging procedures within the same “family”

Procedure with the highest payment will be paid at the full amount; payment for the technical component of additional procedures will be reduced

Professional component is not subject to this reduction

Two-year phase-in process; 25% reduction in 2006, 50% reduction in 2007

Reductions apply to office-based imaging only

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Physician Self-Referral Prohibition

Nuclear medicine Effective 1/1/07, nuclear medicine services

(including PET scans) will be included in the definition of “designated health services” subject to the Stark law

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HCPCS Changes

Many new codes and deleted codesWatch out for new descriptions, new units of measureCode changes are effective 1/1/06

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Drug Administration Services

2005 Medicare G-codes have been deleted effective 12/31/05 and replaced with CPT codes

Definitions for 2006 CPT codes mirror the 2005 Medicare G-codes for drug administration services

ASCO’s coding cross-reference sheet contains the 2006 CPT codes, the 2005 Medicare G-codes, and all definitions

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Drug Administration Services

2006 CPT codes should be recognized by private payers as CPT is the standard coding system recognized by HIPAA Implementation dates may vary by payer

2006 CPT codes for drug administration services are also being used in the hospital outpatient setting under the hospital outpatient prospective payment system Combination of CPT codes and new C-codes Payment still based on APCs

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Drug Administration FAQs

Did CPT keep the terms “initial,” “each additional,” and “additional sequential” that were used with the Medicare G-codes?

Yes. The CPT book includes these same terms and there have been no changes in their definitions.

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Drug Administration FAQs

Did CPT make any additional changes to the definition of an intravenous push?

No. The CPT Editorial Panel has defined an intravenous or intra-arterial push as “an injection in which the healthcare professional who administers the substance or drug is continuously present to administer the injection and observe the patient, or an infusion of 15 minutes or less.”

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Drug Administration FAQs

We are still very confused about concurrent infusions. Has there been any clarification or definition of a concurrent infusion?

The American Medical Association (AMA) defines a concurrent infusion as one in which multiple infusions are provided through the same intravenous line.

The concurrent infusion code (90768) is for non-chemotherapy infusions only.

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Drug Administration FAQs

If a second drug is added to a bag for intravenous administration, can the administration of the second drug be reported?

No. More than one substance in a single bag is considered one infusate and one infusion. In this scenario, only one administration can be reported. The J-code for each substance is separately reportable.

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Drug Administration FAQs

If two drugs are infused simultaneously but hung in two separate bags, would it still be a concurrent infusion?

Yes. Even if multiple drugs are hung separately, they administration is considered to be concurrent because the drugs are running simultaneously. In this situation you would report an initial or subsequent administration for the first drug and a concurrent administration for the second drug.

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Drug Administration FAQs

What if two drugs are mixed in the same bag and administered for fifteen minutes?

If an infusion lasts 15 minutes or less, it meets the definition of a push and the appropriate push code (initial or subsequent) should be reported. In this situation, the infusion would be reported as one push; however, each substance or drug would be separately reported.

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Drug Administration FAQs

Can more than one concurrent administration code be reported? A concurrent infusion can be billed once per patient

encounter.

Is there a code for concurrent chemotherapy? No. There is no code to report concurrent

chemotherapy administrations. If a concurrent chemotherapy administration occurs, only one chemotherapy administration code can be reported. Each drug can be separately reported.

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Drug Administration FAQs

Are there guidelines for reporting the duration of an infusion?

Yes. After the first hour of infusion, round infusion times to the nearest 30 minutes. For infusions of 30 minutes or less, round down. For infusions greater than 30 minutes, round up.

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Drug Administration FAQs

When reporting infusion times, does the infusion time start when the drug/substance is being mixed or when the actual infusion starts?

The infusion time begins when the infusion starts. Infusion time reflects the time the drug/substance is actually being administered.

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Drug Administration FAQs

Can we bill separately for starting an IV or accessing a port when providing drug administration services?

Starting an IV or accessing an IV or port are considered integral to the drug administration service and are therefore not separately reportable. In addition, use of local anesthesia, flushing at the conclusion of infusion, and standard tubing, syringes and supplies associated with infusions are considered to be included in the service.

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Drug Administration FAQs

Is there a CPT code for flushing a port?

Yes. CPT code 96523 is for the irrigation of an implanted venous access device. Under Medicare rules, 96523 is payable only if it is the only physician fee schedule service provided on a date of service. This code should not be reported when an injection or infusion occurs on the same date of service.

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And Last But Not Least… Part D

Medicare prescription drug benefit began 1/1/06Initial enrollment period continues through 5/15/06Prescription drug plans (PDPs) are available in all statesPremiums vary depending on the plan selectedBeneficiaries can choose A stand-alone PDP which adds a drug benefit to

traditional Medicare, or A Medicare Advantage prescription drug plan or

other Medicare health plan with prescription drug coverage

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Part D

Part D does not affect coverage of Part B drugs; drugs covered under Part B will remain covered as Part B drugsPrescription drug plans must provide coverage under the “cancer drugs/antineoplastic” category but not all drugs will be coveredPrescription drug plans must have an exception process in place for formularies You may need to advocate for coverage for

particular drugs for your patientsDirect patient questions to 1-800-MEDICARE

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ASCO ResourcesOncology Demonstration Project FAQs Complete list of G-codes Documentation templates Impact assessment tool Complete listing of ASCO and NCCN

guidelines ASCO guidelines – synopsis of

recommendationsAll available at www.asco.org/2006Demo

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ASCO ResourcesFAQs on drug administration codes and other changes in the 2006 physician fee schedule http://www.asco.org/asco/downloads/FAQs_for_2006_Dr

ug_Administration_122705.pdf

For drug administration coding information “Practical Tips for the Practicing Oncologist”

3rd Edition and Supplement for 2005 Available online at www.asco.org/practicaltips

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ASCO Resources

Ask a Coding Question: Call 703-299-1054 or Email practice@asco.org

Journal of Oncology Practice Available by subscription and online at

www.jopasco.org

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Practice Guidelines

ASCO clinical practice guidelines www.asco.org/guidelines

NCCN practice guidelines www.nccn.org

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CMS ResourcesOncology Demonstration Project Guidance on data reporting for participating physicians http://www.asco.org/asco/downloads/Medlearn_Article_

Demo_Documentation_and_Reporting.pdf Guidance on billing and coding http://www.asco.org/asco/downloads/Medlearn_Article_

Demo_Billing_and_Coding.pdf Carrier instructions http://www.cms.hhs.gov/transmittals/downloads/r36de

mo.pdf HCPCS code updates http://www.cms.hhs.gov/HCPCSReleaseCodeSets/02_H

CPCS_Quarterly_Update.asp#TopOfPage