Debra L. Patterson, MD

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TrailBlazer Health Enterprises, LLC Medicare
Administrative Contractor Oklahoma , Colorado,
New Mexico, and Texas

• Debra L. Patterson, MD
• J4 MAC Medical Director

Published May 2008
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Todays Discussion

• J4 MAC Implementation Status.
• Recent MR Activities Of Interest to Oncology
• PCA.
• LCD.
• Odds and Ends.

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Jurisdiction 4

• J4 MAC implementation is complete
• Oklahoma Part A and B and New Mexico Part B
  cutover March 1, 2008.
• Colorado Part B cutover March 23, 2008.
• Texas Part A and B, New Mexico Part B, and
  Colorado Part B cutover June 13, 2008.

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TrailBlazer Wins J4 Contract
J4 Texas, New Mexico, Colorado and Oklahoma
http//www.cms.hhs.gov/MedicareContractingReform/A
BMAC/list.aspTopOfPage
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J4 MAC Web Site

• Effective July 1, 2008 the J4 MAC Web site was
  consolidated with the main Medicare Web site.
• http//www.trailblazerhealth.com

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Contact Information

• Providers may submit questions regarding the
  implementation process or other issues to
• PartB.J4_at_trailblazerhealth.com
• Questions or concerns about NPI may be addressed
  through the NPI issues e-mail address at
• NPI.issues_at_trailblazerhealth.com

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Jurisdiction 4

• Going Forward
• Unresolved implementation issues.
• Provider enrollment and NPI backlog.
• 2009 Budget and Medical Review Strategy.
• LCD Re-work.

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Medical Review

• 2009 Medical Review Strategy And Budget Under
  Development
• 2009 Problem List unchanged from 2008
• Drugs.
• Ambulance.
• Imaging.
• E/M.
• CERT report (for 2007 claims) due in November 08.

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Medical Review

• Recent Post-pay audits
• ESAs.
• Chemotherapeutic agents.
• Nuclear cardiac imaging.

Incomplete
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Medical Review

• Recent Probe Results ESAs
• Selected records representing patients who had
  been on ESAs for prolonged periods of time (gt12
  wks).
• Overall, about 11 of patients who get an ESA,
  remain on the ESAs for a prolonged period (gt12
  weeks).
• Most of the patients had either MDS or CKD.

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Medical Review

• ESA Probe included 198 claims (all TX providers)
• 21 Paid.
• 79 Denied.
• 56 (28) - non-covered diagnosis
• Untreated correctable anemia (e.g., iron
  deficiency).
• Myelofibrosis.
• 48 (24) - lack of evidence for response to ESA.
• 23 (12) lack of documentation for incident
  to.
• 19 (10) - lack of documentation.
• 3 claims denied due to high Hematocrit (gt40).

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ESA LCD 3rd Edition

• Background
• Several studies indicate increased mortality with
  higher hemoglobin levels
• CHOIR Study in CKD patients.
• Four studies in cancer patients.
• Other.
• FDA added Black Box warning to label and issued
  Safety Alert.
• CMS issued NCD on cancer related uses.

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ESA Policy 3nd Edition

• The previous ESA LCD included indications for
  dialysis and cancer patients
• Use of ESAs in dialysis patients has specific
  coverage described in the CMS On Line Manual.
• CMS recently issued an NCD for use of ESAs in
  cancer patients.
• This version eliminates those services subject to
  National policy and clarifies coverage for other
  indications
• Myelodysplastic syndrome.
• Chronic Kidney Disease.
• Anemia of Chronic Disease.
• Anemia related to certain drugs.

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ESA LCD 3rd Edition

• Status
• Comment period ends 8/11/08.
• Policy effective date December 2008.
• Submit comments via Web site or e-mail to
  draft.lmrp_at_trailblazerhealth.com

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Miscellaneous Information
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Miscellaneous Information
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Miscellaneous Information
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ESA LCD 3rd Edition

• Status
• Comment period ends 8/11/08
• Policy effective date December 2008
• Submit comments via Web site or email to
  charles.haley_at_trailblazerhealth.com

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November 2007 CERT Report - Part B Carrier
Combined Error Rate by Type of Error Claims
Submitted 4/1/2006 - 3/31/2007
Paid Claims Error Rate 4.8
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E/M Computer Based Training Modules

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E/M Frequently Asked Questions

• 1. The 1995 DG state that a notation indicating
  all other systems are negative is permissible.
  Why then does Trailblazer not accept this
  language as evidence of a complete systems
  review?
• The guidelines specify how many systems must be
  documented for each level of ROS.  That a system
  that is negative may be documented with a
  notation of "negative" in no way implies
  absolution from documenting the specified number
  of systems either with pertinent positives,
  pertinent negatives, or, if asymptomatic and not
  related to the presenting problem, simply noted
  as "negative". 

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E/M Frequently Asked Questions

• 2. May I count a system in the ROS when I counted
  it in HPI?
• HPI and ROS are generally fundamentally different
  kinds of information but they overlap with the
  HPI element called associated signs and
  symptoms. The system related to a HPI sign or
  symptom may be counted only if it is not double
  counting of a single bit of information.

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E/M Frequently Asked Questions

• 3. Who may perform the HPI?
• The HPI, Examination, and Medical Decision Making
  must be performed by the physician or other
  qualified non-physician practitioner under whose
  Medicare ID the service is reported to Medicare.
  The ROS, and PFSH may be performed, if clinically
  appropriate, by ancillary personnel.

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E/M Frequently Asked Questions

• 4. TrailBlazer uses Medical Decision Making that
  is different from CMS E/M Guidelines. Why?
• The CMS E/M Guidelines provide no quantification
  for the first two components of MDM
  (diagnoses/management options and data).
  TrailBlazers auditing tool is different from
  some of the commercial and non-commercial
  auditing tools that have appeared over the last
  13 years but are totally consistent with CMS E/M
  Guidelines. Provider choice of auditing method
  for MDM is optional, but TrailBlazer suggests
  careful evaluation of methods to validate results
  and verify their consistency with Medical
  Necessity.

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E/M Frequently Asked Questions

• 5. How many organ systems must be documented for
  a detailed examination
• DETAILED examination requires the same number of
  organ systems as EXPANDED PROBLEM FOCUSED
  examination, 2-7. The difference between these
  two examinations is not organ systems but is the
  amount of detail given about the systems. EPF is
  a limited examination whereas DETAILED is and
  extended examination.

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New Headaches

• ICD-10

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• Questions?