Practice Management Series

1
Practice Management Series

• ASCO
• Clinical Practice Series

2
Practice Management Curriculum

• Adapting to Changes in Medicare
• Generating Practice Efficiencies
• Health Information Technology in Practice

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Adapting to Changes in Medicare2006

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

4
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

5
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 categories
• 1. 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

8
Who Can Participate?

• Midlevel providers (NPs, PAs) who may bill
  independently for Medicare services are not
  eligible to participate in the demonstration
• ASCOs interpretation of the carrier instructions
  is that visits performed in compliance with
  Medicares 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 Categories

• Head 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-Hodgkins 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

12
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 Visits

• The 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 patients 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 Requirements

• Physicians 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_Articl
  e_Demo_Documentation_and_Reporting.pdf
• If such a template is used, physicians do not
  have to provide any additional documentation in
  the patient record
• Again, local carriers are instructed not to
  impose additional documentation requirements

21
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 Disease
• G9053 Oncology Expectant Management of Patient
• G9054 Oncology Supervision Palliative
• G9055 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 Guidelines

• G9056 Management Adheres to Guidelines
• G9057 Management Differs from Guidelines as a
  Result of Enrollment in Clinical Trial
• G9058 Management Differs from Guidelines because
  the Physician Disagrees with the Guidelines
• G9059 Management Differs from the Guidelines
  because the Patient Opts for Different Treatment
• G9060 Management Differs from Guidelines for
  Reasons Associated with Patient Illness
• G9061 Patients Condition Not Addressed by
  Guidelines
• G9062 Management Differs from Guidelines for
  Other Reasons

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G9056 Management Adheres to Guidelines
Focus of the Visit What to Look For
G9050 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 For
G9053 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 patients 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 patients
  enrollment on an IRB-approved clinical trial,
  G9057 should be reported as described above.

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Coding Guidance Disease Status

• Physician providing the E M service on that day
  should determine the single code that best
  represents the disease status of the patients
  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 Codes
Gastric 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 G9117
Non-Hodgkins 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 FAQs

• How 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 FAQs

• Is a physician required to select the G-codes for
  the demonstration or can this be done by a nurse
  reviewing the patients 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 factor
• Payment for covered outpatient drugs and
  biologicals
• Diagnostic imaging
• Physician self-referral prohibition
• HCPCS changes

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Conversion Factor

• CF was scheduled to decrease 4.4 on 1/1/06
• Before 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 report
• House is expected to re-pass the report, but this
  is not guaranteed
• Timing is unclear, probably late January or
  February
• Freeze on CF will likely be retroactive to
  1/1/06 impact on claims processing unclear at
  this time

40
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

41
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.

42
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

43
Diagnostic Imaging

• Multiple 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

44
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

45
HCPCS Changes

• Many new codes and deleted codes
• Watch out for new descriptions, new units of
  measure
• Code changes are effective 1/1/06

46
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
• ASCOs 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

48
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.

50
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.

52
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.

54
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.

55
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.

57
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.

58
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 1/1/06
• Initial enrollment period continues through
  5/15/06
• Prescription drug plans (PDPs) are available in
  all states
• Premiums vary depending on the plan selected
• Beneficiaries 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 drugs
• Prescription drug plans must provide coverage
  under the cancer drugs/antineoplastic category
  but not all drugs will be covered
• Prescription drug plans must have an exception
  process in place for formularies
• You may need to advocate for coverage for
  particular drugs for your patients
• Direct patient questions to 1-800-MEDICARE

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ASCO Resources

• Oncology Demonstration Project
• FAQs
• Complete list of G-codes
• Documentation templates
• Impact assessment tool
• Complete listing of ASCO and NCCN guidelines
• ASCO guidelines synopsis of recommendations
• All available at www.asco.org/2006Demo

62
ASCO Resources

• FAQs on drug administration codes and other
  changes in the 2006 physician fee schedule
• http//www.asco.org/asco/downloads/FAQs_for_2006_D
  rug_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

63
ASCO Resources

• Ask a Coding Question
• Call 703-299-1054 or
• Email practice_at_asco.org
• Journal of Oncology Practice
• Available by subscription and online at
  www.jopasco.org

64
Practice Guidelines

• ASCO clinical practice guidelines
• www.asco.org/guidelines
• NCCN practice guidelines
• www.nccn.org

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CMS Resources

• Oncology Demonstration Project
• Guidance on data reporting for participating
  physicians
• http//www.asco.org/asco/downloads/Medlearn_Articl
  e_Demo_Documentation_and_Reporting.pdf
• Guidance on billing and coding
• http//www.asco.org/asco/downloads/Medlearn_Articl
  e_Demo_Billing_and_Coding.pdf
• Carrier instructions
• http//www.cms.hhs.gov/transmittals/downloads/r36d
  emo.pdf
• HCPCS code updates
• http//www.cms.hhs.gov/HCPCSReleaseCodeSets/02_HCP
  CS_Quarterly_Update.aspTopOfPage