Medical Oncology Coding Update December 1, 2005

1. Medical Oncology Coding Update December 1, 2005 Neltner Billing & Consulting Services “We Bring The Pieces Together For You”

2. NBC • Neltner Billing & Consulting Services, Inc. 6463 Taylor Mill Road Independence, KY 41051 (800) 676-7639 (859) 363-4900 www.neltnerbilling.com • Martin E. Neltner, President (859) 363-4981 office (859) 743-6192 cell mneltner@earthlink.net Neltner Billing & Consulting Services

3. Billing Expertise • 41 practices, 139 physicians, 8 specialties in 16 states • Billing and coding • A/R management • Practice management • Process review and design • Forms development • Compliance audits and program development • Documentation review • Consulting, lobbying and advocacy Neltner Billing & Consulting Services

4. Agenda • Drug Administration Codes • Demonstration Project • Chemotherapy Drug Issues • E&M Coding Issues Neltner Billing & Consulting Services

5. Drug Administration Codes Neltner Billing & Consulting Services

6. Code Crosswalk Neltner Billing & Consulting Services

7. Code Crosswalk Neltner Billing & Consulting Services

8. Code Crosswalk Neltner Billing & Consulting Services

9. Code Crosswalk Neltner Billing & Consulting Services

10. IVIG Code • Creating temporary G-code to describe additional preadministration services related to obtaining IVIG • Only for 2006 • Presently significant fluctuations in IVIG marketplace • G0332: preadministration-related services of intravenous infusion of immunoglobulin, per infusion encounter (this services is to be billed in conjunction with administration of immunoglobulin) • Bill once per day Neltner Billing & Consulting Services

11. AMA Descriptions • AMA released changes to drug descriptions in 2006 CPT book • Descriptions include coding guidelines that mirror CMS payment policies • Following slides identify key points • Note that old CPT codes have been deleted for 2006 Neltner Billing & Consulting Services

12. AMA Descriptions Physician work related to hydration, injection, and infusion services predominantly involves affirmation of treatment plan and direct supervision of staff. Neltner Billing & Consulting Services

13. AMA Descriptions If performed to facilitate the infusion or injection, the following services are included and are not reported separately: a. Use of local anesthesia b. IV start c. Access to indwelling IV, subcutaneous catheter or port d. Flush at conclusion of infusion e. Standard tubing, syringes, and supplies f. Preparation of chemotherapy agent(s) Neltner Billing & Consulting Services

14. AMA Descriptions (Report 90761 for hydration infusion intervals of greater than 30 minutes beyond 1 hour increments) Neltner Billing & Consulting Services

15. AMA Descriptions The fluid used to administer the drug(s) is incidental hydration and is not separately reportable. Neltner Billing & Consulting Services

16. AMA Descriptions These services typically require direct physician supervision for any or all purposes of patient assessment, provision of consent, safety oversight, and intra-service supervision of staff. Neltner Billing & Consulting Services

17. AMA Descriptions Intravenous or intra-arterial push is defined as: a) an injection in which the health care professional who administers the substance/drug is continuously present to administer the injection and observe the patient, or b) an infusion of 15 minutes or less. Neltner Billing & Consulting Services

18. AMA Descriptions 90767 additional sequential infusion, up to 1 hour Report 90767 only once per sequential infusion of same infusate mix 96417 each additional sequential infusion (different substance/drug), up to 1 hour Neltner Billing & Consulting Services

19. AMA Descriptions 90768 concurrent infusion (List separately in addition to code for primary procedure) (Report 90768 only once per encounter) Neltner Billing & Consulting Services

20. AMA Descriptions 90772 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular (Do not report 90772 for injections given without direct physician supervision. To report, use 99211) Neltner Billing & Consulting Services

21. AMA Descriptions 90775 each additional sequential intravenous push of a new substance/drug (List separately in addition to code for primary procedure) Neltner Billing & Consulting Services

22. AMA Descriptions 96522 Refilling and maintenance of implantable pump or reservoir for drug delivery, systemic (eg, intravenous, intra-arterial) 96523 Irrigation of implanted venous access device for drug delivery systems (Do not report 96523 if an injection or infusion is provided on the same day) It's back! Neltner Billing & Consulting Services

23. -59 Modifier • “Modifier -59 in an important NCCI-associated modifier that is often used incorrectly.” • Modifier 59 (distinct procedural service) is used to identify procedures/services that are not normally reported together • Required only with hydration add-on per CMS program transmittal • However, different carriers had different requirements in 2005 • Some required use of -59 for ALL G-codes • Some required use of -59 for selective G-codes Neltner Billing & Consulting Services

24. Advocacy • Opportunities for advocacy related to coding of drug administration services • Physician work component update • Treatment planning codes • Adequacy of practice expense component • Inclusion of various services in chemo (see slide 12) • Inclusion of handling costs for pharmaceuticals • Billing of higher visit levels • Adequate documentation of complexity • Definition of face-to-face time vs. floor time • Port flush (again!) • Bundling in office visits • Bundling in injections Neltner Billing & Consulting Services

25. Demonstration Project Neltner Billing & Consulting Services

26. 2005 Demonstration Project • $130 payment per chemo encounter • Report three quality measures on 4pt scale • Pain • Nausea • Fatigue Neltner Billing & Consulting Services

27. Demo Letter • Letter written in September by the OIG to the Senate Committee on Finance • Cost of demo • $111 million in first six months • $3.6 million paid inappropriately • $22 million beneficiary liability • One physician received more than $320K Neltner Billing & Consulting Services

28. Demo Letter • Preliminary concerns • Reliability and usefulness of data • Inconsistent timeframes (week vs. day) • Data collection by interpretation (nurses vs patients) • No data collected on interventions initiated • Level of reimbursement • Exceeds level 5 office visit • Patient assessments already part of routine care prior to demonstration Neltner Billing & Consulting Services

29. 2006 Demonstration Project • Revising G-codes for reporting • Encourage quality care • Promote best clinical practices • Lead to improved patient outcomes • Report G-codes per E&M visit (99212-99215) • Primary diagnosis of cancer (13 major diagnostic categories) • $23 payment • Submit one G-code from each of three categories • Primary focus of E&M service • Current disease state • Whether current management adheres to clinical guidelines • Fact sheet http://www.cms.hhs.gov/media/press/release.asp?Counter=1717 Neltner Billing & Consulting Services

30. Breast cancer Chronic myelogenous leukemia Colon cancer Esophageal cancer Gastric cancer Head and neck cancer Multiple myeloma Ovarian cancer Non-Hodgkin’s lymphoma Pancreatic cancer Prostate cancer Rectal cancer Non-small cell/small cell lung cancer Cancer Diagnoses in Demo Neltner Billing & Consulting Services

31. Primary Focus • Physicians will choose one: • Work-up evaluation, staging • Therapy Management • Treatment decision making occurring after disease is staged • Counseling about treatment • Supervising or coordinating active therapy • Managing toxicity of therapy • Disease surveillance • Expectant management of patient with existing disease (no active therapies) • Supervising, coordinating, or managing • Palliative care • End-of-life care • Other Neltner Billing & Consulting Services

32. Guideline Adherence • Physicians will report if their care complies with professional guidelines • Management adherent to guidelines • Management differs from guidelines due to patient enrollment in clinical trial or protocol • Management differs from guidelines because the treating physician disagrees with guidelines • Management differs from guidelines because the patient has opted for alterative or no treatment • Management differs from guidelines for reasons associate with patient comorbid illness or performance status • Patient’s condition not addressed by available guidelines Neltner Billing & Consulting Services

33. Current Disease State • Depends on cancer • Options range from 1 to 8 different choices for each cancer • See http://www.asco.org/asco/downloads/2006_onco_demo_project_codes-1.pdf Neltner Billing & Consulting Services

34. Chemotherapy Drug Issues Neltner Billing & Consulting Services

35. OIG Study • Adequacy of Medicare Part B Drug Reimbursement to Physician Practices for the Treatment of Cancer Patients • A-06-05-00024 • Published in September • Conclusions • Average prices for 35 out of 39 drugs < Medicare allowable • Why didn’t OIG compare to ASP instead of allowable? • At least half of practice months • What about the other half? • No study of impact of beneficiaries ability to pay co-insurance Neltner Billing & Consulting Services

36. CAP • No vendors applied for CAP last year! • CMS agrees “that the best outcome for both the ASP methodology and the CAP programs would be one in which prices under CAP did not affect payment amounts under the ASP methodology” Neltner Billing & Consulting Services

37. NBC Experience • Solo practitioner • Drug purchasing • 24 out of 32 drugs cost > Medicare allowable • 7 out of 32 drugs cost > ASP < allowable • 1 out of 32 drugs cost < ASP • Negotiated new payment plan • Took $500K loan to pay off past due drug bills • 13 out of 32 drugs cost > Medicare allowable • 9 out of 32 drugs cost >ASP < allowable • 10 out of 32 drugs cost < ASP • Secondary coverage • Medicare quotes 80% of beneficiaries have 2nd • Our client: • 1/3 had 2nd coverage for entire co-insurance amount • 1/3 had 2nd coverage of <co-insurance amount • 1/3 had no 2nd coverage Neltner Billing & Consulting Services

38. E&M Coding Issues Neltner Billing & Consulting Services

39. Recent Audit Experiences • Anthem audited oncologist for high-level office consults • Downcoded services based on review of documentation • Requested refund • NBC successfully defended against refund request • Documentation did not include ROS • NBC used argument of complexity of care Neltner Billing & Consulting Services

40. Recent Audit Experiences • CMS Program Integrity audit based on frequency of multiple high visit levels • Audit performed by Program Safeguard contractor • Used 1997 guidelines instead of both 1995 and 1997 as required by CMS • Referenced a retired LMRP • Failed to provide sufficient information for physician education • NBC defense still under review Neltner Billing & Consulting Services

41. Recent Audit Experiences “Medical necessity of a service is the overarching criterion for payment …” … this is the opportunity for the oncology community to document complexity • Look at the treatment protocol • Let the protocol drive the order • Let the order drive the treatment • Document changes to the treatment based on medical necessity This is a tremendous opportunity! Neltner Billing & Consulting Services

42. CMS Manual Instructions • Transmittal 731, Change Request 4032 • “This transmittal will update the E/M manual section indicating Medicare will pay for a medically necessary office/outpatient visit (when it meets a higher complexity level than CPT code 99211) billed on the same day as a drug administration service as specified.” • Define medically necessary • 99211 is not separately billable with any drug administration service, including injections • NCCI edits updated in July • Effective January 2005 Neltner Billing & Consulting Services