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Practice Management Series 2004 - 2005

ASCO Clinical Practice Series Updated: 3/22/05. Practice Management Series 2004 - 2005 . Practice Management Curriculum. 1. Adapting to Changes in Medicare. 2. Generating Practice Efficiencies . 3. Organizing for Service Expansion . 2. Adapting to Changes in Medicare.

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Practice Management Series 2004 - 2005

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  1. ASCO Clinical Practice Series Updated: 3/22/05 Practice Management Series2004 - 2005

  2. Practice Management Curriculum 1. Adapting to Changes in Medicare 2. Generating Practice Efficiencies 3. Organizing for Service Expansion 2

  3. Adapting to Changes in Medicare Identifying and understanding the Medicare changes in 2005 and their effect on your practice. 3

  4. Who should attend • Physician Leader of the Practice • President of the PA, Founder • Practice Administrator • CEO, Executive Director, COO • Contracting Officer • Contract Administrator, Director of Billing • Clinical Manager • Medical Director, Nursing Team Leader 4

  5. After this session, you will be able to: • Identify changes in Medicare from 2003-2006. • Assess the degree to which your practice has made the necessary changes to adapt to new Medicare regulations. • Define new opportunities for oncology practices. • Understand changes to margins for chemotherapeutic and supportive care products. • Understand the role of the physician practice leader and the administrator in adapting to these changes. 5

  6. Medicare Prescription Drug Improvement and Modernization Act (MMA)What happened in 2004? • Average Wholesale Price decreased with most drugs at 80 -85% of AWP April 1, 2003 • 99211 can no longer be billed with chemotherapy but… • 0.17 RVUs added for physician work component of chemotherapy administration 6

  7. What happened in 2004? • Increase in practice expense component of chemotherapy administration • 2004 Conversion factor of $37.3374 (1.5% over 2003) • 32% transitional add-on to the practice expense component of chemotherapy administration • This 32% kept most oncology practices “whole,” comparable to 2003 7

  8. MMA….2005 • AWP is gone • Drug reimbursement now based on Average Sales Price (ASP) • Effective 1/1/05 drugs furnished incident to a physician’s service are paid at ASP + 6% • ASP data will be updated quarterly with a two quarter lag (ex. 4/1/05 payments based on 4th qtr 2004 data) 8

  9. What is ASP? • ASP = total US sales for an NDC (national drug code) divided by the total number of units sold (incl discounts) • Unit is defined as the lowest identifiable quantity of the drug or biological by NDC that is dispensed, exclusive of diluents • Manufacturers must report ASP quarterly • 12 month averaging is used to smooth price changes • ASP must include volume discounts, prompt pay discounts, free goods that are contingent on any purchase requirement, charge backs and all rebates other than the Medicaid rebates

  10. MMA….2005 • ASP • If data is not available to calculate ASP (ex. new drugs), payment will be made based on wholesale acquisition cost or the methodologies in effect on 11/1/03 to determine payment amounts, “for a limited period” • Influenza, pneumococcal and hepatitis B vaccines will be paid based on 95% of AWP – AWP will be updated quarterly • ASP payment files are available at http://www.cms.hhs.gov/providers/drugs/default.asp 10

  11. ASP Update - April 1, 2005 • Significant decrease in payment for Carboplatin (from $125.47 to $75.75) • Payment rate published for paclitaxel protein-bound particles (Abraxane) at $8.44/1 mg. • IVIG codes have changed: • Q9941 IVIG lyophilized 1 gram $56.36 • Q9942 IVIG lyophilized 10 mg. $0.56 • Q9943 IVIG non-lyophil. 1 gram $39.14 • Q9944 IVIG non-lyophil. 10 mg. $0.39

  12. ASP Update - April 1, 2005 • Revisions to first quarter payment rates • CMS has not yet issued implementation instructions

  13. ASP Update - April 1, 2005 • More revisions

  14. A few ASP examples…

  15. ASP - Your “To Do” List • Complete ASCO’s ASP spreadsheet and send to ASCO • Know the current Medicare payment amounts and update your system every quarter • Watch for drugs that cost more than your Medicare payment • Inform ASCO, CMS • Shop aggressively • Understand financial implications before you begin treatment 15

  16. MMA….2005 • Drug Administration Payment Policy and Coding • MMA required evaluation of existing drug administration codes with any changes exempt from budget neutrality requirements • MMA required the “use of existing processes” and consultation with physician specialties affected by the provisions that change Medicare payment for drug administration 16

  17. MMA….2005 • Drug Administration Payment Policy and Coding • AMA CPT Editorial Panel formed a workgroup; presented recommendations to CPT Editorial Panel in August; AMA RUC met in September; ASCO very involved in process • Established new interim G-codes for 2005 • These codes correspond with new CPT codes that will become active in 2006 and replace the G-codes • NOTE: 32% add-on decreases to 3% add-on in 2005 17

  18. MMA….2005 • Established new codes in three categories • Infusion for hydration • Non-chemotherapy therapeutic/diagnostic injections and infusions other than hydration • Chemotherapy administration (other than hydration) which includes infusions/injections • These codes are for use in office-based practices only 18

  19. MMA….2005 • Changes in Drug Administration Coding • Under the new codes, chemotherapy administration codes apply to: • parenteral administration of non-radionuclide anti-neoplastic drugs • anti-neoplastic agents provided for the treatment of non-cancer diagnoses (e.g., cyclophosphamide for autoimmune conditions) 19

  20. MMA….2005 • More changes… • Infusion of substances such as monoclonal antibody agents or other biologic response modifiers is reported under the chemotherapy administration codes • Drugs commonly considered to fall under the category of monclonal antibodies: infliximab, rituximab, alemtuzumab, gemtuzumab, and trastuzumab • Administration of anti-anemia drugs and anti-emetics by injection or infusion for cancer patients is not considered chemotherapy administration and should be reported using new codes G0347 – G0354 • CMS will NOT be developing a national list of approved chemotherapy drugs but will allow each carrier to develop such a list; check your local policies

  21. MMA….2005 • More changes… • There are new codes in both the chemotherapy and non-chemotherapy sections for reporting the “additional sequential infusion” of different substances or drugs • Injection services (therapeutic, prophylactic or diagnostic injections) are now separately paid even if another physician fee schedule service is billed for the same patient that day

  22. MMA….2005 • ASCO handout – “Coding and Payment Changes for Medicare Drug Administration Codes” • A complete cross-walk between 2004 CPT codes and 2005 Medicare G-codes • Includes RVUs for 2004 and 2005 • Includes national average payment rates for 2004 (including 32% add-on) and 2005 (including 3% add-on) 22

  23. Let’s Define Some Terms…Initial Service • The initial code is the code that best describes the service the patient is receiving and the additional codes are secondary to the initial code • If a combination of chemotherapy drugs, non-chemotherapy drugs, and/or hydration is administered by infusion sequentially, the initial code that best describes the service should always be billed irrespective of the order in which the infusions occur 23

  24. Initial Service • Only one initial drug administration service code should be reported per patient per day, unless protocol requires that two separate IV sites must be utilized • If a patient has to come back for a separate identifiable service on the same day, or has two IV lines per protocol, these services are separately payable and reported with modifier -76 (repeat procedure by same physician)

  25. What is a push? • Federal Register definition: • Intravenous or intra-arterial push is defined as an injection/infusion of short duration (i.e., 30 minutes or less) in which the healthcare professional who administers the substance/drug is continuously present to administer the injection and observe the patient

  26. What is a push? • CPT revision February, 2005: • Intravenous or intra-arterial push is defined as a) an injection in which the healthcare 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. • Additional guidance from CMS is expected soon

  27. New Service Codes • Several new service codes have been added • Codes are intended to recognize additional work and practice expense associated with the provision of multiple drugs • Several of these new codes are add-on codes and should be used for drugs provided after the first • Add-on codes include: G0346, G0348, G0349, G0350, G0354, G0358, G0360, G0362 27

  28. Hydration • Codes G0345 and G0346 are intended to report an IV infusion that consists of a prepackaged fluid and/or electrolyte solution, but are not used to report infusion of drugs or other substances • On 1/27/05, CMS clarified that electrolytes that are prepackaged or mixed are reported using the hydration codes • Continue to use -59 modifier to indicate that hydration is performed before or after the chemotherapy infusion 28

  29. Hydration • Report G0346 for hydration infusions of greater than 30 minutes beyond one-hour increments • Also report G0346 for hydration greater than 30 minutes when it is provided as a secondary or sequential service after a different initial infusion or chemotherapy service • Example – use G0346 for hydration of >30 minutes following chemotherapy infusion using G0359

  30. Injections and Infusions(non-chemotherapy, other than hydration) 30

  31. Injections and Infusions(non-chemotherapy, other than hydration) • G0350 - concurrent infusion – simultaneous infusion of two or more non-chemotherapy drugs • Cannot bill for multiple hours of concurrent infusion • No concurrent infusion code for chemotherapy drugs • Clarification from CMS to ASCO 1/6/05 – “not limited to one concurrent infusion per encounter”

  32. Concurrent Infusion • On 2/24/05 CMS informed ASCO that “carriers have discretion” on policy for concurrent infusions • Check with your carrier on specific coverage issues • Some carriers are not covering concurrent infusions when two drugs are administered from the same bag • The Illinois carrier has stated: “It is not appropriate to bill an infusion administration code for each drug that is contained within an IV bag. Only one IV bag is being administered and should be billed as one infusion service.”

  33. Injections and Infusions(non-chemotherapy, other than hydration) 33

  34. Injections and Infusions(non-chemotherapy, other than hydration) • G0354 - each additional sequential intravenous push, non-chemotherapy • It is possible that a non-chemotherapy drug administered IV push may follow the administration of a chemotherapy drug by IV push; G0354 would then be an add-on to G0357 • Example: Vinorelbine G0357 Palonosetron G0354 34

  35. Chemotherapy Administration • Drugs commonly considered to fall under the category of hormonal anti-neoplastics include leuprolide acetate and goserelin acetate. 35

  36. Chemotherapy Administration 36

  37. Chemotherapy Administration • G0362 – each additional sequential infusion, up to one hour • Example: if you administer three chemotherapy drugs by infusion, you should report one “initial” code (G0359) and two “additional sequential” codes (G0362) 37

  38. Chemotherapy Administration • G0363 - Irrigation of an implanted venous access device (“port flush”) • Medicare will pay for G0363 if it is the only service provided that day • If there is a visit or other drug administration service provided on the same day, payment for this service is bundled into payment for the other service • No longer use 99211 for port flush; G0363 is a more accurate definition of service and has better reimbursement • Some carriers pay for heparin used in port flush; check your carrier for their policy

  39. Chemotherapy Administration • G0363 - Irrigation of an implanted venous access device (“port flush”) • Communication from CMS to ASCO 1/6/05 – “Payment is allowed for G0363 if it is the only physician fee schedule service provided for a patient on that day. Payment could be made for G0363 and clinical laboratory services paid under the clinical laboratory fee schedule.”

  40. Some codes are NOT changing in 2005 • 90783 Therapeutic or diagnostic injection, intra-arterial • 90788 Intramuscular injection of antibiotic • NOTE: CPT will be deleting 90788 (intramuscular injection of antibiotic) in 2006. CMS is maintaining 90788 until it is changed in the CPT system. • 96405 Chemotherapy administration, intralesional, up to and including 7 lesions • 96406 more than 7 lesions 40

  41. More codes that are NOT changing in 2005 • 96420 Chemotherapy administration, intra-arterial, push technique • 96422 infusion technique, up to one hour • 96423 infusion , each add’l hour, one to eight hours • 96425 infusion, initiation of prolonged infusion • 96440 Chemotherapy administration into pleural cavity • 96445 Chemotherapy administration into peritoneal cavity • 96450 Chemotherapy administration into CNS 41

  42. More codes that are NOT changing in 2005 • 96520 Refilling and maintenance of portable pump • 96530 Refilling and maintenance of implantable pump • 96542 Chemotherapy injection, subarachnoid or intraventricular via subcutaneous reservoir, single or multiple agents 42

  43. Relative Value Comparison96410 Chemo infusion, 1st hourG0359 Chemo infusion, single/initial drug, 1st hour

  44. A Clinical Example…Carboplatin/Docetaxel • Carboplatin 600 mg. over 45 minutes • Docetaxel 135 mg. over 60 minutes • Dexamethasone 20 mg. infused over 15 minutes • Ondansetron 24 mg. infused over 15 minutes • Compare chemotherapy administration codes and payment rates for 2004 and 2005

  45. Carboplatin/Docetaxel

  46. Carboplatin/Docetaxel **CMS clarification on administrations > 15 minutes is forthcoming. For now, follow your local carrier guidelines.

  47. Chemo Admin Codes - Your “To Do” List • Put two sets of codes in place in your office for 2005 – one for Medicare (new G codes) and one for other payers (CPT codes) • Train your staff • Update your office tools – ex: charge ticket, fee schedules, pharmacy inventory cabinet • Make sure your nursing documentation is complete and reflective of these new codes and their descriptions • Talk to your non-Medicare payers about their plans regarding codes for chemotherapy services

  48. Severe drug reaction management • A severe drug reaction management code was requested and denied during the CPT process • CMS “recognizes that considerable physician effort may be required to monitor and attend to patients” with adverse reactions and complications • CMS: These services can be billed using existing CPT codes

  49. Severe drug reaction management • Bill for the Physician Visit • If a patient has a significant adverse reaction to drugs during a chemotherapy session and the physician intervenes, the physician could bill for a visit in addition to the chemotherapy administration services • Assumes no other physician visit on date of service • E & M guidelines should be used to determine the appropriate level of service to report; documentation must support the service level billed

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