Practice Management Series 2004 2005

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Practice Management Series2004 - 2005

• ASCO
• Clinical Practice Series
• Updated 3/22/05

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

• Identifying and understanding the Medicare
  changes in 2005 and their effect on your
  practice.

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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

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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.

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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

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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

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MMA.2005

• AWP is gone
• Drug reimbursement now based on Average Sales
  Price (ASP)
• Effective 1/1/05 drugs furnished incident to a
  physicians 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)

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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

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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
  

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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

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ASP Update - April 1, 2005

• Revisions to first quarter payment rates
• CMS has not yet issued implementation instructions

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ASP Update - April 1, 2005

• More revisions

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A few ASP examples
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ASP - Your To Do List

• Complete ASCOs 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

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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

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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

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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

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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)

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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

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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

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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)

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Lets Define Some TermsInitial 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

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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)

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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

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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

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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

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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

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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 gt30 minutes
  following chemotherapy infusion using G0359

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

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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

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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.

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

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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

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Chemotherapy Administration

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

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Chemotherapy Administration
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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)

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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

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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.

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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

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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 addl 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

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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

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Relative Value Comparison96410 Chemo infusion,
1st hourG0359 Chemo infusion, single/initial
drug, 1st hour
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A Clinical ExampleCarboplatin/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

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

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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

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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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Severe drug reaction management

• Bill for the Higher-Level Physician Visit
• If the patient had already seen the physician
  prior to a chemotherapy session.the physician
  may bill a visit for a significant adverse drug
  reaction. The total time, resources, and
  complexity of the physicians interaction with
  the patient may justify a higher level of visit
  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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Severe drug reaction management

• Bill for a Prolonged Service (99354 99355)
• If the patient had a physician visit prior to the
  chemotherapy session and experienced a
  significant adverse reaction to drugs on the same
  day, the physician can bill a prolonged service
  code in addition to the physician visit. The
  physician must have a face-to-face encounter with
  the patient and must spend at least 30 minutes
  beyond the typical time for that level of visit
  for the physician to bill for the prolonged
  service code.
• There are several code combinations to use
  depending on the number of minutes involved.

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Severe drug reaction management

• Bill for Critical Care Services (99291 99292)
• If the patient had a physician visit prior to the
  chemotherapy session and experienced a
  life-threatening adverse reaction to the drugs,
  the physician could bill for a critical care
  service in addition to the visit if the
  physicians work involves at least 30 minutes of
  direct face-to-face involvement managing the
  patients life-threatening condition.
• Examples of life-threatening conditions central
  nervous failure, circulatory failure, shock,
  renal, hepatic, metabolic and/or respiratory
  failure.

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Bone Marrow Aspiration and Biopsy

• Bone Marrow Aspiration and Biopsy through the
  Same Incision on the Same Date of Service
• New add-on G-code, G0364 Bone aspiration
  performed with bone marrow biopsy through same
  incision on same date of service
• Use CPT 38221 for bone marrow biopsy and G0364
  for second procedure, bone marrow aspiration
• CMS clarifies If the two procedures,
  aspiration and biopsy, are performed at different
  sites (for example, contralateral iliac crests,
  sternum/iliac crest or two separate incisions on
  the same iliac crest), the -59 modifier is
  appropriate to use and Medicares multiple
  procedure rule will apply
• Use 38221 for biopsy and 38220-59 for aspiration

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Specimen Collection

• G0001 (routine venipuncture for collection of
  specimen) has been deleted
• Medicare will now accept 36415 (collection of
  venous blood by venipuncture)
• 36416 (finger/heel/ear stick) is NOT covered by
  Medicare

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The Demonstration Project

• From CMS
• In order to identify and assess certain oncology
  services in an office-based oncology practice
  that positively affect outcomes in the Medicare
  population, we will initiate a one-year
  demonstration project for CY 2005.
• While we encourage optimal care in all facets of
  treatment, the focus of the demonstration project
  will be on three areas of concern often cited by
  patients pain control management, the
  minimization of nausea and vomiting, and the
  reduction of fatigue.

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The Demonstration Project

• What do practitioners need to do?
• Practitioners must provide and document
  specified measurements related to pain control
  management, minimization of nausea and vomiting,
  and the reduction of fatigue.
• The assessment may be taken either by the
  practitioner or by a qualified employee of the
  office under the supervision of the practitioner
  (incident to). If the assessment is performed by
  an employee, CMS expects the practitioner to
  review the data as part of the patient
  assessment.
• CMS states We expect that the patients
  responses will be recorded and included as part
  of the patients medical records.

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The Demonstration Project

• How is the assessment performed?
• Patients will assess their symptoms for the past
  week using four patient assessment levels "not
  at all," "a little," "quite a bit," "very much"
• These levels, based on the Rotterdam scale, were
  chosen by CMS because they appear to be less
  burdensome for the practitioner and more easily
  understood by the patient
• The responses are submitted on the claim form

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The Demonstration Project

• Assessment is to be performed at the time of a
  patient chemotherapy encounter
• What is a patient chemotherapy encounter?
• Chemotherapy administered through intravenous
  infusion (G0359) or push (G0357), limited to once
  per day injections are not included
• Who can participate?
• Any office-based physician or non-physician
  practitioner operating within the State scope of
  practice
• Must be providing chemotherapy to oncology
  patients in an office setting
• By billing the designated G-codes, the
  practitioner self-enrolls in the project and
  agrees to all of the terms and conditions of the
  demonstration project

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The Demonstration Project
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The Demonstration Project

• During the course of the project, an additional
  payment of 130 per encounter will be paid to
  participating practitioners for submitting the
  patient assessment data.
• A G-code for each patient status factor must
  appear on the claim for payment to be made under
  the demonstration project. Three codes are
  required, one from each symptom category. Claims
  without three codes will be denied.

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The Demonstration Project

• CMS will pay based on the lesser of 80 of the
  actual charge or the allowance by code
• G9021 G9024 43.34
• G9025 G9028 43.33
• G9029 G9032 43.33
• These services are paid on an assignment basis
  and the usual Part B coinsurance and deductible
  apply.

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The Demonstration Project

• The three symptom codes (one from each category)
  should be reported on the same claim and for the
  same date of service as either a chemotherapy
  infusion (G0359) or a chemotherapy push (G0357).
• The patient must have a cancer diagnosis.
• The place of service is office (11).
• Only Medicare beneficiaries who are NOT enrolled
  in a Medicare Advantage plan are included within
  the demonstration project.

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Demonstration Project - Your To Do List

• Use these codes for ALL Medicare patients
  receiving chemotherapy (except Medicare Advantage
  patients)
• Put systems in place in your office for 2005 to
• Identify appropriate patients
• Determine who will obtain this information (MD,
  nurse, MA, other staff member)
• Establish a process for documentation and billing
• Update your office tools as needed
• Be proactive with your non-Medicare payers
  discuss this program and ask about their plans

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Putting it all together

• Carboplatin/Docetaxel regimen
• 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
• Epo 40,000 units on the day of treatment
• Participating in Demo Project

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Another example

• CHOP/Rituxin
• Cytoxan 1850 mg over 45 minutes
• Adriamycin 90 mg IV push
• Vincristine 2 mg IV push
• Rituxin 700 mg over several hours, reaction at 1
  hour, infusion stopped then resumed
• Decadron, Aloxi, Benedryl
• Participating in Demo Project

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20 Co-insurance DecreasesA Plus for Our
Patients
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MMA 2005 - FAQs

• How are the each additional hour and the
  additional sequential drug codes different?
• Several codes have been added for additional
  sequential drugs. These codes are intended to
  recognize the additional work and practice
  expense associated with the provision of multiple
  drugs. The initial code refers to the first
  drug/agent administered and the additional
  sequential drug codes should be used for each
  drug provided after the first. The each
  additional hour codes should be reported if a
  particular drug is infused for more than one hour
  and 30 minutes.

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FAQs

• Do we need to use the -25 modifier to report E
  M visits conducted on the same day as
  chemotherapy?
• CMS continues to require that the -25 modifier be
  attached to E M services provided on the same
  day as chemotherapy. Significant, separately
  identifiable E M services will be paid if
  appropriate documentation is provided.
  Additional documentation beyond what is outlined
  in the 1995 or 1997 E M guidelines should not
  be required by your carrier. For E M services
  provided on the same day, a different diagnosis
  is NOT required.

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FAQs

• If multiple injections of the same drug are given
  because of clinical protocol or package insert
  instructions, can both injections be reported?
  For example, the package insert for Vidaza states
  doses greater than 4 mL should be divided
  equally into 2 syringes and injected into 2
  separate sites?
• CMS has responded to this question and said that
  they will defer to local carriers on this policy
  as local carriers are responsible for decisions
  regarding reasonableness and medical necessity.
  Check with your local carrier for their policy.

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FAQs

• If an electrolyte is not prepackaged and requires
  mixing before infusion, is this included in the
  hydration codes or can it be billed using the
  therapeutic/diagnostic infusion codes?
• According to CMS electrolytes that are
  prepackaged or mixed are reported using the
  hydration codes (G0345, G0346).

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FAQs

• Can a level one office visit be billed on the
  same day as chemotherapy?
• No. Under Medicare, a level one office visit
  (99211) cannot be billed on the same day as
  chemotherapy. After CMS adopted this policy for
  2004, ASCO requested reconsideration. However,
  CMS has not changed its position. If appropriate
  documentation can be provided, a higher level
  office visit may be billed.
• Also, CMS has clarified that 99211 may not be
  billed with diagnostic or therapeutic injections
  codes in 2005.

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FAQs

• I understand that the code changes include
  clarification of reporting times for infusion
  codes. Is that true?
• Yes. Reporting times for infusion codes
  (hydration, non-chemotherapy infusions, and
  chemotherapy infusions) have been clarified as
  follows
• After the first hour of infusion, round infusion
  times to the nearest 30 minutes. For 30 minutes
  or less, round down. For greater than 30
  minutes, round up.
• continued

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FAQs

• Example
• If you infuse one chemotherapy drug for 1 hour,
  45 minutes, you would bill
• G0359 Chemo IV infusion, initial hour
• G0360 Chemo IV infusion, ea addl hour
• Start the timing over when you switch to a
  different drug (e.g. another chemotherapy agent
  or anti-emetic)

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FAQs

• If a patient is infused with saline concurrent
  with infusion of a chemotherapy drug, can the
  hydration be billed separately?
• No. Hydration may be billed separately only if
  it is given prior to chemotherapy infusion or
  subsequent to drug infusion. If hydration is
  provided to facilitate drug delivery, then it is
  considered incidental to that infusion and is not
  separately billable.

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FAQs

• Do we need to use a -59 modifier to report
  multiple infusion services?
• ASCOs interpretation is that the -59 modifier is
  not needed to report multiple infusion services
  since the code descriptors now provide clear
  differentiation between the first and subsequent
  drugs.
• The -59 modifier should continue to be used to
  report hydration prior to or subsequent to
  chemotherapy administration.

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FAQs

• Do we need to use the -59 modifier to bill for
  hydration provided on the same day as
  chemotherapy?
• Yes. The -59 modifier should be used to indicate
  that hydration was provided prior to or following
  chemotherapy. Hydration provided at the same
  time as chemotherapy to facilitate drug delivery
  is not separately reportable.

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FAQs

• In the past, CMS has not covered injections when
  provided on the same day as other services. Has
  CMS revised its policy on injection payments?
• Yes. Effective January 1, 2005, Medicare will
  now pay separately for non-chemotherapy
  injections and IV pushes even if another service
  is billed that day. Therefore, codes G0351-G0354
  will be eligible for separate payment.

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FAQs

• When we have tried to bill prolonged and critical
  care service codes, they are frequently denied or
  our carrier requires significant document. What
  is ASCOs advice?
• ASCO has urged that CMS a) remind carriers that
  codes for prolonged and critical care services
  can be billed in the office setting, b) recognize
  time spent with the patient (as documented in
  nursing notes) and a brief description of the
  problem as sufficient documentation to support
  billing for critical care services, c) eliminate
  pre-payment reviews or pre-payment demands for
  documentation with respect to these services, and
  d) restrict post-payment audits for these
  services to situations where they appears to be a
  pattern of excessive use.

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FAQs

• Are the new G codes for drug administration
  available for services provided in the outpatient
  hospital setting?
• No. The new drug administration codes are to be
  used in the office setting only.

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FAQs

• Will the Medicare codes for 2005 mirror the 2004
  CPT code?
• No. The changes reflected in the new G codes
  will not be published as CPT codes until 2006.

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What about 2006?

• Competitive Acquisition Program (CAP) is planned
• Proposed rule published on 3/4/05
• This is not a mandatory program physicians will
  choose ASP 6 or CAP
• Proposed rule discusses phase-in period beginning
  1/1/06 categories of drugs still to be
  determined
• Significant paperwork requirements
• ASCOs summary of the rule can be accessed at
• http//www.asco.org/asco/downloads/ASCO_CAP_Summa
  ry.pdf

91
What about 2006?

• Comments on the CAP program must be submitted by
  April 26, 2005
• Submit your questions and concerns independently
  or to ASCO for inclusion in ASCOs comments
• Email to practice_at_asco.org
• G codes will transition to CPT codes
• New codes and definitions will be published in
  CPT
• Most private payers are expected to convert to
  the new codes at this time
• Demonstration Project ???

92
More To Do

• Stop billing leaks
• Capture all service charges
• E M
• Chemotherapy administration
• Therapeutic Infusion
• Laboratory
• Documentation is critical
• Dont lose any drug charges!
• Chemotherapy
• Supportive care

93
More To Do

• Understand rule changes
• Document and bill by the rules (CMS, AMA)
• Disseminate billing and coding information in
  your practice
• Update drug pricing/charges ASAP
• Update fee schedule, superbill at least yearly
• Dont miss any billing opportunities
• Ensure that your documentation is complete,
  especially nursing documentation for the new
  administration codes

94
More To Do

• Financial consultation
• Know your patients insurance status BEFORE
  treatment
• Identify co-pay, co-insurance problems
• Have a plan for indigent care
• local/state resources
• pharmaceutical companies
• www.needymeds.com
• www.helpingpatients.org
• www.rxassist.org

95
Role of the Physician Practice Leader

• Stay current on the moving target of Medicare
  rules and regulations
• Reinforce to your partners the importance of
  Medicare compliance
• A great resource is the CMS Carrier Advisory
  website, and the CAC website
• Work with your state society to establish
  productive relationships with your Medicare
  carrier and commercial payers
• Support your Practice Administrator as they
  implement policies to deal with these changes

96
Role of the Administrator

• Update your coding books, reference materials,
  fee schedule, charge ticket annually or as
  changes occur
• Ensure that your staff is knowledgeable about
  reimbursement issues for all payers
• Establish and implement policies to immediately
  respond to changes as they occur
• Enroll in Medicare list serves to stay
  up-to-the-minute on changes
• Work cooperatively with your physician leader in
  providing leadership for your staff in this
  challenging environment

97
Know Your Medicare Carrier

• Carrier Website
• Carrier Medical Director
• Carrier Contact Information
• Subscribe to your carriers listserv
• Circulate carrier bulletins to staff

98
The CMS Websitewww.cms.hhs.gov

• To access the Physician page
• www.cms.hhs.gov/physicians/
• To access manuals
• www.cms.hhs.gov/manuals/
• To access the Drug Pricing page
• www.cms.hhs.gov/providers/drugs/default.asp

99
Know Medicare Nationally
100
Know Medicare Nationally
101
ASCO Resources

• Practical Tips for the Practicing Oncologist
• 3rd edition
• Practical Tips for the Practicing Oncologist
• Supplement for 2005 coming soon
• Ask a Coding Question
• Call 703-299-1050 or
• Email practice_at_asco.org

102
ASCO Resources

• www.asco.org/MMA
• Look for the FAQs - updated as new information is
  available
• www.asco.org/CAC
• A great resource for information on the Medicare
  Carrier Advisory Committee process