Practice Management Series

1
Practice Management Series

• Clinical Practice Series
• Audioconference
• 3/7/06

2
Practice Management Curriculum

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

3
Topics for Today

• National Oncologic PET Registry
• Medicare Part D
• Updates
• 2006 Oncology Demonstration Project
• Coding for drug administration services
• CAP Timeline
• Deficit Reduction Act of 2005
• Conversion factor
• Medicare participation
• Questions?

4
National Oncologic PET Registry (NOPR)

• CMS has established coverage with evidence
  policy for the use of Positron Emission
  Tomography scans (FDG-PET) for previously
  non-covered cancer indications in an NCD issued
  in 2005
• Under this policy, Medicare will cover PET scans
  when
• Patients are enrolled in an FDA-approved PET
  clinical trial OR
• Data is collected (e.g. through a registry) at
  the time of the scan as part of a clinical study
  to assess how PET scans are used in patient
  management

5
What is the NOPR?

• The National Oncologic PET Registry (NOPR) was
  developed in response to CMSs expanded coverage
• NOPR is sponsored by the Academy of Molecular
  Imaging (AMI) and the American College of
  Radiology (ACR) ASCO was active in the
  development of the registry protocol
• Registry database will be managed by American
  College of Radiology Imaging Network (ACRIN)

6
How will the registry work?

• Registry was expected to open this week but has
  been delayed pending clarifications regarding IRB
  exemptions
• Registration for PET facilities is now open
• No registration process required for physicians

7
How will the registry work?

• If you are participating in and enrolling your
  Medicare patients in the PET trial, when you
  order a PET scan for one of the identified cancer
  indications you will be required to
• Complete a pre-PET data collection form and send
  it to the registered PET facility with the PET
  referral
• Complete and return a post-PET form after the
  scan is completed

8
NOPR

• Timeline is now uncertain waiting for
  clarification on IRB issues
• Check the NOPR website for updates
• www.cancerpetregistry.org
• ASCO will also provide updates and instructions

9
Medicare Part D

• Medicare prescription drug benefit began 1/1/06
• Initial beneficiary enrollment period continues
  through 5/15/06 penalties for late enrollment
• Beneficiaries can choose either
• A stand-alone PDP which adds a drug benefit to
  traditional Medicare, or
• A Medicare Advantage prescription drug plan
• Prescription drug plans (PDPs) are available in
  all states and premiums vary depending on the
  plan selected

10
Part B/Part D

• Part D is not meant to replace Part B
• If a drug is provided and administered in the
  office setting, it continues to be covered under
  Part B
• Some drugs may be covered under both Part B and
  Part D
• Coverage may depend on indication and/or
  diagnosis
• To avoid confusion CMS has recommended including
  diagnosis, indication and status as Part B or
  Part D on the written prescription
• Oral anticancer drugs, oral anti-emetics

11
Oral Anticancer Drugs

• Busulfan
• Capecitabine
• Cyclosphosphamide
• Etoposide
• Melphalan
• Methotrexate
• Temozolomide
• When prescribed for cancer diagnosis, these are
  Part B drugs if used for non-cancer diagnosis,
  Part D

12
Oral Anti-emetics Given with Chemotherapy

• 3-drug combination aprepitant, a 5-HT3
  antagonist, and dexamethasone
• Diphenhydramine hydrochloride
• Prochlorperazine maleate, oral
• Granisetron hydrochloride, oral
• Dronabinol
• Promethazine hydrochloride
• Chlorpromazine hydrochloride
• Trimethobenzamide hydrochloride

13
Oral Anti-emetics

• Perphenazine hydrochloride
• Hydroxyzine pamoate
• Ondansetron hydrochloride
• Dolasetron mesylate
• Unspecified oral dosage form, FDA approved
  prescription anti-emetic, for use as a complete
  therapeutic substitute for an IV anti-emetic at
  the time of chemotherapy treatment, not to exceed
  a 48-hour dosage regimen

14
Dual Eligibles

• Patients covered by Medicare and Medicaid have
  been transitioned to Part D plans for
  prescription coverage
• No change in coverage for services provided in
  office
• Drugs obtained with a prescription at the
  pharmacy are covered by Part D
• Part B covers incident to drugs drugs obtained
  from a pharmacy are not incident to a physician
  service
• Statutory exceptions for oral anticancer drugs
  and oral anti-emetics

15
Coverage Determination Requests

• Exceptions
• PDPs must have an exception process in place for
  formularies
• Through the exceptions process an enrollee can
  request an off-formulary drug, an exception to
  the plans tiered cost sharing structure, and an
  exception to cost utilization management tools
  (ex. step therapy requirement or prior
  authorization requirement)
• Exception requests can be made by the enrollee,
  by an authorized representative of the enrollee
  or by the prescribing physician on behalf of the
  enrollee
• Prescribing physician must provide an oral or
  written statement to support the exception request

16
Coverage Determination Requests

• Appeals
• Enrollees have the right to appeal coverage
  determinations made by the PDP
• Prescribing physicians can request an expedited
  redetermination on behalf of enrollees
• Part D plans must respond to expedited
  redeterminations no later than 72 hours after
  receiving the request
• Enrollees can make standard redetermination
  requests
• Decisions must be communicated within 7 days of
  the request

17
Coverage Determination Requests

• Information on how to file a complaint, coverage
  determination or appeal
• www.medicare.gov/Publications/Pubs/pdf/11112.pdf
• For plan contact information
• http//www.cms.hhs.gov/prescriptiondrugcovgenin/04
  _formulary.asp

18
Part D Resources for Patients

• Call 1-800-MEDICARE
• Phone lines are open 24/7
• Personalized assistance for Medicare
  beneficiaries with enrollment
• www.medicare.gov
• Enrollment information
• Plan finder
• Social Security Administration 1-800-772-1213 or
  www.socialsecurity.gov/prescriptionhelp
• For patients who need additional financial help

19
Part D Resources for Practices

• Formulary finder
• http//formularyfinder.medicare.gov/formularyfinde
  r/selectstate.asp
• Formulary information on Epocrates
• www.epocrates.com
• Access by computer or download to PDA

20
Part D Resources for Practices

• CMS has dedicated help for physicians
• Email PRIT_at_cms.hhs.gov
• Join weekly conference call, Tuesdays at 200
  p.m. EST
• 1-800-619-2457, passcode RBDML
• Calls open to all physicians and healthcare
  providers

21
Part D Resources for Practices

• ASCO continues to share oncologists Part D
  experiences with CMS
• Send name of health plan and nature of problem to
  ASCO at practice_at_asco.org
• Implementation updates will continue to be
  distributed as needed through Medicare Quality
  Care Updates

22
2006 Oncology Demonstration Project

• Billing requirements
• CMS CR 4219 instructs carriers to accept claims
  as long as the three G codes are on the same date
  of service as an approved level 2, 3, 4 or 5
  established patient office visit.
• While CR 4219 specifies that these services do
  not have to be on the same claim, CMS has
  indicated that they would prefer that providers
  list the three G codes and the appropriate E M
  service on the same claim.

23
Physician Specialties

• Physician specialties that qualify for
  participation in the 2006 Oncology Demonstration
  project include hematology (82),
  hematology/oncology (83), and medical oncology
  (90).
• CMS has indicated that gynecological oncology
  (98) is included in the list of eligible
  specialties for the 2006 oncology demonstration,
  retroactive to 1/1/06. Carriers will adjust
  claims that are resubmitted.

24
Midlevel Practitioners

• CMS CR 4219 states midlevel practitioners, such
  as nurse practitioners or others who may bill
  independently for Medicare services, are not
  eligible to participate in this demonstration.

25
Midlevel Practitioners

• CMS has now clarified that midlevel practitioners
  can provide demonstration project services
  incident to the services of a physician
• Nonphysician practitioners may provide the
  services/information described by the G codes as
  incident to the services of the physician
• If the practice could bill appropriately for the
  underlying incident to service, then the practice
  or physician can also bill for the associated
  oncology demonstration G codes

26
Demonstration Project Payment

• Many practices are now receiving payment for the
  2006 Demonstration Project
• Contact ASCOs Cancer Policy Clinical Affairs
  Department at 703-299-1050 or publicpolicy_at_asco.or
  g to report any problems

27
Coding for Drug Administration Services

• Some carriers are not following AMA/CPT guidance
  for use of drug administration codes
• One example is denials for 90767 (additional
  sequential infusion) when billed multiple times
• Also problems with use of initial codes
• ASCO has encouraged CMS to issue guidance for
  carriers on this issue, specifically instructing
  carriers to follow AMA/CPT coding guidelines
• Contact ASCO at practice_at_ASCO.org with specific
  problems ASCO will provide this info to CMS

28
Use of Modifiers

• 90772 (therapeutic/diagnostic subcutaneous or
  intramuscular injection)
• When 90772 is used on the same day as other drug
  administration services, providers should use -59
• E M Services (99212 99215)
• Level 2 Level 5 E M services can be reported
  on the same day as drug administration services.
  Attach the -25 modifier to the E M service
• A separate diagnosis is not required
• Documentation to support a significant,
  separately identifiable E M service should
  support the level of service billed

29
Competitive Acquisition Program (CAP)

• Original program implementation date was 1/1/06
  vendor bidding process was stopped and program
  put on hold to allow CMS to consider issues
  raised
• Revised vendor application period was 11/21/05
  12/22/05
• By April 3, 2006 CMS will post on its website
• List of the vendors that have been selected for
  2006
• Categories of drugs each vendor will be providing
• Geographic areas for each vendor

30
CAP

• Physician election period will begin when vendors
  are announced election period will end May 18,
  2006
• Physician election is at the group practice
  level members of a group practice cannot elect
  to participate individually
• First CAP year will run from 7/1/06 12/31/06
• Drug administration services for CAP drugs must
  be billed as assigned
• Physicians who participate in CAP program agree
  to submit drug administration claims to Medicare
  within 14 days of drug administration

31
CAP

• New modifiers for CAP program
• J1 CAP, no-pay submission for a prescription
  number
• J2 CAP, restocking of emergency drugs after
  emergency administration and a prescription
  number
• J3 CAP, drug not available through CAP as
  written, reimbursed under ASP methodology
• For more information
• Medlearn Matters Number MM4064
• Medlearn Matters Number MM4309

32
Deficit Reduction Act of 2005

• Conversion factor
• DRA signed into law 2/6/06, retroactive to 1/1/06
• Revises conversion factor update from 4.4
  reduction to 0 update 2006 Medicare Physician
  Fee Schedule revised accordingly
• Payments for drug administration codes have
  decreased remember that the 3 transitional
  add-on is gone
• Medicare contractors are automatically
  reprocessing claims physicians do not need to
  resubmit claims
• Reprocessing will be completed around 7/1/06
• Lump sum payments will be issued

33
Deficit Reduction Act of 2005

• Participation enrollment period
• Because of the change in the conversion factor,
  CMS is offering a second enrollment period for
  2006 from 2/15/06 3/31/06
• Enrollment revisions will be retroactive to
  1/1/06
• If you do not wish to change your status, no need
  to do anything
• To change enrollment status, submit form CMS-460
  to your local Medicare carrier

34
ASCO Resources

• Oncology Demonstration Project
• ASCO and CMS 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

35
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

36
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

37
Practice Guidelines

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

38
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
• FAQs