Implementing Medicare and Commercial Insurance Coding Changes in 2006

1
Implementing Medicare and Commercial Insurance
Coding Changes in 2006

• Patricia Falconer, MBA
• President, Health Options
• 650-949-2526 phone
• 650-745-1122 fax
• Healthoptions_at_worldnet.att.net

2
Strategies For 2006

• Financial Issues
• Medicare Demonstration Project
• Fee Schedule Management
• Operations

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Financial Issues

• Plan for Reduced Cash Flow
• Medicare Revenue Loss from Elimination of 2005
  Demonstration Project
• Medicare Revenue Loss from 3 Reduction in
  Administration CPT Codes
• Delays in Medicare payments due to 1/17/06
  implementation date for Demonstration codes
• Fee Schedule Reductions from Commercial PPO
  Insurance Plans

4
Medicare Demonstration Project 2006

• Should you participate?
• How to facilitate the billing process
• Documentation Requirements

5
Demonstration Project Philosophy

• The project builds on the use of G-codes to
  gather more specific information about patients
  with particular types of cancer, including
  information about the primary focus of the visit
  and the spectrum of care that you provide. It
  will emphasize practice guidelines as the source
  for standards of care, permitting CMS to monitor
  and encourage quality care to cancer patients,
  and to identify and promote best cancer care
  practices that should lead to improved patient
  outcomes.
• MediLearn Matters Number SE0589
• Effective Date 1/1/06

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Demonstration Project Revenue Projection

• Calculate the total Number of 99212-99215 visits
  in 2005.
• Estimate the percentage of Medicare patients in
  the practice.
• Estimate the percentage of visits representing
  the 13 major diagnostic categories.
• Multiply each element above and then multiply the
  number by 23.00

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Implement A New Superbill

• Add all Codes on Superbill.
• This will require a two page superbill.
• First page E M codes, Procedure Codes,
  G-Codes, and Lab
• Second page 2006 Administration CPT codes,
  supplies, and J-Codes for drugs. G-Codes and 2004
  CPT codes may be required for specific contracts.
• Patient insurance must be on the superbill
• Update all new CPT and J-Codes

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Lung Cancer (162.2 162.9)
G9063 NSCLC, Stage I, Stable
G9064 NSCLC, Stage II, Stable
G9065 NSCLC, Stage IIIA, Stable
G9066 NSCLC, Stage IIIB-IV or Progression
G9067 NSCLC , Unknown, NOS
G9068 SCLC Limited
G9069 SCLC Extensive or Progression
G9070 SCLC Extent Unknown
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Breast Cancer (174.0 174.9)
G9071 Breast Stage I-II or T3, N1, M0, ER/PR , Stable
G9072 Breast Stage I-II or T3, N1, M0, ER/PR -, Stable
G9073 Breast Stage III not T3, N1, M0, ER/PR , Stable
G9074 Breast Stage III not T3, N1, M0 ER/PR -, Stable
G9075 Breast M1 or Progression
G9075 Breast Extent Unknown NOS
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Prostate Cancer (185)
G9077 Prostate T1-T2C Gleason 2-7 and PSA lt 20 Stable
G9078 Prostate T2 or T3A Gleason 8-10 or PSA gt 20 Stable
G9079 Prostate T3B-T4 Any N Any T N1 Stable
G9080 Prostate Rising PSA or Lack of Decline after Initial Treatment
G9081 Prostate M1 at Diag or Metastatic, Non-Castrate
G9082 Prostate M1 at Diag or Metastatic, Castrate
G9083 Prostate, Extent Unknown NOS
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Colon Cancer (153.0 153.9)
G9084 Colon T1-3, N0, M0, Stable
G9085 Colon T4, N0, M0, Stable
G9086 Colon T1-4, N1-2, M0, Stable
G9087 Colon M1 or Recurrent with evidence of disease
G9088 Colon M1 or Recurrent with no evidence of disease
G9089 Colon Extent Unknown NOS
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Rectal Cancer (154.0, 154.1)
G9090 Rectal T1-2, N0, M0, Stable
G9091 Rectal T3, N0, M0, Stable
G9092 Rectal T1-3, N1-2, M0, Stable
G9093 Rectal T4 Any N M0 Stable
G9094 Rectal, M1 or Recurrent
G9095 Rectal Extent Unknown NOS
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Esophageal Cancer (150.0 150.9)
G9096 Esophageal T1-3, N0-1, or NX, Stable Esophageal T1-3, N0-1, or NX, Stable
G9097 Esophageal T4, Any N, M0, Stable Esophageal T4, Any N, M0, Stable
G9098 Esophageal M1 or Recurrent
G9099 Esophageal Extent Unknown NOS Esophageal Extent Unknown NOS
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Gastric Cancer (151.0 151.9)
G9100 Gastric Post R0, Resectable, Stable Gastric Post R0, Resectable, Stable
G9101 Gastric Post R1-2, Resectable, Stable Gastric Post R1-2, Resectable, Stable Gastric Post R1-2, Resectable, Stable
G9102 Gastric M0, Unresectable, Stable Gastric M0, Unresectable, Stable Gastric M0, Unresectable, Stable
G9103 Gastric M1 or Recurrent
G9104 Gastric Extent Unknown NOS
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Pancreatic Cancer (157.0 157.3, 157.8 157.9)
G9105 Pancreatic Post R0, Resectable, Stable
G9106 Pancreatic Post R1-2, Resectable, Stable
G9107 Pancreatic M1 or Recurrent
G9108 Pancreatic Extent Unknown NOS
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Head Neck Cancer (140.0 140.9, 161.0 161.9)
G9109 Head/Neck T1-2, N0, M0, Stable
G9110 Head/Neck T3-4 and/or N1-3, M0, Stable
G9111 Head/Neck M1 or Recurrent
G9112 Head/Neck Extent Unknown NOS
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Ovarian Cancer (183.0)
G9113 Ovarian Stage IA-B Grade 1, Stable
G9114 Ovarian Stage 1A-B Grade 2-3 or Stage 1C All Grades or Stage II Stable
G9115 Ovarian Stage III-IV, Stable
G9116 Ovarian Progression, Recurrence, Plat Resistant
G9117 Ovarian Extent Unknown NOS
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Non-Hodgkins Lymphoma (202.00 202.08, 202.80
202.98)
G9118 NHL Stage I-II Not Relapsed Not refractory
G9119 NHL Stage III-IV Not Relapsed Not Refractory
G9120 NHL Trans to Diffuse Large B-Cell Lymphoma
G9121 NHL I-IV Relapsed/Refractory
G9122 NHL I-IV Possible Relapse or Non-response or Not listed
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Chronic Myelogenous Leukemia (205.10, 205.11)
G9123 CML Chronic Phase Not in Remission
G9124 CML Accelerated Phase Not in Remission
G9125 CML Blast Phase Not in Remission
G9126 CML in Remission
G9127 CML Extent Unknown NOS
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Multiple Myeloma (203.00, 203.01)
G9128 Multiple Myeloma Smoldering Stage 1
G9129 Multiple Myeloma Stage II or Higher
G9130 Multiple Myeloma Extent Unknown NOS
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Educate Providers

• Physicians and Nurse Practitioners who bill as
  incident to
• Use Resources
• Educate Billing Staff
• Set up Charge Entry and Documentation Audit
  System

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Documentation RequirementsPrimary Focus of
VisitG9050 G9055

• Progress note section, chief complaint or primary
  reason for visit, should match G-Code
• Work-Up Evaluation
• Treatment Decision/Management
• Surveillance for Disease
• Expectant Management of Patient
• Supervision Palliative
• Other- Visit Unspecified

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Documentation RequirementsFor Guideline
Adherence Codes (G9056 G9062)

• Must Document Source of Guideline
• ASCO
• NCCN
• Both
• No Guideline Available or None
• Clinical Trials

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Documentation Guidelines Current Disease
StateG9063- G9130

• Choose the single G-Code that best represents the
  disease status based on the best available data
  at the time of service
• G-Code selected must match ICD-9 code
• Staging should be documented in progress note

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2006 Fee Schedule- Medicare

• US House of Representatives passed a federal
  budget package that stopped the 4.4 Medicare cut
  in December 2005 but could not obtain final
  approval before the holiday break. CMA and AMA
  are now working with congress to pass the payment
  freeze.
• Practices should use billed charges or the 2005
  Medicare fee schedule for dates of service in
  2006 except with the new administration CPT
  codes.
• The new administration CPT codes will be paid
  using the 2006 fee schedule. These codes are not
  part of the freeze.

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If Congress Freezes 2006 Medicare Payments at
2005 Rates...

• Medicare carrier will have 2 business days to
  begin to automatically reprocess claims that were
  paid under the 4.5 conversion reduction.
• Payments will be issued in one lump sum by July
  2006
• Additional Medicare payments will increase
  patients co-payments if they do not have
  secondary insurance
• Decision to recover co-payments from patients is
  up to the individual practice
• Waiving co-payments due to the change in
  conversion factor would not be viewed as an
  inducement

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Fee Schedule- PPO Commercial

• Lower Contracted Reimbursement Rates for 2006
  Administration CPT Codes
• Blue Shield of California PPO Default Fee
  Schedule
• Average of 30 Reduction
• Blue Cross Prudent Buyer PPO Default Fee
  Schedule
• Average of 33 Reduction
• Monitor PPO Plans rate changes through their
  websites
• Electronic Claim Clearing House Edits
• Can you submit 2004 CPT codes or 2005 G-codes if
  your payer contracts require them?

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Commercial Default Fee Schedule Change Examples
CPT 2006 CPT 2005 2006 Allowable 2005 Allowable 2006 Medicare Allowable
Blue Cross Prudent Buyer PPO
96409 G0357 117.66 186.12 173.95
Blue Shield PPO
96409 96408 173.95 236.88 173.95
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Fee Schedule - HMO Commercial

• HMO Plans
• Take this opportunity to renegotiate your IPA HMO
  contracts to include 2006 CPT codes.
• Find out if your IPAs carved out the financial
  responsibility for drug reimbursement for 2006
• Who pays you for drugs and procedures for each
  health plan?
• What rate?
• Any other changes?

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Managing Drug Purchasing

• Compare Quarter 1 2006 ASP with your current
  practice acquisition costs
• Manage your drug distributors
• Use Distributors Website for Drug Purchasing
• Monitor price changes with each order
• Order from multiple distributors
• Review drugs within therapeutic classes to
  maximize purchase power
• Growth Factors
• Antiemetics
• Bisphosphonates

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Operations

• Implement Automated Functions wherever possible
• Electronic Claim Submission for all payers that
  will accept them. Can your software submit three
  digit units?
• Electronic Remittance
• Electronic Patient Statements
• Reduce Accounts Receivable days to match or beat
  drug distributor payment terms

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Resources

• www.anco-online.org
• www.asco.org
• www.nccn.org
• www.medicarenhic.com
• www.bluecrossca.com
• www.mylifepath.com
• www.cigna.com
• www.aetna.com
• www.unitedhealthcareonline.com
• www.practicemanagerinsider.com
• www.caring4cancer.com