Coding, Value Programs, RACs, Audits

Transcription

1 Coding, Value Programs, RACs, Audits

2 Coding Drug Admin ICD-10 Preview Medicare Value Programs PQRI E-Prescribing Get Ready for Audits of All Sorts

3 Payers differ on their guidelines. Please verify coding for each payer and claim. This is not legal or payment advice. This content is abbreviated for Medical Oncology. It does not substitute for a thorough review of code books, regulations, and Carrier guidance. This information is good for the date of the information and may contain typographical errors. CPT is the trademark for the American Medical Association. All Rights Reserved. All denial data from RemitDATA. Copyrighted to them and all rights reserved.

4 CMS has long had confusing rules relative to consults. So, the easiest way to deal with the problem is to eliminate them altogether. What this means is: New consults in the office will be coded as New Patients ( ). This means that no one in practice of your specialty has seen the patient at all for 36 months. Established consults in the office will be coded as Established Patients ( ) this is not an exact match with consultation criteria. Hospital consults will be coded as Admissions ( ) with a new modifier ( AI ) signifying who was the admitting physician. There is no exact crosswalk of five levels to three. TeleHealth consults are the exception. They have special G-codes. 4

5 Link to the Final Rule The section showing the consultation changes can begins on page

6 Service Performed CPT Code Documentation required Problem Severity Medicare History/Exam/MDM Consult level 1 Consult level 2 Consult level 3 Consult level 4 Consult level (15 min) (30 min) (40 min) (60 min) (80 min) PF/PF/Straightforward Self limited or minor (10 min) EPF/EPF/Straightforward Low severity (20 min) Detailed/Detailed/Low Moderate severity (30 min) Comp./Comp./Moderate Comp./Comp./High Moderate to high severity Moderate to high severity (45 min) (60 min) 6

7 Service Performed CPT Code Documentation required (All 3 to 2 out of 3) Problem Severity Medicare History/Exam/MDM Consult level (15 min) PF/PF/Straightforward Self limited or minor (10 min) Consult level (30 min) EPF/EPF/Straightforward or Low for Low severity (15 min) Consult level (40 min) Detailed/Detailed/Low or Moderate for Moderate severity or (15-25 min) Consult level (60 min) Comp./Comp./Moderate or High for Moderate to high severity or (25-40 min) Consult level (80 min) Comp./Comp./High Moderate to high severity (40 min) 7

8 CPT Code History Exam MDM Traditional Medicare (20 min) (40 min) (55 min) PF Hx PF Exam SF MDM EPF HX EPF Exam SF MDM Det Hx Det Exam Low MDM (30 min) (80 min) Comp Hx Comp Exam Moderate MDM (50 min) (110 min) Comp Hx Comp Exam High MDM (70 min) 8

9 Is CMS going to crosswalk the CPT consultation codes that are no longer recognized to the E/M codes for each setting in which an E/M service that could be described by a CPT consultation code can be furnished? No, providers must bill the E/M code (other than a CPT consultation code) that describes the service they provide in order to be paid for the E/M service furnished. The general guideline is that the provider should report the most appropriate available code to bill Medicare for services that were previously billed using the CPT consultation codes. For services that could be described by inpatient consultation CPT codes, CMS has stated that providers may bill the initial hospital care service CPT codes and the initial nursing facility care CPT codes, where those codes appropriately describe the level of service provided. When those codes do not apply, providers should bill the E/M code that most closely describes the service provided. MLN Matters Number: SE1010 9

10 How should providers bill for services that could be described by CPT inpatient consultation codes or 99252, the lowest two of five levels of the inpatient consultation CPT codes, when the minimum key component work and/or medical necessity requirements for the initial hospital care codes through are not met? There is not an exact match of the code descriptors of the low level inpatient consultation CPT codes to those of the initial hospital care CPT codes. For example, one element of inpatient consultation CPT codes and 99252, respectively, requires a problem focused history and an expanded problem focused history. In contrast, initial hospital care CPT code requires a detailed or comprehensive history. Providers should consider the following two points in reporting these services. First, CMS reminds providers that CPT code may be reported for an E/M service if the requirements for billing that code, which are greater than CPT consultation codes and 99252, are met by the service furnished to the patient. Second, CMS notes that subsequent hospital care CPT codes and 99232, respectively, require a problem-focused interval history and an expanded problem focused interval history and could potentially meet the component work and medical necessity requirements to be reported for an E/M service that could be described by CPT consultation code or MLN Matters Number: SE

11 How will more reporting of initial hospital care CPT codes instead of CPT consultation codes affect the review of claims by Medicare contractors? CMS has alerted MAC audit staff as well as Medicare Recovery Audit Contractors of its expectation that physicians may bill more E/M codes for initial hospital care in place of billing inpatient CPT consultation codes. CMS has also alerted contractors to expect a different proportion of various initial hospital care CPT codes under the new policy. CMS expects contractors to consider that these may be appropriate changes when making decisions about whether to pursue medical review and other types of claims review. MLN Matters Number: SE

12 Because CPT consultation codes are no longer recognized by CMS for payment, is the definition of transfer of care no longer relevant? Yes, CMS agrees that discontinuing recognition of the CPT consultation codes for payment renders the issues regarding the definition of what constitutes a transfer of care no longer relevant. MLN Matters Number: SE

13 Can a provider provide an advance beneficiary notice (ABN) to the beneficiary and then bill his or her charge for the consultation after the consultation is billed and denied by Medicare? No, when a CPT consultation code is reported to Medicare, the claim is not denied. Instead, the claim is returned to the provider for a different CPT code because Medicare recognizes another code for payment of E/M services that may be described by CPT consultation codes. Once the claim is resubmitted to report an appropriate, payable E/M code (other than a CPT consultation code) for a medically reasonable and necessary E/M service, the beneficiary can only be billed any applicable Medicare deductible and coinsurance amounts that apply to the covered E/M service. MLN Matters Number: SE

14 How should E/M services previously reported by CPT consultation codes and provided in a split/shared manner be billed? The split/shared rules applying to E/M services remain in effect, including those cases where services would previously have been reported by CPT consultation codes. Huh? MLN Matters Number: SE

15 Do admitting physicians still get paid if they do not report the modifier -AI? Yes, the use of the modifier is for informational purposes only. MLN Matters Number: SE

16 A systematic approach Why was the patient here in the office? What did we give them? How did we give it? How long did it take? Form Dr. Laurence Martinelli s initial presentation regarding Drug Administration coding in 2006 This differs in the hospital 4/6/10 CPT Codes American Medical Association. All rights reserved. 16

17 The reason for the visit Sick patient, needs hydration Chemotherapy administration, will also see provider Follow up visit, intractable nausea/vomiting, needs drug therapy This used to determine the initial infusion regardless of when it happens in the context of other infusions or injections. This approach is not true for hospital based cancer centers which utilize a hierarchy approach. 4/6/10 CPT Codes American Medical Association. All rights reserved. 17

18 Separate hydration over 30 minutes? Anti-emetics or other drugs? Chemotherapy? This determines which category of administration code(s) to bill And don t forget to bill for the J-codes 4/6/10 CPT Codes American Medical Association. All rights reserved. 18

19 IV infusion? IV push? SC or IM injection? A combination? This determines which specific administration code(s) to bill and if there are concurrent, subsequent, and/or sequential services. 4/6/10 CPT Codes American Medical Association. All rights reserved. 19

20 or > 15 minutes (push vs. infusion) One hour Additional hours Round to nearest 30 minutes Same or different substance? Remember that infusion times are measured by when the infusate is actually running; pre- and post-infusion times are not included Documentation of start/stop times for each agent is recommended 4/6/10 CPT Codes American Medical Association. All rights reserved. 20

21 Hydration, Therapeutic, Prophylactic, and Diagnostic/Injections and Infusions Diagnostic Injections and Infusions (Excludes Chemotherapy) Physician affirms the treatment plan and supervises the staff. If significant separately identifiable Evaluation and Management service is performed, the appropriate E/M service code, use modifier 25 in addition to For same day E/M service a different diagnosis is not required. If you use these to facilitate the infusion or injection, the following services 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 For de-clotting a catheter or port, see lots of folks leave this off their Superbills! Watch the unbundling do not use with any other service that day. 4/6/10 CPT Codes American Medical Association. All rights reserved. 21

22 Hydration, Therapeutic Injections and Infusions When multiple drugs are administered, report the service(s) and the specific materials or drugs for each. That does not mean you can use a drug administration code for each. When administering multiple infusions, injections or combinations, only one initial service code should be reported, unless protocol requires that two separate IV sites must be used. If an injection or infusion is of a subsequent or concurrent nature, even if it is the first such service within that group of services, then a subsequent or concurrent code from the appropriate section should be reported (eg, the first IV push given subsequent to an initial one-hour infusion is reported using a subsequent IV push code). However, if a patient comes back for a separate session OR has separate lines, use -59. When reporting codes for which infusion time is a factor, use the actual time over which the infusion is administered. This can be called bag up/bag down or needle in/needle out depending upon when the substance goes in. But, you may not count prep time. 4/6/10 CPT Codes American Medical Association. All rights reserved. 22

23 Hydration Intravenous infusion, hydration; initial, thirty-one minutes to one hour each additional hour, up to 8 hours (List separately in addition to code for primary procedure) Codes are intended to report a hydration IV infusion to consist of a pre-packaged fluid and electrolytes (eg, normal saline, D5-½ normal saline+30meq KCl/liter), but are not used to report infusion of drugs or other substances. Hydration is essentially watering the patient. Hydration IV infusions typically require direct physician supervision for purposes of consent, safety oversight, or intra-service supervision of staff. Typically such infusions require little special handling to prepare or dispose of, and staff that administer these do not typically require advanced practice training. After initial set-up, infusion typically entails little patient risk and thus little monitoring. No concurrent hydration may be billed. It may only be billed if it is separate or sequential from IV therapy is used for hydration infusion intervals of greater than 30 minutes beyond 1 hour increments. Also use it to identify hydration if provided as a secondary or subsequent service after a different initial service [96360, 96365, 96374, 96409, 96413] through the same IV access. Use -59 to denote a separate sequential hydration over 30 minutes. 4/6/10 CPT Codes American Medical Association. All rights reserved. 23

24 Therapeutic, Prophylactic, and Diagnostic Injections and Infusions The fluid used to administer the drug(s) is incidental hydration and is not separately reportable. This means, with the exception of hydration infusions, fluids may not be separately billed. 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. Typically, such infusions require special consideration to prepare, dose or dispose of, require practice training and competency for staff who administer the infusions, and require periodic patient assessment with vital sign monitoring during the infusion. 4/6/10 CPT Codes American Medical Association. All rights reserved. 24

25 Therapeutic, Prophylactic, and Diagnostic Injections and Infusions additional sequential infusion, up to 1 hour (List separately in addition concurrent infusion (List separately in addition to code for primary procedure) to code for primary procedure) Report in conjunction with 96365, 96374, 96409, if provided as a secondary or subsequent service after a different initial service. Report only once per sequential infusion of same infusate mix is reported when multiple infusions are provided in separate bags simultaneously through a single line. Piggy backed drugs can be reported with Report only once per encounter and in conjunction with 96365, 96366, 96413, AMA CPT Assistant, November 2007 says In order to report a concurrent administration, the drugs cannot simply be mixed in one bag; there must be more than one bag is not billed for HOPDs 4/6/10 CPT Codes American Medical Association. All rights reserved. 25

26 Therapeutic, Prophylactic, and Diagnostic Injections and Infusions Therapeutic, prophylactic or diagnostic injection (specify substance or drug); subcutaneous or intramuscular intra-arterial may not be reported unless there is direct physician supervision, according to CPT. CPT instructs you to use for an injection without the physician present. This is not to be done for Medicare patients, since incident to rules mean that direct supervision is always required. None of the above is true of hospitals. 4/6/10 CPT Codes American Medical Association. All rights reserved. 26

27 Therapeutic, Prophylactic, and Diagnostic Injections and Infusions intravenous push, single or initial substance/drug each additional sequential intravenous push of a new substance/ drug (List separately in addition to code for primary procedure) intravenous push of the same substance > 30 minutes past after a previous one in a facility Unlisted therapeutic, prophylactic or diagnostic intravenous or intra-arterial injection or infusion. This replaces Use for initial infusion of 15 minutes or less. Use in conjunction with 96365, 96374, 96409, Use to identify intravenous push or infusion of 15 minutes or less of a new substance/drug if provided as a secondary or subsequent service after a different initial service is provided. 4/6/10 CPT Codes American Medical Association. All rights reserved. 27

28 Chemotherapy And Other Highly Complex Drug or Highly Complex Biologic Agent Administration Chemotherapy administration codes can be used for parenteral administration of non-radionuclide anti-neoplastic drugs; and also to anti-neoplastic agents provided for treatment of non-cancer diagnoses (eg, cyclophosphamide for auto-immune conditions) or to administer substances such as monoclonal antibody agents and/or other biologic response modifiers. For Medicare, the drug list for is Carrier-determined. The agents require physician work well beyond that of therapeutic drug agents. These services can be provided by any physician (not just Oncologists). Chemotherapy services are typically highly complex and require direct physician supervision for any or all purposes of patient assessment, provision of consent, safety oversight and intra-service supervision of staff. Typically, such chemotherapy services require advanced practice training and competency for staff who provide these services; special considerations for preparation, dosage or disposal; and commonly, these services entail significant patient risk and frequent monitoring. Examples are frequent changes in the infusion rate, prolonged presence of nurse administering the solution for patient monitoring and infusion adjustments, and frequent conferring with the physician about these issues. 4/6/10 CPT Codes American Medical Association. All rights reserved. 28

29 Chemotherapy Administration These are included services, if performed just to prepare for chemo 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 For declotting a catheter or port, please use along with the declotting agent. 4/6/10 CPT Codes American Medical Association. All rights reserved. 29

30 Chemotherapy Administration Report separate codes for each parenteral method of administration employed when chemotherapy is administered by different techniques. The administration of medications (eg, anti-emetics, narcotics, analgesics) administered independently or sequentially as supportive management of chemotherapy administration, should be separately reported using 96360, 96361, 96365, as appropriate. The fluid used to administer the drug(s) is considered incidental hydration and is not separately reportable. Check with Medicare before adopting this policy for your Carrier. When administering multiple infusions, injections or combinations, only one "initial" service code should be reported, unless protocol requires that two separate IV sites must be used. The initial code that best describes the key or primary reason for the encounter should always be reported irrespective of the order in which the infusions or injections occur. But, if separate sessions or multiple lines are used, use -59 to denote this. 4/6/10 CPT Codes American Medical Association. All rights reserved. 30

31 Injection and Intravenous Infusion Chemotherapy intravenous, push technique, single or initial substance/drug intravenous, push technique, each additional substance/drug (List separately in addition to code for primary procedure) (Use in conjunction with 96409, 96413) These codes used for short chemotherapy infusions as well. 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. 4/6/10 CPT Codes American Medical Association. All rights reserved. 31

32 Injection and Intravenous Infusion Chemotherapy Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug each additional hour, 1 to 8 hours (List separately in addition to code for primary procedure) Initiation of a Prolonged infusion, requiting of a portable or implantable pump Each additional sequential infusion Report to identify hydration over 30 minutes, or 96366, 96367, to identify therapeutic, prophylactic, or diagnostic drug infusion or injection, if provided as a secondary or subsequent service in association with Use for over 30 minutes into the next hour of chemotherapy. For infusions of 30 minutes or less into the following hour, do not report any infusion time is often considered to be an initial service by payers by Check the CCI for modifier guidelines. Often, use of -59 will help. 4/6/10 CPT Codes American Medical Association. All rights reserved. 32

33 Concurrent chemo? Due to evidence of current practice standards, there is no code for concurrent administration of chemotherapeutic drugs. Multiple drugs given at the same session are considered sequential using codes or CPT 2006: An Insider s View You must use an unlisted code (96549) if you believe that you are giving concurrent chemotherapy or complex biologic agent. Leucovorin or Mesna was not considered as chemotherapy by the Drug Administration Work Group of CPT. 4/6/10 CPT Codes American Medical Association. All rights reserved. 33

34 Injection and Intravenous Infusion Chemotherapy Irrigation of implanted venous access device for drug delivery systems Chemotherapy injection, subarachnoid or intraventricular via subcutaneous reservoir, single or multiple agents Unlisted chemotherapy procedure Code does not require direct physician supervision. That is CPT, not Medicare. Drug administration is still an incident to service, unless you hear otherwise. Do not report if an administration or E& M service is provided on the same day has been deleted. For collection of blood specimen from a completely implantable venous access device, use Medicare does not pay for it with any other service, but private payers often do. 4/6/10 CPT Codes American Medical Association. All rights reserved. 34

35 On August 22, 2008 CMS published 2 NPRMs One proposed upgrading X12 and NCPDP HIPAA administrative transactions, with an April 1, 2010 compliance date One proposed replacing ICD-9-CM with ICD-10-CM for diagnoses ICD-10-PCS for inpatient hospital procedures With an implementation date of Oct. 1, 2011 for the change (services provided on or after that date) 35

36 HHS, with approval from the Office of Management and Budget (OMB) finalized and approved the ruling on implementation dates for ICD-10-CM. In quick summary, the ruling requires the X12 standard, version 5010 electronic filing standards by January 1, 2012 and ICD-10-CM code set by October 1, In the final ruling, 5010 standards were moved back by a year and a half and ICD-10-CM codes moved back by two years. You can find the full ruling at: edocket.access.gpo.gov/2010/pdf/e9-743.pdf

37 37 Codes change every year anyway Transaction version changes (X12 version 5010) will be in place to handle the codes Why not business as usual?

38 38 Not just the usual annual update ICD-10 markedly different from ICD-9 Requires changes to almost all clinical and administrative systems. Requires changes to business processes. Changes to reimbursement and coverage. Why?

39 Diagnosis Codes (ICD-9 to ICD-10-CM) Goes from 5 positions (first one alphanumeric, others numeric) to 7 positions, all alphanumeric From 13,000 existing codes to 68,000 existing codes Much greater specificity 39

40 40

41 41 Diabetes mellitus codes are expanded to include the classification of the diabetes and the manifestation. The category for diabetes mellitus has been updated to reflect the current clinical classification of diabetes and is no longer classified as controlled/uncontrolled: E08.22, Diabetes mellitus due to an underlying condition with diabetic chronic kidney disease E09.52, Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy with gangrene E10.11, Type 1 diabetes mellitus with ketoacidosis with coma E11.41, Type 2 diabetes mellitus with diabetic mononeuropathy1

42 42 ICD-9-CM Hematuria (blood in urine) ICD-10-CM R31.0 Gross hematuria R31.1 Benign essential microscopic hematuria R31.2 Other microscopic hematuria R31.9 Hematuria, unspecified

43 43 W21.00 Struck by hit or thrown ball, unspecified type W21.01 Struck by football W21.02 Struck by soccer ball W21.03 Struck by baseball W21.04 Struck by golf ball W21.05 Struck by basketball W21.06 Struck by volleyball W21.07 Struck by softball W21.09 Struck by other hit or thrown ball W21.31 Struck by shoe cleats Stepped on by shoe cleats W21.32 Struck by skate blades Skated over by skate blades W21.39 Struck by other sports foot wear W21.4 Striking against diving board W21.11 Struck by baseball bat W21.12 Struck by tennis racquet W21.13 Struck by golf club W21.19 Struck by other bat, racquet or club W Struck by ice hockey stick W Struck by field hockey stick W Struck by ice hockey puck W Struck by field hockey puck W21.81 Striking against or struck by football helmet W21.89 Striking against or struck by other sports equipment W21.9 Striking against or struck by unspecified sports equipment

44 Laterality Left Versus Right C50.1 Malignant neoplasm, of central portion of breast C Malignant neoplasm of central portion of right female breast C Malignant neoplasm of central portion of left female breast

45 ICD-9-CM 143 Malignant neoplasm of gum Upper gum Lower gum ICD-10-CM C03 Malignant neoplasm of gum C03.0 Malignant neoplasm of upper gum C03.1 Malignant neoplasm of lower gum

46 Conversion of ICD-9-CM to ICD-10 Map codes so you don t have to Coding goes both ways From old to new From new to old These can easily be loaded and computerized, so it is not as hard as might look

47 General ICD-10 information icd10des.htm ICD-10-CM files, information and general equivalence mappings between ICD-10-CM and ICD-9-CM icd10cm.htm GEMS 2010 Update ICD10/02m_2010_ICD_10_CM.asp#TopOfPage

48 Key mechanism for transforming Medicare from passive payer to active purchaser. Current Medicare Physician Fee Schedule is based on quantity and resources consumed, NOT quality or value of services. Value = Quality / Cost Incentives can encourage higher quality and avoidance of unnecessary costs to enhance the value of care. 48

49 TRHCA Tax Relief & Health Care Act, 2006 Established 2007 PQRI, 7/1-12/31/07, authorized 1.5% incentive subject to a cap, claims-based reporting by eligible professionals (EPs) of up to 3 individual applicable measures for 80% of eligible cases MMSEA - Medicare, Medicaid, and SCHIP Extension Act of 2007 Authorized 2008 PQRI, 1.5% incentive, eliminated cap Incentive Required alternative reporting periods and alternative reporting criteria for 2008 and 2009 Requires alternative reporting for measures groups and for registry-based reporting MIPPA - Medicare Improvements for Patients and Providers Act Section 131: 2009 PQRI Authorized PQRI 2009 raised incentive to 2%, adds qualified audiologists as eligible professionals, no effect on 2007 or 2008 incentive payments FR requires CMS to post on our web site names of EPs who satisfactorily report quality measures for 2009 PQRI Section 132: e-prescribing Incentive Program Authorized separate 2% incentive payment to EPs who successfully use a qualified eprescribing system erx measure removed from 2009 PQRI --separately posted measure specifications. The Secretary has the authority to update the codes of the electronic prescribing measure in the future. FR requires names of eligible professionals who are successful e-prescribers be posted on the CMS web site 49

50 Physicians MD/DO Podiatrist Optometrist Oral Surgeon Dentist Chiropractor Therapists Physical Therapist Occupational Therapist Qualified Speech- Language Pathologist Practitioners Physician Assistant Nurse Practitioner Clinical Nurse Specialist Certified Registered Nurse Anesthetist Certified Nurse Midwife Clinical Social Worker Clinical Psychologist Registered Dietician Nutrition Professional Audiologist 50

51 153 PQRI quality measures for PQRI quality measures proposed so far for 2010; this includes all ways of reporting. Coding and measure specifications are available at: Read all measures before choosing. 51

52 The Oncology Pain Measures (#143 and 144) will be reportable ONLY by registries. The Melanoma measures (# ) will only be reportable by Registry in CMS is moving toward Registry reporting and away from claims-based reporting. There is a new measure, Cancer Stage Documented --Measure #194 for colon, breast, rectal, etc. cancer. Check it out!!! 52

53 Measure Groups Report on one or more measure groups---13 measure groups Diabetes mellitus, chronic kidney disease, preventive care, coronary artery bypass graft, rheumatoid arthritis, peri-operative care, back pain, hepatitis C, heart failure, coronary artery disease, ischemic vascular disease, HIV/AIDS, community-acquired pneumonia Choose a measure group only if ALL the measures within the group are applicable to services provided to Medicare patients by the reporting provider. Review the 2010 PQRI Measures Group Specifications Manual to determine if a particular measures group is applicable for your practice 53

54 Reporting period: January 1, 2009 December 31, reporting periods for reporting measures groups and registry-based reporting: January 1, 2009 December 31, 2009 July 1, 2009 December 31, 2009 In 2010, 2 reporting periods apply to claims, registries, and measures groups. 54

55 Criteria for claims-based submission of individual measures (1 option): 3 PQRI measures or 1-2 measures if < 3 apply* 80% of applicable Medicare Part B FFS patient claims for 1-3 measures If < 3 measures, measures are subject to measure applicability validation (MAV) Criteria proposed for 2010 annual reporting also includes that each measure must have a minimum of 15 patients for each measure. THIS WAS NOT APPROVED IN THE FINAL RULE! 55

56 Registries are trained to process and submit data. 96% of EPs reporting by registry in 2008 were successful, which accounted for 17% of all payments. Registries save you from having to submit at the time of service by claim. Registries do cost $$$, but your time is worth $$$. This is not to represent that registries will take all of the work out of PQRI, but you will have a better handle on getting paid. It s not too late!! Get the list--- communityoncology.info/pqri-e-prescribing-folder/ 56

57 CECity, Simone Karp x311 DocSite, Patient360, Wellcentive LLC, x702 57

58 EHR/EMR Reporting 10 specific individual measures, but none in Oncology Must meet these criteria if Oncology does get EMR/ EHR reporting including Be able to transmit data elements per specific CMS criteria Be able to separate out and report on CMS FFS patients only Be able to transmit TIN/NPI information Be able to transmit in approved formats Be able to transmit in a HIPAA secure format Enter into legal arrangements that permit receipt of and transmission of patient-specific data Obtain permission by NPI number Must pass CMS test. Group Practices may report, but only if they have 200 providers. 58

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60 Year Successful** Not % 0% % 0% % 0% % -1% % -1.5% % -2% In 2009 and 2010, physicians who successfully e- prescribe may receive a bonus payment of 2 percent of their overall Medicare reimbursement in addition to a potential 2 percent incentive related to PQRI for a potential bonus of 4 percent in Medicare reimbursement. ***No double incentives for those participating in the ARRA EMR incentive program. 60

61 E-prescribing measure is reportable only through claims in 2009; in 2010, CMS proposes three methods claims, registries, and EHRs. Limitation to applicability of incentive payment Denominator codes (E/M etc) for the e-prescribing measure must comprise at least 10% of an EP s total allowed charges for all covered services furnished by the EP during the reporting period 61

62 PBM Critical Step Visit Documented in Medical Record & Rx Generated Rx Transmitted to Pharmacy Encounter Form Coding & Billing N-365 NCH Analysis Contractor National Claims History File Carrier/MAC Confidential Report Incentive Payment 62

63 Numerator: erx Quality-Data Code for Successful Reporting: Prescription(s) Generated and Transmitted via Qualified erx System G8553: At least one prescription created during the encounter was generated and transmitted electronically using a qualified erx system REPORTING DENOMINATOR: Any patient visit for which one (or more) of the following denominator codes applies and is included on the claim Denominator Criteria (Eligible Cases): Patient visit during the reporting period (CPT or HCPCS): 90801, 90802, 90804, 90805, 90806, 90807, 90808, 90809, 90862, 92002, 92004, 92012, 92014, 96150, 96151, 96152, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0101, G0108, G0109 To figure out if you are eligible: Put the allowed reimbursement of the above codes OVER Your total allowed revenue for MPFS services (EXCLUDES DRUGS AND LAB) 25 Encounters with G8553 per Eligible Provider 63

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65 Redundancy of CMS Auditors Roles of Medicare Improper Payment Review Entities PSCs are now ZPICs = Zone Program Integrity Contractors 65

66 Multiple Layers of Audits Federal Medicare Incorrectly Billed Claims Processing Errors Medical Necessity Incorrect Payment Amounts Noncovered Services Incorrectly Coded Services Duplicate Services RAC X X X X X X X MAC X X X X X X X PSC/ZPIC X X X X X CERT X X X X X MAC Billing Audits X X X X X X Office of Audit Services Audits X X X X Annual Work Plan Projects X X X X X X Large $ Items X X X

67 Department of Justice Health Care Fraud and Abuse Control Program FY 2010 President Obama increased fraud audit funding by more than $300 million for Approximately $1.8 Billion overall being allocated for FY The Federal Government is sending a clear message that Healthcare Fraud Audit and Recovery of Improper Payments are top priorities.

68 Don t feel like the roof fell in... Be Prepared! 68

69 Past and future consults are problem areas for almost all physicians in our sample. There are very high profiles for: Consults and Hospital Admissions Use of modifier -25 with visits, chair visits Hospital visits New versus established patients (RAC)

70 Drug Administration Use of for more than one drug in a bag Confusion about use of sequential codes as opposed to additional hours Use of more than one initial code per day Billing of fluids to transport drugs Billing of with drug administration Billing of with other services Billing with other services

71 Responding to Audit Requests Usually your first contact with the auditors will be a written request for documents. This usually comes by FAX. Often you will receive additional written requests for documents and/or verbal requests for additional documents. How do you respond to all of these requests? Do you know what type of audit that you are responding to? Are they planning to come to your facility? Have a Plan and Team put together before the audit begins! Do you need a lawyer?

72 Form Your Response Team Who is in charge? What is the chain of command? Who has decision-making authority to bring in outside attorney/consultant? Who has authority to speak for the organization? Who is the lead or point person for contact with the auditors? Who shall review and screen charts? CEO, CFO, Compliance Officer, providers, billers/coders and should all be involved.

73 Responding to Audit Requests No records should be sent to the OIG, CMS, the State AG or HHS divisions, MAC, RAC, AC, Managed Care Plan Administrator or any other governmental entity or agent until the following issues are addressed: Were your Administrator and Head MD made aware of the request? Before records are sent, has your Team followed procedures to insure that: => For the patient s record being requested, every document required by regulation, including all claim forms and charge data were submitted in response to the auditor s request? => All records were copied correctly, two sided documents have legible dates and signatures, and information has not been cut off?

74 Responding to Audit Requests Example: Admission/Coding summary History and Physical Progress notes Nurses notes Diagnosis Hospital records Lab/Outpatient records All Physician orders and notes Clinical protocols/pathways

75 MACs/ Carriers per their own internal screens CERT Auditors Medical Integrity Contractors Bundling and Medically Unlikely Edits Private Insurance Companies on behalf of MA or themselves.

76 1. Try to figure out what they are looking for what do charts requested have in common drugs, procedures, visits 2. Get personally involved with seeing that charts are put together correctly. 3. Call the requestor, if you have questions 4. Copy ALL records involved in the request office, hospital, lab. 5. Check for legibility and continuity of charts. Find unfiled documentation, if that is an issue 6. When in doubt, send more rather than less--- but do not send unrelated material.

77 6. Check for correct provider names, dates, authentication. 7. For major audits, have a physician and nurse reviewer. 8. Write addenda as necessary. 9. Send to the correct contractor. 10. Make sure documentation gets there when it is due. Send by traceable mail (Express, Fedex, etc) 11. Keep a record of records checked out, why request was made, and to whom.

78 Hmmmm you counseled the patient regarding the chemo and care at home but the time of counseling is not clear Medical Record Reviewers do not fill in gaps in a note or lapses in dictation. If it wasn t written, it was not done not negotiable!! Documentation for each visit, treatment and procedure must stand alone: Medical Record Reviewers will NOT look back at prior notes to support a level of service. 78

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