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Volume 7, Issues 5 & 6 : December 2012 | Patient Assistance Resources Download for iPad

PREPARING FOR 2013 CHANGES

Medicare’s Physician Fee Schedule (MPFS) Final Rule for Calendar Year 2013 was released by the Centers for Medicare and Medicaid Services (CMS) on November 1, 2012, CMS will be accepting public comments on the Final Rule until 5:00 P.M. on December 31, 2012.

The PFS final rule addresses changes to the physician fee schedule, payments for Part B drugs, and other Medicare Part B payment policies. The PFS final rule also implements certain provisions of the Affordable Care Act (ACA).

In this newsletter, we will review the Medicare final rule and provide the information necessary to prepare for the 2013 billing, coding and program changes.
Risë Marie Cleland

 

MEDICARE PHYSICIAN FEE SCHEDULE FINAL RULE

The MPFS Final Rule for CY 2013, published on November 16, 2012 is based on current law, which includes a negative update for 2013 due to the Sustainable Growth Rate (SGR) formula and the expiration of the Physician Work Geographic Adjustment Floor of one-percent.

The SGR formula, created by Congress in 1997, sets a target growth rate for physician services and caps total Medicare expenditures on these services when utilization increases above this target. This is accomplished through the application of a conversion factor. When expenditures for the previous year exceed the target growth rate, the conversion factor decreases payments for the next year. When the expenditures are less than the target growth rate, the conversion factor increases the payments to physicians for the next year.

For each of the past ten years the SGR formula has resulted in a negative update and a scheduled reduction in physician reimbursement rates. However, every year since 2003, Congress has stepped in and temporarily prevented the scheduled cuts. Only Congress has the authority to repeal the SGR formula and while everyone agrees that the SGR formula is no longer a valid methodology for setting physician payment rates there are many differing opinions on how to reform physician payment.

Without Congressional action to stop the SGR cuts, the Medicare conversion factor used to calculate physician payment rates would decrease from $34.0376 in 2012 to $25.0008 in 2013 resulting in a 26.5% cut to physician payments for services on or after January 1, 2013.

The latest estimates by the Congressional Budget Office (CBO) places the cost of a one-year delay to the scheduled physician payments cuts at $25 billion.

Still, Congress is expected to once again step in and prevent this massive cut to physician payments and CMS states that they will quickly work to update MPFS payment rates if Congress does pass legislation preventing the payment cuts from going into effect on January 1, 2013.

PAYMENT RATE CHANGES
In the 2013 proposed rule, CMS reported that the proposed changes would result in an estimated payment decrease of 1% to hematology/oncology. However, the final rule revises the estimated impact to a payment increase of 2% for hematology/oncology. This good news is due in large part to changes to the Relative Value Units (RVUs) for CPT codes 96413 (Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug) and 96416 (Initiation of prolonged chemotherapy infusion (more than 8 hours) requiring the use of a portable or implantable pump).

After considering comments by the American Society of Clinical Oncology (ASCO), the American Society of Hematology (ASH) and other commenters, CMS refined the practice expense (PE) inputs adding six additional minutes of clinical labor time for CPT code 96413 and eleven additional minutes of clinical labor time for CPT 96416.

In Figure 1, the Medicare 2012 payment rate is compared to the estimated 2013 national payment rate. The estimated 2013-payment rate shown uses the 2012 Conversion Factor (CF) rate (based on the assumption that Congress will halt the scheduled SGR cuts) and factors in the estimated 2013-budget neutrality adjuster. As shown, the majority of the drug administration codes would see increases in the payment rate based on the reported RVUs.

While Congress is expected to stop the SGR cuts, there remain a great many unknowns as to how this will be accomplished, although another temporary fix appears to be the most likely action. Congress may also choose to temporarily freeze the CF (with or without an increase for 2013). With any luck, Congress will have acted by the time you are reading this newsletter!

The addenda to the rule, including Addendum B, which lists the proposed RVUs for each CPT code, are not listed in the final rule but are available on the PFS page of the CMS website.

ANALYSIS OF ESTIMATED 2013 MEDICARE PAYMENTS


CPT CODE

DESCRIPTION

2012

2013

% Difference*

96360 Hydration, initial 57.18 58.49 2.29%
96361 Hydration, each additional hour 15.32 15.30 -0.13%
96365 Non-chemo IV Infusion, initial 72.50 75.49 4.12%
96366 Non-chemo IV infusion, each additional hour 21.44 21.76 1.49%
96367 Non-chemo, each additional sequential IV infusion 32.34 31.96 -1.18%
96368 Non-chemo, concurrent infusion 19.06 18.70 -1.89%
96372 Non-chemo, injection, SQ/IM 24.17 25.85 6.91%
96373 Non-chemo, intra-arterial 19.74 20.06 1.62%
96374 Non-chemo, IV push 55.82 57.47 2.96%
96375 Non-chemo, each additional sequential IV push new drug 22.46 22.44 -0.09%
96401 Chemo, injection, SQ/IM non-hormonal 73.18 75.83 3.62%
96402 Chemo, injection, SQ/IM hormonal 33.70 32.64 -3.14%
96409 Chemo, IV push, single or initial drug 110.96 111.87 0.83%
96411 Chemo, IV push, each additional drug 62.29 62.57 0.45%
96413 Chemo, IV infusion initial 138.53 143.16 3.34%
96415 Chemo, IV infusion, each additional hour 30.63 30.60 -0.09%
96416 Chemo, IV initiation prolonged infusion >8 hrs requiring a pump 138.19 142.48 3.1%
96417 Chemo, IV infusion each additional sequential drug 71.14 71.07 -0.09%
96440 Chemo, pleural cavity, requiring & including thoracentesis 827.45 904.84 9.35%
96446 Chemo, peritoneal cavity via indwelling port or catheter 192.31 199.94 3.97%
96450 Chemo, CNS (intrathecal) requiring & including spinal puncture 187.21 181.24 -3.19%
96521 Pump refill/maintenance portable 136.83 140.77 2.88%
96522 Pump refill/maintenance reservoir system 110.96 114.26 2.97%
96523 Irrigation of implanted venous access device for drug delivery 25.19 25.16 -0.12%

Figure 1 Based on 2013 MPFS Final Rule *assuming Congress stops the SGR cuts and applying the stated 2013 Budget Neutrality (BN) Factor, estimates shown are based on the national payment rate and as such do not include geographical adjustments.

Figure 2 shows the reported estimated impact of the CY 2013 Physician Fee Schedule for the specialties of Hematology/Oncology, Radiation/Oncology and Family Practice. Among the factors impacting physician payments for these specialties are:

  • The transition to the new PE RVUs using PPIS data (2013 is the final year of the four-year transition);
  • New and revised codes;
  • The expansion of the Multiple Procedure Payment Reduction (MPPR) policy;
  • Updates to the equipment interest rate assumption;
  • The establishment of the new post-discharge transitional care management policy and payment for care coordination under new CPT codes 99495 and 99496; and
  • Input changes for certain radiation therapy procedures.
  Impact of End of PPIS Transition New & Revised Codes, MPPR, New Utilization & Other Factors Updated Equipment Interest Rate Assumption Transitional Care Management Input Changes for Certain Radiation Therapy Procedures Total Cumulative Impact
Hematology/Oncology -1% 3% 1% -1% 0% 2%
Radiation/Oncology -4% 2% -3% -1% -1% -7%
Family Practice 1% 1% 0% 4% 0% 7%

Figure 2 Source: CMS Medicare Physician Fee Schedule Final Rule 2013
*These impacts do not include the effects of the negative conversion factor change that is scheduled for Jan. 2013 unless Congress acts to halt it.

 

RADIATION ONCOLOGY GETS PARTIAL REPRIEVE

In the 2013 final rule, CMS responded to commenters who urged them to reconsider the proposed cuts of 14% on radiation oncology services, warning that such cuts would threaten life-saving treatment to cancer patients nationwide. Commenters seeking a reduction in the proposed cuts included the American Society for Radiation Oncology (ASTRO), the Radiation Therapy Alliance (RTA), the Cancer Leadership Council (CLC), as well as more than 130 members of Congress.

In particular, commenters objected to CMS’ use of publically available patient education materials to establish procedure time assumptions for IMRT (CPT code 77418) and SBRT (CPT code 77373). The use of these patient education materials would result in a decrease in procedure time assumptions and PE RVUs thus resulting in a decrease in reimbursement rates for these services.

The current direct PE inputs for IMRT reflects a procedure time assumption of 60 minutes while an ASTRO patient fact sheet and a patient information website cosponsored by the American College of Radiation (ACR) and the Radiological Society of North America (RSNA) both state that IMRT sessions typically last between 10 and 30 minutes. Similarly, the ACR/RSNA patient information website states that SBRT treatment “can take up to one hour” while the current procedure time assumption used for this service is 90 minutes.

Commenters objected to the use of the patient education materials stating that they are not designed to reflect or describe the time necessary to deliver professional services. The AMA Specialty Society Relative Value Scale Update (RUC) Committee also opposed the use of these materials in the process of setting Medicare payment rates saying that they are not evaluated by the same standards applied to the data used in the AMA RUC process.

CMS noted in the final rule that none of the commenters who objected to the proposal to adjust the time assumptions presented alternative sources of objective information to determine accurate procedure time assumptions. Furthermore, in explaining their decision to finalize the proposed adjustments, CMS said, “We believe medical societies and practitioners strive to offer their cancer patients accurate information regarding the IMRT OR SBRT treatment experience.”

While CMS did finalize the proposed procedure time cuts to IMRT and SBRT, they also accepted the updated equipment costs data submitted by commenters and added a 2% increase due to new and revised codes. Together these changes resulted in an overall cut of 7% to Radiation/Oncology rather than the proposed 14% reduction.
In a November 2, press release, Michael L. Steinberg, MD, FASTRO, chairman of ASTRO’s Board of Directors, responded to the final rule stating, “While we remain concerned about the overall level of the cuts to radiation oncology, we appreciate that CMS heard our concerns, and we look forward to working with CMS and Congress to achieve meaningful payment reforms that place incentives on value rather than volume. ”

 

BUNDLED PAYMENTS

In the final rule, CMS discusses their authority to make coding revisions that may include consolidation of individual services into bundled codes for payment under the PFS. In addition, the Middle Class Tax Relief and Job Creation Act of 2012 (MCTRJCA) requires that they conduct a study examining options for bundled or episode-based payment to cover physicians’ services that are currently paid under the PFS.

The final rule makes clear that CMS is very interested in pursuing and expanding bundled payments with the goals of improving quality, reducing costs and promoting efficiencies. CMS will continue to study options for bundled or episode-based payments and will provide recommendations and implementation options in their report to Congress. CMS also states they are looking forward to hearing from stakeholders interested in testing some of these concepts within the PFS.

CMS reports that they have had representatives of specialty groups, including radiation oncologists, volunteer to work with them to create a bundled payment for their services. The American Society of Radiation Oncology (ASTRO) confirms they have met with CMS officials, informing them of the Society’s commitment to work on payment reform in radiation therapy, which may include bundling of services.

With respect to a radiation therapy bundling project, CMS states that they would be interested in exploring an episode-based payment that would allow Medicare to pay for the full course of the typical radiation therapy along with the medical services the patient may receive to treat side effects.

Read what ASTRO has to say about the 2013 Medicare PFS and their comments on CMS’ interest in a radiation therapy bundling project on the ASTRO website at www.astro.org.

More information on Medicare’s Bundled Payments for Care Improvement Initiative is available on the CMS Innovation Center website.

NEW PAYMENT FOR TRANSITIONAL CARE MANAGEMENT

If there is one consistent theme in the 2013 final rule, it is CMS’ commitment to prioritize improvement for primary care services. In fact, the greatest percentage increase of payments goes to the Family/Practice specialty. As shown in Figure 2, Family/Practice providers will receive an estimated increase in payments of 7% in 2013.

Primary care specialists will see their payments increase due to the final transition of the 4-year transition to the new PPIS data as well as the redistributions from changes in payments for services furnished by other specialties (due to the budget neutrality adjustment whereby decreases in payments for one service result in increases in payments for others).

However, it is CMS’ decision to finalize their proposal to pay for coordination of care services that provides the biggest boost in payment for primary care specialties. In 2013, CMS will adopt the AMA’s two new CPT codes 99495 and 99496 for Transitional Care Management (TCM) to provide payment for managing a beneficiary’s care following discharge from an inpatient hospital stay, skilled nursing facility (SNF), an outpatient hospital observation, partial hospitalization services, or a community mental health center. In order to maintain budget neutrality, the new coordination of care service will be financed by a standard reduction in payments for all other services through application of the budget neutrality adjuster.

CPT

DESCRIPTION

EFFECTIVE
DATE

99495 Transitional care management services with moderate medical decision complexity (face to face visit within 14 days of discharge) Jan. 01, 2013
99496 Transitional care management services with high medical decision complexity (face to face visit within seven days of discharge) Jan. 01,2013

The new TCM services will be payable when furnished by a physician or qualified nonphysician practitioner (NPP). The new codes will be payable to only one provider and only once per patient within 30 days of discharge. The TCM service is billable at the end of the 30-day period post discharge, if more than one provider bills for the service the claim that is received first will be paid.

The final rule provides clarification that TCM services are not limited to primary care physicians and practitioners, as CMS believes there will be circumstances in which oncologists or other specialists will be in the best position to furnish transitional care coordination after a hospital discharge.

Medicare Requirements of the TCM Codes

99495 Transitional Care Management Services with the following required elements:

  • Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge.
  • Medical decision making of at least moderate complexity during the service period.
  • Face-to-face visit, within 14 calendar days of discharge.

99496 Transitional Care Management Services with the following required elements:

  • Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge.
  • Medical decision making of high complexity during the service period.
  • Face-to-face visit, within 7 calendar days of discharge.

Figure 3 Source: CMS Medicare Physician Fee Schedule Final Rule 2013

The new TCM codes are not to be billed routinely for patients post-discharge. CPT codes 99495 and 99496 are only appropriate when reporting TCM services for a patient whose medical and/or psychosocial problems require moderate or high complexity decision making during transitions in care from an inpatient hospital setting, partial hospital, observation status in a hospital, or skilled nursing facility/nursing facility to the patient’s community setting (home, domiciliary, rest home or assisted living).

In response to comments requesting that the requirement for a face-to-face visit be dropped from the TCM codes CMS states that the primary goal in creating the new TCM codes was to improve care coordination and to ensure that these patients are seen in a physician’s office, rather than be at risk for readmission. Nevertheless, CMS also said that they view the requirement for a face-to-face visit in association with the non-face-to-face tasks of TCM to be a short-term, transitional strategy while they explore further improvements to advanced primary care payment.

CMS provides the following guidance on who may perform the non-face-to-face services included in the TCM codes:
Non-face-to-face services provided by the clinical staff, under the direction of the physician or other qualified health care professional may include:

  • Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge.
  • Communication with home health agencies and other community services utilized by the patient.
  • Patient and/or family/caretaker education to support self-management, independent living, and activities of daily living.
  • Assessment and support for treatment regimen adherence and medication management.
  • Identification of available community and health resources.
  • Facilitating access to care and services needed by the patient and/or family.

Non-face-to-face services provided by the physician or other qualified health care provider may include:

  • Obtaining and reviewing the discharge information (for example, discharge summary, as available, or continuity of care documents).
  • Reviewing need for or follow-up on pending diagnostic tests and treatments.
  • Interaction with other qualified health care professionals who will assume or reassume care of the patient’s system-specific problems.
  • Education of patient, family, guardian, and/or caregiver.
  • Establishment or reestablishment of referrals and arranging for needed community resources.
  • Assistance in scheduling any required follow-up with community providers and services.

In their discussion of the new CPT TCM codes, CMS reminds us of their initiative to prioritize support of primary care and care management stating that the new TCM codes provide a separate reporting mechanism for the community physician in this context. CMS says the policies that are finalized in this rule may be short-term payment strategies that may be revised over time to be consistent with their broader primary care and care management initiatives.

In fact, the Community-based Care Transitions Program (CCTP), created by Section 3026 of the ACA, is focused on improving care transitions from the hospital to other settings and reducing readmissions for high-risk Medicare beneficiaries. Through the CCTP, CMS seeks to improve the quality of care provided to transitioning Medicare beneficiaries and to achieve measurable savings to the Medicare program.

Finally, if you are interested in billing for the new TCM services carefully review all of the required face-to-face and non-face-to-face follow-up services and documentation requirements before submitting any claims for these services. Watch for additional guidance from CMS on reporting and documenting the new TCM services.

 

MEDICARE: NEW COMPLEX CARE CODES ARE BUNDLED

The American Medical Association’s (AMA) CPT Editorial Panel developed three new CPT codes to describe complex chronic care coordination services that are patient centered management and support services. According to the AMA, the new CPT codes 99487, 99488 and 99489 were created so that medical practices could bill for time that was not necessarily face-to-face but spent connecting patients to community services, transitioning them from inpatient to other settings and preventing readmissions. The new codes are effective for dates of service on or after January 1, 2013.

While private payers may pay these new codes, CMS has determined not to pay for the new complex care codes in 2013. In response to comments suggesting they adopt the new codes, CMS said they were assigning CPT codes 99487-99489 a PFS procedure status indicator of B (always bundled into payment for other services) explaining that they believe the services are bundled into the services to which they are incident and are not separately payable. CMS did however say they would consider these codes in the future as they continue their multi-year strategy to recognize and support primary care management.

Review the AMA’s CPT 2013 and the AMA’s CPT Changes: An Insider’s View 2013 for complete information on the appropriate billing and documentation of these and all new codes prior to billing them to any payer.

 

NEW CODES EFFECTIVE JANUARY 1, 2013

CPT

DESCRIPTION

MEDICARE
STATUS

99487 Complex chronic care coordination services; 1st hr of clinical staff time, directed by provider, no face-to-face visit, per calendar month Status B: Bundled
99488 1st hr of clinical staff time, directed by provider, with 1 face-to-face visit, per calendar month Status B: Bundled
99489 Each additional 30 minutes of clinical staff time directed by a provider, per calendar month Status B: Bundled

CPT DESCRIPTION MEDICARE
STATUS
99495 Transitional care management services: communication with the patient and/or caregiver within 2 business days of discharge, medical decision making of at least moderate complexity during service period, face-to-face visit within 14 calendar days of discharge Separately payable
99496 Transitional care management services: communication with the patient and/or caregiver within 2 business days of discharge, medical decision making of high complexity during service period, face-to-face visit within 7 calendar days of discharge Separately payable
G0454 Physician documentation of face-to-face visit for Durable Medical Equipment determination performed by NP, PA or CNS – policy effective July 1, 2013 Separately payable

CPT

DESCRIPTION

MEDICARE
STATUS

32554 Thoracentesis, needle or catheter, aspiration of the pleural space; without imaging guidance Separately payable
32555 Thoracentesis, needle or catheter, aspiration of the pleural space; with imaging guidance Separately payable
32556 Pleural drainage, percutaneous, with insertion of indwelling catheter; without imaging guidance Separately payable
32557 Pleural drainage, percutaneous, with insertion of indwelling catheter; with imaging guidance Separately payable

CPT

DESCRIPTION

MEDICARE STATUS

86152 Cell enumeration using immunologic selection and identification in fluid specimen (e.g. , circulating tumor cells in blood); (Technical Component) Payable on the Clinical Lab Fee Schedule
86153 Cell enumeration using immunologic selection and identification in fluid specimen (e.g. , circulating tumor cells in blood); physician interpretation and report, when required (Professional Component) – report with modifier 26 to bill for this service under the MPFS Separately payable
G0452 Molecular pathology procedure; physician interpretation and report. *
*The other new molecular pathology CPT codes will be payable on the Clinical Lab Fee Schedule
Separately payable

EXPANDING THE MULTIPLE PROCEDURE PAYMENT REDUCTION PROGRAM

Medicare’s Multiple Procedure Payment Reduction (MPPR) policies are intended to lower Medicare costs by modifying multiple payments to reflect the reduced resources involved with furnishing services that are frequently furnished together.

Under the current advanced imaging MPPR policy, full payment is made for the technical component (TC) and professional component (PC) of the highest paid procedure, and payment for the TC and PC are reduced by 50 percent and 25 percent respectively, for each additional advanced imaging procedure furnished to the same patient on the same day by the same physician.

In the 2012 final rule, the advanced imaging MPPR policy was expanded to include the services provided by multiple physicians in the same group. However, the policy was not operationalized in 2012 due to implementation issues. CMS reports that the system changes necessary to apply the MPPR policy to both the TC and PC of advanced imaging services to multiple physicians in the same group practice have now been made. Thus, the MPPR for these services will be applied to the second and subsequent advanced imaging procedures furnished to the same patient, on the same day, by one or more physicians in the same group practice (same group NPI) effective January 1, 2013.

CMS explains that the application of the imaging MPPR to physicians in the same group practice will remove any financial incentive for physicians in a group practice to split imaging interpretation services for a beneficiary among different physicians in the group.

Another technical issue has been corrected and will result in the previously established MPPR for nuclear medicine being applied to CPT code 78306 (Bone imaging; whole body) when followed by CPT code 78320 (Bone imaging; SPECT), effective for services furnished on or after January 1, 2013.

Several commenters addressed the need for guidance on what constitutes a separate session and the problematic use of modifier 59, which may be used to bypass the Correct Coding Initiative (CCI) edits or the MPPR. However, when appropriately used to bypass the CCI edits this modifier may also inappropriately bypass the MPPR.

In response, CMS acknowledged the conflict with the use of modifier 59 saying that they are considering creating a new modifier for the MPPR and refining the definition of “same session.” Alternatively, they may consider modifying the MPPR policy to apply to procedures furnished on the same day, rather than in the same session, this option would have to be done through future rulemaking subject to public comment.

CMS reiterated that they may determine in future rulemaking to apply the MPPR to the TC and/or PC of all imaging services (excluding diagnostic and screening mammography), excluding add-on codes that are always furnished with another service and have been valued accordingly.

They also maintain their interest in expanding the MPPR to the TC of all diagnostic tests by applying a payment reduction to the TC of the second and subsequent diagnostic tests (such as radiology, cardiology, audiology, etc.) furnished in the same encounter. Add-on codes that are always furnished with another service and have been valued accordingly could be excluded.

 

PART B DRUGS

Pricing of Physician Administered Part B Drugs
The Office of Inspector General (OIG) conducts studies comparing Part B drugs average sales prices (ASP) to the widely available market prices (WAMP) and the average manufacturers prices (AMP). If the OIG finds that the ASP for a drug exceeds the WAMP or AMP by a certain percentage CMS is allowed to disregard the ASP and substitute the lesser of WAMP or 103% of AMP.

For 2013, CMS finalized their proposal under which they would substitute 103% of the AMP for 106% of ASP. Price substitution of AMP +3% will be allowed when ASP exceeds WAMP by 5%, or, AMP by 5%, for 2 consecutive preceding quarters, or 3 out of 4 of the last preceding quarters. Furthermore, matching sets of NDCs must be used in the comparison and the value of the AMP based price substitution must be less than the ASP payment limit that is calculated for the quarter in which the substitution is applied. Price substitution will remain in effect for one quarter.

The final rule also sets the AMP and WAMP threshold at 5% until a change in the threshold amount is warranted.

CMS also finalized their proposal that price substitution cannot be used for drugs that are listed by the FDA as being in shortage.

“Incident to” and Part B Drugs
CMS finalized as written, the proposed provision clarifying their payment policies regarding billing for Medicare Part B drugs provided “incident to” a physician’s service. The clarification by CMS was prompted by concern voiced in response to CR 7397 Transmittal 2437, which was updated on April 4, 2012 and which states, “Pharmacies may not bill Medicare Part B for drugs furnished to a physician for administration to a Medicare beneficiary. When these drugs are administered in the physician’s office to a beneficiary, the only way these drugs can be billed to Medicare is if the physician purchases the drugs from the pharmacy. In this case, the drugs are being administered “incident to” a physician’s service and pharmacies may not bill Medicare Part B under the “incident to” provision.”

In particular, the provision clarifies that drugs used by a physician to refill any implanted item of DME falls within the “incident to” benefit category and not the DME benefit category. CMS will be adding regulation text to codify the policy.

NEW HCPCS

Below is a list of some of the new HCPCS, effective for services on or after January 1, 2013. For a complete list of all the new, revised and deleted HCPCS, refer to the 2013 HCPCS Annual Update, published on CMS’ HCPCS Web site at: www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/Alpha-Numeric-HCPCS.html

HCPCS Description Billing
Unit
Effective
Date
C9295 Injection, carfilzomib* 1 mg Jan. 1, 2013
C9296 Injection, ziv-aflibercept* 1 mg Jan. 1, 2013
J7131 Hypertonic saline solution 1 ml Jan. 1, 2013
J9002 Injection, Doxil 10 mg Jan. 1, 2013
J9019 Injection, asparginase (erwinaze) 1000 iu Jan. 1, 2013
J9042 Injection, brentuximab vedotin 1 mg Jan. 1, 2013

* C – codes are billable to Medicare by hospital outpatient departments, (although some private payers may accept the C-codes). Physician offices are instructed to bill Medicare with the appropriate not otherwise classified (NOC) code.

VALUE BASED MODIFIER

The ACA mandated the establishment of a value-based payment modifier (VBM) in order to provide differential payment to physicians and group practices based upon the quality of care furnished to Medicare beneficiaries compared to the cost of that care during a specific performing period.

The VBM will be applied to Medicare Fee for Service (FFS) payments and will be phased in starting January 1, 2015, and will apply to all physicians and groups of physician by 2017. CMS had proposed to apply the VBM in 2015 to physician groups of 25 or more providers. However, in the final rule, CMS said commenters that recommended applying the VBM only to larger provider groups persuaded them. Therefore, CMS will apply the VBM to physician groups with 100 or more eligible professionals in 2015.

For 2015 and 2016, the VBM will not apply to groups of physicians participating in the Medicare Shared Savings Program Accountable Care Organizations (ACOs), the Pioneer ACO model, or the Comprehensive Primary Care (CPC) Initiative.

The VBM will be applied at the Tax Identification Number (TIN) level for the group practice, which means that if a physician moves from one group to another group, the physician’s payment will be adjusted based on the TIN the physician bills under so that all physicians billing under a TIN receive the same value-based payment modifier.

CMS finalized their proposal to base the VBM adjustment on participation in the Physician Quality Reporting System (PQRS) incentive program. This is in keeping with CMS’ intention of aligning the VBM program with the quality measure reporting criteria in the PQRS and to alleviate confusion as the group’s participation in PQRS determines how they are treated for the VBM program. For this reason, under the VBM program, CMS will count all eligible providers (EPs) (not just physicians) as determined under PQRS (see Figure 4) for purposes of determining a group’s size.

Although non-physician EPs will be included when determining group size, CMS is required by statute to limit the application of the VBM to services billed by physicians until January 1, 2017. At that time, CMS, at their discretion, may expand the VBM to Medicare FFS payments paid to EPs who are not physicians.

The 2015 VBM payment adjustment will be based on the 2013 PQRS reporting period. In 2015, the VBM payment adjustment of -1% will be applied to groups of 100 or more eligible providers who are not PQRS reporters (groups not self-nominating to participate in the PQRS Group Practice Reporting Option (GPRO) and not reporting at least one measure). This downward VBM payment adjustment is in addition to any PQRS payment penalty.

CMS received comments expressing concern that groups with little or no experience with PQRS would be penalized twice (receiving a PQRS payment adjustment and the VBM payment adjustment) for failing to report satisfactorily under the PQRS. CMS responded to these comments by modifying the requirements to avoid the VBM payment adjustment, and allowing groups who self-nominate for the PQRS GPRO to avoid the negative payment adjustment by reporting at least 1 PQRS measure or electing the PQRS administrative claims option for CY 2013.

There are also opportunities to earn upward payment adjustments under the VBM program. In 2015, groups of physicians that are subject to the VBM may elect to participate in the quality-tiering option of the VBM program, which allows a payment incentive based on the quality and cost of care they provide. The VBM program must be budget neutral, accordingly, the upward payment adjustment that may be earned cannot be determined until all downward payment adjustments have been determined. In other words, payments will increase for some groups of physicians based on high performance and decrease for others based on low performance.

The VBM payment adjustments will be applied to the Medicare paid amounts for services paid under the Medicare physician fee schedule so as not to affect beneficiary cost sharing or coinsurance.

In the final rule, CMS outlined the 5 principles governing the implementation of the value-based payment modifier (see Figure 5). The VBM program will evolve and become more comprehensive as it is phased in over the next several years, it will be important to monitor this program in order to prepare for your eventual required participation. Learn more about this program by visiting the CMS VBM website.

ELIGIBLE PROFESSIONALS UNDER THE 2013 PQRS

  • Medicare Physicians
    • Doctor of Medicine
    • Doctor of Osteopathy
    • Doctor of Podiatric Medicine
    • Doctor of Optometry
    • Doctor of Oral Surgery
    • Doctor of Dental Medicine
    • Doctor of Chiropractic
  • Practitioners
    • Physician Assistant
    • Nurse Practitioner
    • Clinical Nurse Specialist
    • Certified Registered Nurse Anesthetist (and Anesthesiologist Assistant)
    • Certified Nurse Midwife
    • Clinical Social Worker
    • Clinical Psychologist
    • Registered Dietician
    • Nutrition Professional
    • Audiologists
  • Therapists
    • Physical Therapist
    • Occupational Therapist
    • Qualified Speech-Language Therapist

Figure 4
Source: www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/index.html



5 Principles Governing the Implementation of the Value-Based Payment Modifier

  • A Focus on Measurement and Alignment – To maintain high quality care and improve quality and performance, and align with other CMS quality initiatives.
  • A Focus on Physician Choice – To allow physicians to choose the level at which their
    performance will be assessed.
  • A Focus on Shared Accountability – Through assessment at the group practice level and focusing on the total costs of care.
  • A Focus on Actionable Information – Provided by CMS to help physicians identify clinical areas
    where they are doing well and areas in which performance can be approved.
  • A Focus on Gradual Implementation – Beginning with a focus on outliers and gradually increasing the scope of measures assessed and payment incentives for high performance.

Figure 5 Source: CMS Medicare Physician Fee Schedule Final Rule 2013

ACTION ITEMS FOR GROUPS OF 100+ ELIGIBLE PROVIDERS

  1. Participate as a Group in PQRS in 2013
    1. Self-nominate as a group between December 1, 2012 — January 31, 2013, or during a second period from July — October 15, 2013
  2. Select a PQRS GPRO reporting mechanism
    1. GPRO Web interface
    2. CMS-qualified registry
    3. Administrative claims
    Note: Groups whose physicians participate as individuals in PQRS must self-nominate as a group and elect administrative claims for the Value Modifier to avoid the negative VBM payment adjustment
  3. Decide whether to elect the quality-tiering approach to calculate the VBM by October 15, 2013.

Source: CMS Physician Feedback and Value-Based Modifier Program National Provider Call, November 28, 2012

 

APPICATION OF THE 2015 VBM PAYMENT ADJUSTMENT

Figure 6 Based on information in the 2013 Medicare Physician Fee Schedule Final Rule

PHYSICIAN COMPARE: QUALITY MEASURES & PATIENT EXPERIENCE DATA

Development of the Physician Compare website was mandated by the ACA. CMS launched the first phase of Physician Compare on December 30, 2010. The initial phase included basic information for Medicare beneficiaries including a provider’s hospital affiliations, practice locations, gender, education, and languages spoken and whether or not the provider satisfactorily submitted quality data for the 2009 PQRS. Currently, Physician Compare also reports if the providers chose to participate and successfully reported in the eRx program.

The ACA requires that, no later than January 1. 2013, CMS develop a plan for publically reporting physician quality and patient experience metrics on the Physician Compare website. In the final rule, CMS addresses this mandate and states their commitment to make the Physician Compare website a constructive tool for Medicare beneficiaries by providing them with information that will help them make informed healthcare decisions.

In 2014, CMS plans to post the following information on the Physician Compare website:

  • Quality measures reported by group practices and ACOs participating in the 2013 PQRS GPRO and reporting via the GPRO Web Interface,
  • Patient experience data for group practices and ACOs of 100+ EPs reporting through the GPRO Web Interface for 2013 PQRS GPRO,
  • Million Hearts Recognition for EPs reporting on the PQRS Cardiovascular Prevention measures group in program year 2013,
  • Recognition of EPs who earn a PQRS Maintenance of Certification Incentive

CMS is targeting 2015 as the date for positing individual-level measure data collected in program year 2014.

According to CMS, this phased approach to public reporting of physician quality data will allow consumers access to currently available data and allow CMS time to continue development of the infrastructure necessary to support additional types of data and information on physicians’ quality measure performance. Implementation of subsequent phases of the plan will be developed and addressed in future notice and comment rulemaking.

 

ALIGNING THE MEDICARE INCENTIVE PROGRAMS

Physician Quality Reporting System
In 2013, eligible professionals (EPs) successfully reporting in the Physician Quality Reporting System (PQRS) are eligible to receive a 0.5% incentive payment on allowable MPFS services. A more important reason to participate in 2013 is the fact that the 2015 PQRS penalty adjustment is based on the 2013 PQRS reporting period. Therefore, in 2015, EPs who are not successful PQRS reporters in 2013 will see a -1.5% payment adjustment to their Medicare allowable on MPFS services.

The final rule outlines CMS’ approach to achieve their goals of increasing participation in the PQRS by 50% in CY 2015 (which is the first year PQRS will not offer incentives for reporting and instead applies a payment adjustment for unsuccessful reporters), and to ease EPs into reporting for the PQRS payment adjustment.
CMS continues their goal of aligning the PQRS with other Medicare quality reporting programs, such as the Electronic Health Record (EHR) Incentive Program, Medicare Shared Savings Program and the Value-Based Modifier (VBM).

In the final rule, CMS finalized their proposal to extend the PQRS Medicare EHR Incentive Pilot to 2013, whereby EPs can submit specific PQRS EHR Measures through their ONC certified EHR system to meet the core objective for reporting CQMs for the Medicare EHR Incentive Program and meet the requirements for satisfactory reporting under the PQRS.

An EP participating in both the PQRS and EHR incentive programs may participate in the PQRS-Medicare EHR Incentive Pilot through one of the following methods:

  • Submission of data extracted from the EP’s certified EHR technology through a Physician Quality Reporting System qualified EHR data submission vendor; or
  • Submission of data extracted from the EP’s certified EHR technology, which must also be through a PQRS qualified EHR.

Eligible professionals participating in the PQRS-Medicare EHR Incentive Pilot are still required to report the other meaningful use objectives through the Medicare and Medicaid EHR Incentive Programs’ Registration and Attestation System.

In response to the positive comments received, CMS finalized their proposals for additional options for avoiding the 2015 PQRS payment adjustment. In order to encourage participating in the PQRS CMS provides three ways an Individual EP or Group practice may avoid the 2015 PQRS payment adjustment.

EPs Reporting as Individuals may avoid the 2015 PQRS payment adjustment by:

  • Meeting the criteria for satisfactory reporting for the 2013 PQRS incentive; or
  • Reporting 1 valid measure or measures group using the claims, registry, or EHR-based reporting mechanisms, or
  • Electing to be analyzed under the administrative claims-based reporting mechanism.

EPs Reporting as a Group Practice may avoid the 2015 PQRS payment adjustment by:

  • Meeting the criteria for satisfactory reporting for the 2013 PQRS incentive under the GPRO; or
  • Reporting 1 valid measure or measures group using the registry, or GPRO Web Interface reporting mechanisms, or
  • Electing to be analyzed under the administrative claims-based reporting mechanism.

The administrative claims-based reporting mechanism is new in 2013 and in the 2013 PQRS, it is only used to avoid the 2015 payment adjustment. Under this reporting mechanism, EPs and group practices are not required to submit quality data codes (QDCs) on claims to CMS. Instead, CMS will analyze their claims data to determine whether the EP or group practice has performed any of the 14 process and 3 outcomes measures in the PQRS administrative claims-based measure set (the list of measures are outlined in Table 123 of the 2013 MPFS Final Rule).

EPs and group practices wishing to participate in the administrative claims-based reporting must elect to do so by October 15, 2013 via the web.

The reporting period for the 2013 PQRS incentive payment is for 12 months January 1 — December 31, 2013, with the exception of EPs reporting measures groups through a registry for which there is also a 6-month reporting option running July 1 — December 31, 2013.

Other changes to the 2013 PQRS include a new definition of a group practice and expanding the use of the registry-based reporting option to group practices participating in the Group Practice Reporting Option (GPRO). For the 2013 PQRS a group practice is defined as a single Tax Identification Number (TIN) with 2 or more eligible professionals, as identified by their individual National Provider Identifier (NPI) who have reassigned their Medicare billing rights to the TIN. More information on reporting the PQRS under the Group Practice Reporting Option (GPRO) is available on the PQRS website.

The new proposed oncology measures group was finalized as proposed and will be available for reporting beginning in 2013. The measures group is reportable through registry based reporting only. The following reporting options are available for individual EPs wishing to report measures groups in 2013.

INDIVIDUAL ELIGIBLE PROVIDERS REPORTING MEASURES GROUPS IN 2013

Reporting Period Measure Type Reporting Mechanism Reporting Criteria
Jan , 2013 –
Dec 31, 2013
Measures
Groups
Claims Report at least 1 measures group, AND
Report each measures group for at least 20 Medicare Part B FFS patients. Measures groups containing a measure with a 0% performance rate will not be counted.
Jan , 2013 –
Dec 31, 2013
Measures
Groups
Registry Report at least 1 measures group, AND
Report each measures group for at least 20 patients, a majority (11) of which must be Medicare Part B FFS patients. Measures groups containing a measure with a 0% performance rate will not be counted.
Jul 1, 2013 –
Dec 31, 2013
Measures
Groups
Registry Report at least 1 measures group, AND
Report each measures group for at least 20 patients, a majority (11) of which must be Medicare Part B FFS patients. Measures groups containing a measure with a 0% performance rate will not be counted.

2013 ONCOLOGY MEASURES GROUP

PQRS # MEASURE
71 Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen Receptor/Progesterone
72 Colon Cancer: Chemotherapy for Stage III Colon Cancer Patients
110 Preventative Care and Screening: Influenza Immunization
130 Documentation of Current Medications in the Medical Record
143 Oncology: Pain Intensity Quantified
144 Oncology: Plan of Care for Pain
194 Oncology: Cancer Stage Documented
226 Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention

Figure 7 Source: Medicare Physician Fee Schedule Final Rule

Visit the CMS website at www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/PQRS/ for complete information on the Medicare PQRS program.

Electronic Prescribing
The most substantial and welcome change to the eRx program in 2013 is the expansion of the significant hardship exemptions. CMS finalized two new exemptions for the 2013 and 2014 eRx penalties for individual EPs and EPs in a group practice participating in the eRx GPRO.

The first new exemption is for EPs or groups of EPs who achieved meaningful use during certain reporting periods, to qualify for this exemption:

  • For the 2013 payment adjustment, an EP (or every EP in a group practice participating in the eRx GPRO for the 2013 payment adjustment) must have achieved meaningful use of Certified EHR Technology under the EHR Incentive Program for a continuous 90-day EHR reporting period that fell within the 12-month (January 1, 2011 — December 31, 2011) or 6-month (January 1, 2012 — June 30, 2012) payment adjustment reporting period or for an EHR reporting period that is the full CY 2012.
  • For the 2014 payment adjustment, an EP (or every EP in a group practice participating in the eRx GPRO) must achieve meaningful use of Certified EHR Technology under the EHR Incentive Program for a continuous 90-day EHR reporting period that falls within the 12-month (January 1, 2012 — December 31, 2012) or 6-month (January 1, 2013 — June 30, 2013) payment adjustment reporting period or for an EHR reporting period that is the full CY 2012.

The second new exemption is for EPs or groups of EPs who have not previously demonstrated meaningful use, but who intend to.

  • For the 2013 payment adjustment, this significant hardship exemption category would apply to EPs (or every EP in a group practice participating in the eRx GPRO) who demonstrate intent to participate in the EHR Incentive Program by registering for the program between January 2, 2012 and January 31, 2013 and adopt Certified EHR Technology.
  • For the 2014 payment adjustment, this significant hardship exemption category applies to EPs (or every EP in a group practice participating in the eRx GPRO) who demonstrate intent to participate in the EHR Incentive Program by registering for the program between January 1, 2013 and June 30, 2013 and adopting Certified EHR Technology.

CMS states that EPs or group practices will not need to request an exemption for these two new hardship exemptions, as CMS will use the information provided in the EHR Incentive Program’s Registration and Attestation page to determine eligibility.

Other updates to the eRx Incentive Program Include:

  • To successfully participate in the eRx program, individual EPs must submit e-prescribing measures for at least 25 unique electronic prescribing events in 2013.
  • Group practices wanting to participate in the eRx GPRO must self-nominate by January 31, 2013.
  • To be a successful electronic prescriber for the 2013 incentive, group practices comprised of 2—24 eligible professionals that are participating in the eRx GPRO must report the eRx measure at least 75 times during the applicable 12-month reporting period (January 1, 2013 — December 31, 2013) for the 2013 incentives.
  • To be a successful electronic prescriber for the 2014 payment adjustment, group practices comprised of 2–24 eligible professionals that are participating in the eRx GPRO must report the eRx measure at least 75 times during the applicable 2014 6-month payment adjustment reporting period.

The final rule also provides for implementation of an eRx informal review process as follows:
To request an informal review for the 2012 or 2013 eRx Incentives

  • Submit informal review request by email
  • Deadline to submit is 90 days following receipt of the applicable full-year eRx feedback reports

To request an informal review for the 2013 or 2014 eRx Payment Adjustments:

  • Submit informal review request by email
  • Deadline to submit:
    • February 28, 2013 for the 2013 eRx payment adjustment
    • February 28, 2014 for the 2014 eRx payment adjustment


Published by Rise Marie Cleland. Sponsored by Lilly Oncology

CONTACT US
Risë Marie Cleland Rise@Oplinc.com

Oplinc, Inc.
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360.695.1608 office
360.326.1733 fax
www.Oplinc.com
Rise@Oplinc.com

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ABOUT THE EDITOR
Risë Marie Cleland is the Founder and CEO of Oplinc, Inc., a national organization of oncology professionals. Through Oplinc, Inc., Ms. Cleland publishes the weekly Oplinc Fast Facts focusing on the timely dissemination of information pertaining to billing, reimbursement and practice management in the oncology office and Oplinc’s Best Practices Review, which provides a more in-depth look at the issues and challenges facing oncology practices. Ms. Cleland also works as a consultant and advisor for physician practices, pharmaceutical companies and distributors.

IMPORTANT NOTICES
Please note that this newsletter is presented for informational purposes only. It is not intended to provide coding, billing or legal advice. Regulations and policies concerning Medicare reimbursement are a rapidly changing area of the law. While we have made every effort to be current as of the issue date, the information may not be as current or comprehensive when you review it. Please consult with your legal counsel for any specific reimbursement information. For Medicare regulations visit: www.cms.gov.

CPT® is a Trademark of the American Medical Association Current Procedural Terminology (CPT) is copyright 2012 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein.

Copyright ©2013 Oplinc, Inc.

Oplinc, Inc., grants permission to distribute this newsletter without prior permission provided it is forwarded unedited and in its entirety.

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