The Centers for Medicare & Medicaid Services (CMS) launched the Physician Voluntary Reporting Program (PVRP) in 2006 to better analyze the quality of care provided to Medicare beneficiaries by using a set of codes established by Medicare. PVRP-specific G-codes and CPT® Category IIs were reported voluntarily by participating providers. In return, the providers received confidential feedback reports regarding their practice’s performance in 2006. For more information on this program read The PVRP Payment Maze in Oplinc’s Best Practices Review Volume 2 Issue.
The 2006 PVRP ended December 31, 2006. The PVRP will be replaced by the 2007 Physician Quality Reporting Initiative (PQRI), as mandated by the Tax Relief and Health Care Act of 2006.
Under the 2007 PQRI, participating providers (who meet reporting guidelines) may be paid a 1.5% bonus, subject to a CAP, on certain services reported during the reporting period of July 01, 2007 through December 31, 2007.
As of the date of this printing, details have yet to be released but at a January 26, 2007 meeting in Arlington, Virginia, Herb Kuhn, Deputy Administrator of CMS stated that drugs and labs will be excluded from the 1.5% bonus. Mr. Kuhn also stated that CMS had not yet determined if participation will be physician oriented or group oriented.
QualityNet, established by CMS, maintains a web site providing healthcare quality improvement news and resources for healthcare providers. QualityNet provides the confidential feedback reports to PVRP participating providers. According to the QualityNet website providers do not need to enroll to participate in the PQRI. Details about this program are to be published on the CMS website by February 15, 2007.
Watch this publication for more information on the 2007 PQRI as details become available.
Find The Latest Medicare Coding Edits on the CMS Website
The Centers for Medicare and Medicaid Services (CMS) developed and maintains the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to prevent improper coding that leads to inappropriate payment in Part B claims.
The Correct Coding Initiative (CCI) edits are updated and published quarterly. The new versions are effective each January 1, April 1, July 1 and October 1. The latest update is Version 13.0 effective January 01, 2007. In accordance with most payment policies, the effective date of the edits is based on the date of service. For more information on the CCI read The National Correct Coding Initiative in Oplinc’s Best Practices Review Volume 2 Issue 1.
In addition to the Column 1/Column 2 and Mutually Exclusive edit tables CMS publishes and posts the NCCI Policy Manual for Part B Medicare Carriers on their website. This manual provides policy narratives that help explain the edits. The NCCI Policy Manual is not updated as often as the edit tables, the most recent Policy Manual is Version 12.3 published in October 2006.
The current NCCI Policy Manual includes the following policy narrative of interest to oncologists on modifiers, drug administration, and lab services:
Chapter one includes a discussion of the correct use of modifiers -25 and -59. This is a timely reminder as the use of modifiers to bypass CCI edits is discussed in the Office of Inspector General (OIG) Spring 2006 Semiannual Report to Congress. For more information on this report read The OIG Report To Congress in Oplinc’s Best Practices Review Volume 2 Issue 4.
Modifier -59: Modifier -59 is an important NCCI-associated modifier that is often used incorrectly. For the NCCI its primary purpose is to indicate that two or more procedures are performed at different anatomic sites or different patient encounters. It should only be used if no other modifier more appropriately describes the relationships of the two or more procedure codes. The CPT Manual defines modifier -59 as follows:
Example: The column one/column two code edit with column one CPT code 38221 (bone marrow biopsy) and column two CPT code 38220 (bone marrow, aspiration only) includes two distinct procedures when performed at separate anatomic sites or separate patient encounters. In these circumstances, it would be acceptable to use modifier –59. However, if both 38221 and 38220 are performed through the same skin incision at the same patient encounter which is the usual practice, modifier –59 should NOT be used. Although 38221 and 38220 are different procedures, they are bundled when performed through the same skin incision at a single patient encounter. In this scenario bill 38221 for the biopsy and G0364 for the aspiration performed through the same incision.
Modifier -25: Modifier –25 is identified in the CPT Manual as a “significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service”. This modifier may be appended to an evaluation and management (E&M) code reported with another procedure on the same day of service. The NCCI includes edits bundling E&M codes into various procedures not covered by global surgery rules. If in addition to the procedure the physician performs a significant and separately identifiable E&M service beyond the usual pre-procedure, intra-procedure, and post-procedure physician work, the E&M may be reported with modifier –25 appended. The E&M and procedure(s) may be related to the same or different diagnoses.
Chapter 5 clarifies:
If a treating physician orders an automated complete blood count with automated differential WBC count (CPT code 85025) or without automated differential WBC count (CPT code 85027), the laboratory sometimes examines a blood smear in order to complete the ordered test based on laboratory selected criteria flagging the results for additional verification. The laboratory should NOT report CPT code 85007 (microscopic blood smear examination with manual WBC differential count) or CPT code 85008 (microscopic blood smear examination without manual WBC differential count) for the examination of a blood smear to complete the ordered automated hemogram test (CPT codes 85025 or 85027). The same principle applies if the treating physician orders any type of blood count and the laboratory’s practice is to perform an automated complete blood count with or without automated differential WBC count.
If a treating physician orders an automated hemogram (CPT code 85027) and a manual differential WBC count (CPT code 85007), both codes may be reported. However, a provider may not report an automated hemogram with automated differential WBC count (CPT code 85025) with a manual differential WBC count (CPT code 85007) because this combination of codes results in duplicate payment for the differential WBC count. CMS does not pay twice for the same laboratory test result even if performed by two different methods unless the two methods are medically reasonable and necessary.
An example of additional separately payable laboratory tests includes tests that when positive require additional separate follow-up testing which is implicit in the physician’s order. For example, if a urine culture is positive, the laboratory then tests to identify the organism which is separately reportable. In this case the initial positive result has limited clinical value without the additional testing. The additional testing is separately reportable because it is not performed to complete the ordered test. Furthermore, the ordered test if positive requires the additional testing in order to have clinical value.
Many of the coding rules for drug administration services including chemotherapy are listed in this chapter. The following clarifications are included:
CPT codes 90760, 90765, 90774, 96409, & 96413 represent “initial” service codes. Only 1 “initial” service code may be reported unless it is medically reasonable and necessary that the drug or substance administrations occur at separate vascular access sites. To report two different “initial” service codes use NCCI-associated modifiers.
When performing IV and/or intra-arterial infusions and injections the following are routinely necessary and therefore not separately reportable:
However, insertion of central venous access and selective arterial catheterizations are not routinely necessary to perform infusions/injections, therefore these services may be reported separately.
If the sole purpose of fluid administration (e.g., saline, D5W, etc.) is to maintain patency of an access device, the infusion is neither diagnostic nor therapeutic and should not be reported separately. Similarly, the fluid utilized to administer drug(s)/substance(s) is incidental hydration and should not be reported separately.
Transfusion of blood or blood products includes the insertion of a peripheral intravenous line (e.g., CPT codes 36000, 36410) which is not separately reportable. Administration of fluid during a transfusion or between units of blood products to maintain intravenous line patency is incidental hydration and is not separately reportable.
If therapeutic fluid administration is medically necessary (e.g., correction of dehydration, prevention of nephrotoxicity) before or after transfusion or chemotherapy, it may be reported separately.
CPT code 96522 describes the refilling and maintenance of an implantable pump or reservoir for systemic drug delivery. The pump or reservoir must be capable of programmed release of a drug at a prescribed rate. Do not report this code for:
CPT code 96522 and CPT code 96521 (refilling and maintenance of portable pump) should not be reported with CPT code 96416 (initiation of prolonged intra-venous chemotherapy infusion (more than eight hours, requiring use of a portable or implantable pump) or CPT code 96425 (chemotherapy administration, intra-arterial; infusion technique, initiation of prolonged infusion (more than eight hours requiring the use of a portable or implantable pump). CPT codes 96416 and 96425 include the initial filling and maintenance of a portable or implantable pump. CPT codes 96521 and 96522 are used to report subsequent refilling and maintenance of the pump.
A concurrent intravenous infusion of an antiemetic or other non-chemotherapeutic drug with intravenous infusion of chemotherapeutic agents may be reported separately as CPT code 90768 (concurrent intravenous infusion). CPT code 90768 may be reported with a maximum of one unit of service per patient encounter regardless of the number of concurrently infused drugs or the length of time for the concurrent infusion(s).
Prior to January 1, 2005, the NCCI edits with column one CPT codes 96408 (Intravenous chemotherapy administration by push technique) and 96410 (Intravenous chemotherapy administration by infusion technique, up to one hour) each with column two CPT code 90780 (Therapeutic or diagnostic intravenous infusion up to one hour) were often bypassed by utilizing modifier -59. Use of modifier -59 with the column two CPT code 90780 of these NCCI edits was only appropriate if the 90780 procedure was for hydration, antiemetic, or other non-chemotherapy drug administered before, after, or at different patient encounters than the chemotherapy. Modifier -59 should not have been used for “keep open” infusion for the chemotherapy.
Medicare Premiums Tied to Income
Each year CMS updates the Medicare premiums, deductibles and co-payments using a formula set by statute. The law requires that the standard monthly premium, paid by Medicare beneficiaries, for Medicare Part B must cover 25% of Medicare’s costs, including the costs of maintaining a reserve against unexpected spending increases. The federal government pays the remaining 75%.
The standard Medicare Part B monthly premium is $93.50 in 2007. This is an increase of 5.6% or $5.00 over the 2006 rate.
The Medicare Modernization Act of 2003 (MMA) requires that beginning in 2007 higher income beneficiaries (single beneficiaries with annual incomes over $80,000 and married couples with incomes over $160,000) be responsible for a higher percentage of the coverage cost of Medicare Part B, reducing the cost to the federal government. The increase in coverage costs to the higher income beneficiaries will be transitioned in over a three-year period.
By the end of the transitional period higher income beneficiaries will pay a monthly premium equal to 35, 50, 65 or 80 percent of the total cost depending on their income level. The Congressional Budget Office has estimated that this surcharge will raise $15 billion from 2007 to 2013.
2007 Medicare Part B Premium Rates
The 2007 Part B monthly premium rates to be paid by beneficiaries who file an individual tax return (including those who are single, head of household, qualifying widow(er) with dependent child, or married filing separately who lived apart from their spouse for the entire taxable year), or joint tax return are:
*Standard Medicare Part B monthly premium
In addition, the monthly premium rates to be paid by beneficiaries who are married, but file a separate return from their spouse and lived with their spouse at some time during the taxable year are:
(CMS, 2007) www.cms.hhs.gov/apps/media/press/release.asp
CONTRACTING WITH AN INDEPENDENT NURSE FOR FLUCTUATING STAFFING NEEDS
By Sheila Schluterbusch, RN and Stephanie Hartung, RN
Everyone knows that there is a nursing shortage, and that finding a nurse with specialized skills to hire for your practice can be a difficult task. For example, one oncology practice we’ve worked with hasn’t had an experienced chemotherapy nurse apply for an open position in response to their ads in the past two years. Nursing agencies can help with staffing needs, but another resource shouldn’t be overlooked: independent contract nurses. Their numbers are increasing, and they offer some distinct advantages.
These nurses often cost less to hire, since the medical practice works directly with the nurse, eliminating agency fees. Utilizing a contract nurse will enable you to establish a rapport with one nurse, and then build a relationship, so that consistency is established, as opposed to having to accept whomever an agency sends.
Contract length can be more flexible, and the contract can include language that states the nurse will work on an as-needed basis agreeable to both parties, or fix the length to a specific number of weeks; whereas a traveling nurse agency may require a minimum time commitment in order to cover their expense of moving the nurse from another, distant location. This flexibility would enable your business to cover intermittent busy periods, vacations, maternity leave and other unexpected nurse shortages.
Some practices bring in an independent contractor to orient a new nurse to the infusion area, providing hands-on training in mixing and administering chemotherapy. By doing so, the regular staff will not be overburdened with providing patient care as well as training the new nurse. The reverse of this scenario could apply as well – utilize an independent contract nurse to work for a week or two so that the preceptor on staff can devote 100 percent of their time getting the new nurse well trained.
Once you’ve found the contractor, what should the contract look like? It needn’t be a 14-page single-spaced document that many agencies require of their registrants. While we are not attorneys and don’t pretend to know all about contract law, we use a very short, simple format that suits ours and our clients’ needs well.
First, the parties are named, with addresses and phone numbers listed, and the phrases “heretofore known as ‘nurse’” and “heretofore known as ‘facility’” added after the appropriate name. The purpose of the contract should be stated, for example:
“ For the purpose of Ms. X providing the above-named facility with temporary nursing staffing on an individual basis, as requested by the facility, and as agreed upon regarding date, shift times, and nursing role.”
Next come terms and conditions, with each item listed such as:
“Each party voluntarily binds themselves to the following terms and conditions:”
Some other agreements that help ensure quality care of your patients by the contractor:
The nurse agrees to become familiar with the facility’s policies and procedures related to infection control, safety, quality assurance, patient care and ancillary department procedures in order to safely and prudently carry out the duties she has agreed to perform.
The nurse agrees to abide by the rules and policies of the facility while performing duties there.
The nurse agrees to consult with regular staff and supervisors as needed to assure a high standard in delivery of care to patients and to assure continuity of care between providers.
The next two have to do with malpractice insurance, credentials, and licensures:
The nurse will carry her own malpractice insurance above and beyond whatever insurance the facility carries for those performing services in the facility.
The nurse will maintain and keep current the credentials and licensures required to practice nursing in the state in which working, and will be prepared to produce evidence of her or his Registered Nurse License for the state of practice, Oncology Nursing Certification, and / or Cancer Chemotherapy Provider Certification when reporting to the facility for work. If your facility requires Basic Life Support, ACLS, TB testing documentation, etc., you can add those here.
Lastly, provision must be made for ending the contract, or renewing it if necessary:
Termination of Agreement: Either party, facility or nurse, may terminate this agreement at any time without cause or prejudice by a simple verbal notification to the other party. The contract may be reinstated should the facility find an ongoing need for coverage and the nurse agrees to continue her services. A simple notation of cancellation date and /or renewal date will be noted on the contract as necessary. Then add spaces for date and signatures.
Some additional tasks you may want to use a contract nurse for in an Oncology practice are:
In working as traveling independent contract nurses for quite a few years, one of the things we expected to encounter was potential resentment from the regular staff that the contractor was making more in terms of hourly wages than the staffed nurses. The staff can usually be apprised that extra wages may be paid to a contractor in lieu of any benefits. It has been our experience that the staff is very receptive to the idea that they will directly benefit by having the extra set of hands, for whatever term the contractor will be there. The staff in each facility has generally been very thankful for the help and we have not had a negative response from any nursing colleague that we have worked with.
In summary, using a temporary independent contract nurse can benefit everyone – the facility gets expert help in a cost effective manner, tailored to specific needs; the staff is assured of having time off as needed without creating a burden to others the contractor gains additional insight and knowledge about practices, and most of all, the patient undergoing treatment benefits by having adequate nursing coverage, and care provided to them by nurses that are skilled, trained, professional and happy.
In today’s complex health care environment, it may be time for your facility to look at a contract nurse to meet current needs and with which to build a relationship for the future.
Contact the authors:
Stephanie Hartung, RN
Sheila Schluterbusch, RN, OCN
Before You Contract With a Travel Nurse
First and foremost, have your healthcare attorney review any contract prior to signing it. At a minimum your attorney should verify:
Prior to contracting with an individual thoroughly prescreen the individual through interviews, reference checks, verifying education, certifications and licenses.
Most states have a free online State Board of Nursing License Verification page with a searchable database through which you can verify state licensing status. The National Council of State Boards of Nursing (NCSBN) has contact information for most State Boards of Nursing on their website as well as an online national database that you can access for a fee.
Prior to contracting with an agency or individual verify that they have not been excluded from Federal programs by searching the online OIG List of Excluded Individuals. Providers and entities that hire or contract with excluded individuals/entities to provide items or services to Federal program beneficiaries may be subject to a civil monetary penalty (CMP) of up to $10,000 for each service or item furnished by the excluded entity and an additional penalty of up to three times the amount claimed as well as possible exclusion themselves. For more information on the Federal Exclusion Program read the article Compliance Programs: Preventative Medicine for Practices in Oplinc’s Best Practices Review Volume 2 Issue 4.
For the first time in three years oncology practices will not have to deal with massive changes in coding rules and regulations for cancer services. This should mean that claims will be processed by Medicare and private payers without the glitches of past years.
However, there are several factors that could cause improper payments or denials:
If a service or drug that was paid in the past is suddenly being denied the first thing to do is to determine if the denial was an error and if so whether the error was a one-time event or a systems error that will result in continued or widespread payment errors.
Run a report to determine the extent of claims affected. Ask your carrier if they will be performing a mass adjustment to correct the error or if you need to re-file or appeal the claims. Either way you will need to monitor the process to ensure that your claims will be properly corrected and paid.
A recent and on-going problem occurred when a Medicare carrier loaded the wrong diagnoses for two expensive and widely used oncology drugs resulting in incorrect denials. The carrier determined the problem to be wide-spread and thus instructed practices not to go through the appeals process but instead to wait for a mass-adjustment.
However, for reasons yet to be determined the mass-adjustment failed to identify and correct most of the denials. After nearly a year the vast majority of these claims have yet to be corrected and the carrier is waiting for approval to begin a second mass-adjustment. In the meantime practices are concerned that the deadline for appealing the claims is approaching.
If the claims processing error is a systems error notify your state medical oncology society and ask them to speak with the Carrier Medical Director. Keep the society up-to-date on the status of your claims so they can continue to advocate on your behalf for a prompt resolution.
AMA Drug Administration Description Changes in 2007
The American Medical Association (AMA) made a few minor changes and clarifications in the 2007 CPT® code descriptions:
The following codes have been revised to remove the reporting limitations for infusions lasting more than eight hours:
Q. Where do we stand with the Oncology Demonstration Project, should we continue to bill for this?
A. No payment shall be made for the oncology demonstration project codes for dates of service after December 31, 2006:
Q. When are we to use the new Modifier –M2?
A. CMS says that modifier M2 is to be used when a participating CAP physician procures a CAP drug from a source other than the CAP vendor because of a mistake in identifying the patient’s primary insurer. Under these unusual circumstances, modifier M2 is to be used to receive payment for the drug at the non-CAP rate.
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