Prescription For Leadership During Uncertain Times

The world is uncertain. One of the few things we can count on is that at various times throughout our lives circumstances will converge to bring us face-to-face with that reality. Whether those circumstances impact a society as a whole or a single individual, our responses are always individually chosen.

Today, while we are looking to our national leaders for cues about what to expect and how we should respond, others are looking to us – as community, business, and family role models for messages of hope and guidance.

Fortunately, best practices for leadership during good times are also those that are most critical during times of stress and uncertainty. Anticipating the symptoms of stress, focusing on the overall health of our organizational systems, and continuing to move forward in pursuit of our shared vision and goal, will go a long way toward ensuring that our colleagues and our practice will survive and thrive during tough times.

In our individual roles as doctors, practice administrators, nurses, business partners, community leaders and family members – we each have the opportunity to demonstrate our leadership by modeling collaborative and supportive behaviors.

Symptoms of Personal Stress
Unofficial lines of communication that exist during normal periods seem to become even more efficient at spreading misinformation throughout an organization during times of stress, resulting in panic and confusion among the staff. As uncertainty about the future builds, so do feelings of anxiety and a sense of loss of control. The line that separates our personal life from our professional life is revealed to be a myth.

In the absence of clear communication, people tend to become highly suggestible as they grasp for answers, solutions and someone to blame for the situation. In even the most amiable of groups, a sense of panic might result in coworkers becoming victims of “friendly fire.” Effective leaders will be prepared to prevent or defuse such exchanges by acknowledging the emotions that accompany stress and ambiguity.

Communication and Diagnosis
Groups who have already established norms and protocols for communication and information sharing will find these structures to be highly valuable during difficult times. Communicating with colleagues sooner, rather than later, about the impact of a negative situation on the organization will help to maintain a sense of calm. Strive for clear and honest communication about what is known, what is not yet known, and what outcomes can reasonably be expected.

If your practice has a mission statement that includes a commitment to respectful and compassionate communication, now is a good time to discuss how times of stress increase the challenge and importance of this goal. If individuals within your organization have been personally, negatively impacted by the situation – such as those at risk of lost employment, reduced hours or wages, or an increase in job duties – share your genuine concern while remaining positive. This is neither the time to practice emotional “detachment” nor to allow oneself to become caught up in negativity.

How do you practice emotional leadership? Remember your bedside manner. Consider ways of providing structured opportunities for members of the group to share their feelings about what is happening, and to listen to one another with empathy. If the situation is going to create changes in how individuals interact with one another, with patients, or the public, there will be a need for specific guidelines. When personal sacrifice is necessary for the good of the organization, those in roles of positional authority should model the way. One need only recall CEOs arriving in Lear jets to ask for a bailout, to understand the impact of symbolic gestures. Wise leaders demonstrate what is expected of others, especially in tough times.

Prognosis and Optimism
If your practice has an established vision or mission statement with articulated goals, your group has the perfect focal point for maintaining motivation and for inspiring an optimistic attitude. Continue to consistently convey the vision and look for occasions to confirm shared values and reinforce the importance of each team member in achieving the vision.

During uncertain times, we each need more than ever to feel that our actions make a difference. Engage your colleagues in identifying ways that they can improve the situation for themselves, the organization and others. Involvement in outreach efforts shifts the focus and promotes a sense of efficacy.

Maintaining Healthy Habits
All of the best practices for leaders take on added value and importance during challenging times. Leaders who maintain visibility and accessibility are better able to build and maintain healthy working relationships with their employees. Colleagues who use humor appropriately and in a way that focuses on the positive help to de-stress the environment. Recognizing one another’s small victories helps to keep the group focused on the task at hand and goes a long way toward maintaining good morale.

Additionally, leaders need to encourage colleagues to care for their own health and well-being. It is common during times of stress to exhibit irritability, anger, fatigue and sleeplessness. This can frequently lead to reaching for comfort through overeating or indulging in unhealthy foods along with a lack of desire to exercise. If there are resources or services available that can be provided, now is a good time to be reminded of these potential sources of support.

Finally, don’t forget to care for yourself. Remember the scene in Superman when he catches Lois midair saying “I’ve got you!”? She responds by saying “You’ve got me, who’s got you?” Leaders and superheroes need to have their own support systems.

An Ounce of Prevention
The time for attending to good leadership practice is always now. By finding ways to build healthy working relationships, develop shared vision and goals, and continuously contributing to the capacity of your organization - you are increasing the odds that your practice and your colleagues will continue to thrive during both gentle and challenging times.

Pamela Comfort, Ed.D. is a leader of professional and organizational learning, specializing in group facilitation and collaborative decision-making, interest-based problem solving and negotiations, and organizational planning. She can be contacted at pam@pamelacomfort.com


On January 1, 2007 CMS implemented the Medically Unlikely Edits (MUEs), (originally named Medically Unbelievable Edits), for HCPCS/CPT codes. According to CMS the MUEs were developed to reduce the paid claims error rate due to clerical entry mistakes or incorrect coding for Part B claims.

The MUE for a HCPCS/CPT code is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service.  Not every HCPCS/CPT codes will have an MUE.

The MUEs are updated quarterly and published on the National Correct Coding Initiative (CCI) Web page along with the Column One/Column Two Correct Coding Edits table and the Mutually Exclusive Edits CCI files at www.cms.hhs.gov/NationalCorrectCodInitEd.

Both the CCI edits and the MUEs are prepayment claim review programs. However, the MUEs differ from CCI edits in that CCI edits examine claims for certain code pairings while MUEs look at an individual code and the number of times it is billed on one date of service.

Unlike the Column One/Column Two and Mutually Exclusive Edits CMS does not publish all of the MUE values on its Website. In fact, only after receiving considerable pressure from the American Medical Association (AMA) and other physician groups did CMS agree to publish any of the MUEs.

CMS says that while the majority of the MUEs are published certain MUE values, designed to detect and deter questionable payments, rather than billing errors, are confidential and will not be published. According to CMS publishing those MUEs would diminish their effectiveness.

CMS claims processing contractors adjudicate MUEs against each line of a claim rather than the entire claim. Therefore, reporting the same code on separate lines of a claim using the appropriate modifier will enable a provider to report medically reasonable and necessary units of service in excess of an MUE.

CMS reports that they develop MUEs based on anatomical considerations, HCPCS/CPT code descriptors, CPT coding instructions, established CMS policies, nature of service/procedure, nature of an analyte, nature of equipment and clinical judgment. Additionally, national healthcare organizations have the opportunity to review and comment on proposed edits prior to implementation of the new MUEs.

Providers and other interested parties may also request modifications to established MUE values by writing to the Correct Coding Solutions, LLC and including the rationale and supporting documentation for the requested change. Address the request for a change to:

National Correct Coding Initiative
Correct Coding Solutions, LLC
P.O. Box 907
Carmel, IN 46082-0907
Fax 317-571-1745

For concerns about the MUE program other than MUE values for specific codes, contact Valeria Allen (valeria.allen@cms.hhs.gov). CMS reminds providers that inquiries about a specific claim should be addressed to your claims processing contractor.

Drug Administration MUEs

The following table lists the drug administration MUEs from the CMS January 1, 2009 Practitioner/DME Supplier MUE Table effective January 01-March 31, 2009. The majority of the drug administration MUEs are within the usual limit of units reported for the service during a patient encounter. However, the MUE value for CPT code 96372 SQ/IM injection therapeutic/diagnostic is set at 2 and there are occasions when more than 2 medically reasonable and necessary SQ/IM therapeutic/diagnostic injections are performed in a patient encounter.

According to CMS’ instructions when billing for more than 2 units of 96372 it will be necessary to report the additional units on separate line items with the appropriate modifier.

Code Description Maximum Units of Service
96360 IV infusion, hydration, initial, 31 minutes to 1 hr. 2
96368 Concurrent infusion, therapeutic/diagnostic 2
96369 Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); initial, up to 1 hour, including pump set-up and establishment of subcutaneous infusion site(s) 1
96371 Subcutaneous infusion for therapy or prophylaxis (specify substance or drug); additional pump set-up with establishment of new subcutaneous infusion site(s) (List separately in addition to code for primary procedure) 1
96372 SQ/IM inj. therapeutic/diagnostic 2
96373 Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); intra-arterial 2
96374 IV push, single or initial therapeutic/diagnostic 2
96402 SQ/IM inj. hormonal, antineoplastic 2
96405 Chemotherapy administration; intralesional, up to and including 7 lesions 1
96406 Chemotherapy administration; intralesional, more than 7 lesions 1
96409 IV push, single or initial, chemotherapy 2
96413 Chemo IV infusion; up to 1 hr. single or initial 2
96416 Initiation of prolonged chemo infusion (more than 8 hrs.) requiring use of pump 1
96420 Chemotherapy administration, intra-arterial; push technique 2
96422 Chemotherapy administration, intra-arterial; infusion technique, up to 1 hour 2
96425 Chemotherapy administration, intra-arterial; infusion technique, initiation of prolonged infusion (more than 8 hours), requiring the use of a portable or implantable pump 1
96440 Chemotherapy administration into pleural cavity, requiring and including thoracentesis 1
96445 Chemotherapy administration into peritoneal cavity, requiring and including peritoneocentesis 1
96450 Chemotherapy administration, into CNS (eg, intrathecal), requiring and including spinal puncture 1
96521 Refilling and maintenance of portable pump 2
96522 Refilling and maintenance of implantable pump or reservoir for drug delivery, systemic (eg, intravenous, intra-arterial) 1
96523 Irrigation of implanted venous access device for drug delivery systems 1
96542 Chemotherapy injection, subarachnoid or intraventricular via subcutaneous reservoir, single or multiple agents 1


The following CMS MUE FAQs are posted on the CMS Web:

Q. What is the CMS Medically Unlikely Edit (MUE) program?

A. MUEs are designed to reduce errors due to clerical entries and incorrect coding based on anatomic considerations, HCPCS/CPT code descriptors, CPT coding instructions, established CMS policies, nature of a service/procedure, nature of an analyte, nature of equipment, and unlikely clinical treatment.

Q. How do I report medically reasonable and necessary units of service in excess of a Medically Unlikely Edit (MUE) value?

A. Since each line of a claim is adjudicated separately against the MUE value for the code on that line, the appropriate use of Current Procedural Terminology (CPT) modifiers to report the same code on separate lines of a claim will enable a provider/supplier to report medically reasonable and necessary units of service in excess of an MUE value. CPT modifiers such as -76 (repeat procedure by same physician), -77 (repeat procedure by another physician), anatomic modifiers (e.g., RT, LT, F1, F2), -91 (repeat clinical diagnostic laboratory test), and -59 (distinct procedural service) will accomplish this purpose. Modifier -59 should be utilized only if no other modifier describes the service.

Q. Will CMS implement Medically Unlikely Edits (MUEs) for additional Healthcare Common Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes?

A. CMS began implementation of MUEs for HCPCS/CPT codes on January 1, 2007. There are quarterly updates to the MUE files which include MUEs for additional codes. Although most HCPCS/CPT codes will have MUEs, some groups of codes have been temporarily excluded for future consideration

MUE Resources

CMS Announces Final MAC Awards

As part of the Medicare Contracting Reform mandated in section 911 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) CMS replaced 43 Medicare Part A and Part B Contractors with fifteen A/B Medicare Administrative Contactors (MACs) who will process and pay both Part A and Part B claims.

The new MACs are awarded the A/B MAC contract in a competitive bidding process.

On Wednesday, January 07, 2009, CMS announced the final 5 Medicare Administrative Contractor (MAC) awards:

  • Noridian Administrative Services, LLC (NAS) has been awarded a contract for the combined administration of Part A/Part B Medicare claims payment in Jurisdiction 6 comprised of Illinois, Minnesota and Wisconsin.
  • National Government Services, Inc (NGS) has been awarded a contract for the combined administration of Part A/Part B Medicare claims payment in Jurisdiction 8 comprised of Indiana and Michigan. 
  • Cahaba Government Benefit Administrators, LLC (Cahaba GBA) has been awarded a contract for the combined administration of Part A/Part B Medicare claims payment in Jurisdiction 10 comprised of Alabama, Georgia and Tennessee.
  • Palmetto Government Benefits Administrator, LLC (Palmetto GBA) has been awarded a contract for the combined administration of Part A/Part B Medicare claims payment in Jurisdiction 11 comprised of North Carolina, South Carolina, Virginia and West Virginia.
  • Highmark Medicare Services, Inc (HMS) has been awarded a contract for the combined administration of Part A/Part B Medicare claims payment in Jurisdiction 15 comprised of Kentucky and Ohio. 

With the announcement of these final 5 MAC awards CMS has completed the transition from separate Part A and Part B contractors to the combined Part A/B MACs as required by section 911 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA).

However, as of January 07, 2009 two of the MACs (Jurisdiction 2 & 7) remain in question as protests filed by losing bidders have resulted in CMS undertaking either corrective action or a rebid. It remains to be seen whether there will be any protests or appeals filed pursuant to the final five MAC awards.

A total of 19 MAC contracts have been awarded; fifteen A/B MACs and four Durable Medical Equipment (DME) contracts.


Jurisdiction Company States
1 Palmetto GBA American Samoa, Guam, Northern Mariana Islands, CA, HI, NV
2 National Heritage Insurance Corp (NHIC) AK, ID, OR, WA
3 Noridian Administrative Services (NAS) AZ, MT, ND, SD, UT, WY
4 Trailblazer Health Services CO, NM, OK, TX
5 Wisconsin Physician Services (WPS) IA, KS, MO, NE
6 Noridian Administrative Services (NAS) IL, MN, WI
7 Pinnacle Business Solutions AR, LA, MS
8 National Government Services (NAS) IN, MI
9 First Coast Service Options FL, Puerto Rico, Virgin Islands
10 Cahaba GBA AL, GA, TN
11 Palmetto GBA NC, SC, VA, WV
12 Highmark Government Services (HGS) DE, DC, MD, NJ, PA
13 National Government Services (NGS) CT, NY
14 National Heritage Insurance Corp (NHIC) ME, MA, NH, RI, VT
15 Highmark Government Services (HGS) KY, OH


Jurisdiction Company States
A National Heritage Insurance Company (NHIC) CT, DE, DC, ME, MD, MA, NH, NJ, NY, PA, RI, VT 
B AdminaStar Federal Inc. (AdminaStar) IL, IN, KY, MI, MN, OH, WI
C CIGNA Government Services, LLC (CGS) AL, AK, CO, FL, GA, LA, MS, NM, NC, OK, PR, SC, TN, TX, U.S. Virgin Islands, Virginia, WV
D Noridian Administrative Services (NAS) AK, American Samoa, AZ, CA, Guam, HI, ID, IA, KS, MO, MT, NE, NV, ND, Northern Mariana Islands, OR, SD, UT, WA, WY 

Deadline Extended for Adoption of New Diagnosis Code Set

Deadline Extended for Adoption of New Diagnosis Code Set

On January 15, 2009 the U.S. Department of Health and Human Services (HHS) announced the release of two final rules:

  1. HIPAA Administrative Simplification: Modifications to Medical Data Code Set Standards To Adopt ICD–10–CM and ICD–10–PCS
    The ICD-10 final rule adopts the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) for diagnosis coding, and the International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD-10-PCS) for inpatient hospital procedure coding
  2. Health Insurance Reform; Modifications to the Health Insurance Portability and Accountability Act (HIPAA);
    The final rule adopts Version 5010, for certain electronic health care transactions, an updated version of the National Council for Prescription Drug Programs (NCPDP) standard, Version D.0, for electronic pharmacy-related transactions, and a standard for Medicaid pharmacy subrogation transactions. 

In a Jan. 15 press release, Kerry Weems, acting administrator of CMS said that the more than 3,000 comments received on the ICD-10 proposed rule shows that there is strong support for transition to the ICD-10-CM and ICD-10-PCS code sets.

Weems also announced the extension of the implementation dates for both ICD-10 and Version 5010 acknowledging the request by a number of commenters for a delay in the compliance dates for both ICD-10 and Version 5010 citing implementation costs, the need to train health care personnel, and to assure ample time for testing between trading partners. 

As a result of the extension, the implementation deadline for the International Classification of Diseases, 10th Revision, Clinical Modification, or ICD-10-CM, for outpatient diagnosis coding, has been extended to October 1, 2013.

In the January 15, 2009 Fact Sheet HHS outlines the following rationale for adopting ICD-10:

CD-9-CM is the current code sets standard adopted by the Secretary of HHS under HIPAA.  ICD-9 is used by all covered entities to report diagnoses and inpatient hospital procedures on health care transactions for which HHS has adopted a standard.  Shortcomings of ICD-9 include:

  • ICD-9 is outdated, with only a limited ability to accommodate new procedures and diagnoses;
  • ICD-9 lacks the precision needed for a number of emerging uses such as pay-for-performance and biosurveillance.  Biosurveillance is the automated monitoring of information sources that may help in detecting an emerging epidemic, whether naturally occurring or as the result of bioterrorism;
  • ICD-9 limits the precision of diagnosis-related groups (DRGs) as a result of very different procedures being grouped together in one code;
  • ICD-9 lacks specificity and detail, uses terminology inconsistently, cannot capture new technology, and lacks codes for preventive services; and
  • ICD-9 will eventually run out of space, particularly for procedure codes.  

Adoption of the ICD-10 code sets is expected to:

  • Support value-based purchasing and Medicare’s anti-fraud and abuse activities by accurately defining services and providing specific diagnosis and treatment information;
  • Support comprehensive reporting of quality data;
  • Ensure more accurate payments for new procedures, fewer rejected claims, improved disease management, and harmonization of disease monitoring and reporting worldwide; and
  • Allow the United States to compare its data with international data to track the incidence and spread of disease and treatment outcomes because the United States is one of the few developed countries not using ICD-10.  



ASCO Launches New EHR Social Network Site

ASCO Launches New EHR Social Network Site

The American Society of Clinical Oncology (ASCO) recently launched OncologyEHR  a new electronic health record (EHR) social networking site. The networking site was developed by ASCO's Electronic Health Records (EHR) Workgroup and features discussions of issues related to EHRs and ePrescribing.

OncologyEHR provides a forum through which oncologists and their practice staff can connect, collaborate, and find information on EHRs and health information technology. The social network is open to ASCO members, non-member physicians, practice staff, and vendors.

Participants can view and join discussion forums, start blogs, and engage in EHR vendor user groups.  Current discussion forum issues include ePrescribing questions and answers, adoption of EMRs and the pros and cons of EMRs. 

The site also includes a link to ASCO’s 2008 EHR Vendor Directory which lists 20 EHR products and their answers to the following questions:

  • Company
  • Product Name
  • Location
  • Ownership (Public/Private)
  • Number of Employees
  • Host (ASP/Client Server)
  • Typical Customer
  • Number of Current Physician Users (MD/DO)
  • Specialties
  • PM/EHR (Interfaced or Integrated)
  • What is considered a licensed user?
  • Price per Licensed User
  • Interface Fees (Lab, Rx, Imaging)
  • Annual Fee
  • Implementation Fees (Range)
  • Data Backup
  • Length of Contract
  • Cancellation Policy
  • Implementation Timeline (from contract signing to go-live, including any backlog)
  • Website Address
  • Contact Information

Are you currently in the market for an EHR? If so, you might consider purchasing ASCO’s publication,  The Oncology EHR Field Guide: Selecting and Implementing an EHR. According to ASCO this is the only comprehensive oncology-specific handbook developed to equip practitioners with the information and resources needed to select and implement current and future oncology-specific EHRs for clinical practice and management as well as quality-of-care measurement and improvement.

The guide addresses core functionalities desired in an oncology-specific EHR and includes the following topics:

  • The Core Functions of an Oncology EHR
  • Identifying the EHR Team and Beginning the Planning Process
  • Building the Budget
  • Making the EHR Selection
  • Implementing the EHR
  • Making the EHR Work for You
  • Using the EHR to Support Quality of Care and Patient Safety
  • Post-Implementation Ongoing Management


Published by Rise Marie Cleland. Sponsored by Genentech and hsi

Economic Crisis In Cancer Care


National Analysts Worldwide (NA) surveyed 199 practicing oncologists from the Epocrates panel about the current state and future outlook of their profession, including implications for patient care. The results of this survey entitled "Oncologists Look at Oncology: The Prognosis of US Cancer Care" was published on October 28, 2008.

NA reports that the study demonstrates that shrinking insurance reimbursement and rising costs are affecting the practice of oncology. According to NA survey participants estimate that discussions of therapy options with patients are shaped by finances 40% of the time, and they expect that figure will increase to 50% over the next five years.

Susan Schwartz McDonald, Ph.D., President and CEO of National Analysts Worldwide states, "While most oncologists are optimistic about medical advances in their field, many report mounting apprehensions about the way that financial considerations may influence quality of care and individual access to therapy innovation.” Dr. McDonald goes on to say that oncologists report their presentation of therapy options is increasingly influenced by the patient’s ability to pay.

According to the NA study physician discussions about therapy options are influenced by cost:

  • 52% of the time for patients who are uninsured
  • 44% of the time for patients with Medicare only and
  • 35% for patients with private insurance

Moving forward, of the 199 oncologists participating in the NA study 28% predict that they will refuse Medicare-only patients in the next few years, and 35% expect to refuse uninsured patients.

However, the fact that 57% of the oncologists surveyed reported that high out-of-pocket costs have led them to be more explicit about likely treatment outcomes so patients can fully weigh the return on their investment may be seen as a positive. According to Debra Kossman, Ph.D., Senior Vice President, National Analysts Worldwide, "This shift to a more consumer-driven model is an important step toward patient empowerment."

In fact many private payers are implementing consumer directed healthcare initiatives by providing patients with information including likely treatment outcomes and requiring patients to assume more financial responsibility for their own cancer care.

Over half of the survey respondents (53%) believe treatment costs are prompting patients to consider financial well-being over their chances to live longer and nearly half (47%) believe that high out-of-pocket costs are resulting in patients placing more emphasis on quality of life than on duration.

The NA study also looked at whether financial concerns are affecting site of service for cancer patients. According to reporting private practice oncologists financial concerns are directly influencing where patients receive their care and how far they must travel to receive it.

Seventy-three percent (73%) of the private practice oncologists participating in the study report they are sending more of their patients to hospital centers for costly IV therapies due to inadequate insurance reimbursement, a trend that the majority of reporting oncologists view as undesirable.

Furthermore, additional administrative burdens such as increased pre-authorization requirements are resulting in a reduction of time spent with patients and an overall decrease in the oncologists' level of personal satisfaction with the work they do. In the NA study three in ten oncologists found oncology less personally rewarding than expected, and half of the survey participants described oncology as less financially rewarding than expected.

According to McDonald "The study shows that finances are playing a prominent role in the current and future state of cancer care." Furthermore, she says that while our cultural value has been one that suggests no price is too high to pay for life extension, particularly in cancer treatment, this equation seems to be changing. McDonald states, “In the war against cancer, we are now waging battle not just on medical fronts, but on financial fronts as well."

The NA study finds that if unaddressed oncologists' financial and administrative concerns will likely negatively impact the profession.

Source: National Analysts World www.nationalanalysts.com.


PRIT Addresses Providers Question on e-Prescribing Bonus and MA patients

The Physicians Regulatory Issues Team (PRIT) was created by CMS in 1998 in an effort to simplify Medicare requirements or eliminate unnecessary regulations and to improve the responsiveness of the agency to providers. Physicians can contact the PRIT directly to report problems they are encountering or to ask the PRIT to clarify an issue.

Providers can view past and Active PRIT Issues and track their status by clicking on the issue on the PRIT Webpage. On December 01, 2008 PRIT addressed the question of whether the e-prescribing bonus reflects charges submitted to Medicare Advantage (MA) and Private Fee-For-Service (PFFS) Medicare payors. The following is from the PRIT Web site:

Issue Name
E-Prescribing bonus payments for physicians caring for MA patients.

We have been asked if the total e-prescribing bonus payment will reflect charges submitted to MA and PFFS payors.

See below.

Date Issue Created

November 10: We will discuss the question with CMS subject matter experts to determine the intent of Congress and any administrative challenges which might prevent inclusion of MA payments in the calculation of the E-prescribing bonus payment.

December 1: Payment to physicians who have contracted with MA organizations generally are governed by the terms of the contract, and it is up to the MA organization whether to take eligibility for a PQRI bonus or e-prescribing incentive payment into account in establishing the amount the physician is paid. In the case of a private fee-for-service (PFFS) plan, however, if the MA organization offering the plan is meeting access requirements by paying what Medicare would pay, the MA organization is required to include bonus and incentive amounts if the physician would receive them in connection with treating a Medicare beneficiary not enrolled in an MA plan.

Physicians who have not contracted with an MA organization, but provide covered services to an enrollee in an MA plan offered by the organization, are also potentially eligible for both the PQRI bonus payment and the e-prescribing incentive payment from the organization. When a physician is determined by Medicare to have satisfied the requirements and qualified for an incentive under the PQRI, he or she should expect to receive a bonus check from any MA organizations which he or she has billed as a non-contracted provider, or for which he or she has provided covered services under a PFFS plan that meets access standards by paying the Medicare payment rate. The amount of the PQRI payment is calculated just as it is calculated for traditional Medicare, that is to say a percentage (up to 1.5% for 2007 and 2008, and 2% for 2009 and 2010) of Medicare allowed charges for such covered professional services submitted to the plan during the reporting period. When a physician is determined by Medicare to be a successful e-prescriber and qualifies for the 2% incentive under the 2009 E-prescribing Incentive Program, MA plans are required to pay non-contracted physicians 2% of the Medicare allowed charges for any services rendered in 2009 to a member of that plan. This policy also applies to non-physician practitioners who would qualify for payments from traditional Medicare.


Risë Marie Cleland

Oplinc, Inc.
315 W. Mill Plain Blvd.,
Suite 204
Vancouver, WA 98660
360.695.1608 office
360.695.6937 fax



Comments and suggestions for future issues are welcome, please forward correspondence to Risë Marie Cleland by email at: Rise@Oplinc.com



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Risë Marie Cleland is the founder and President 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.



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.hhs.gov.



CPT® is a Trademark of the American Medical Association Current Procedural Terminology (CPT) is copyright 2009 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 ©2009 Oplinc, Inc.
Oplinc, Inc., grants permission to distribute this newsletter without prior permission provided that it is forwarded unedited and in its entirety.

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