Oplinc

The new 2006 CPT (Current Procedural Terminology) codes have now been effective for over a month. Although it takes some time to learn the new codes and to update the practice management system & necessary forms, the transition should be smoother this year as the new CPT codes mirror last year’s temporary G-codes for Medicare.

In order to review the billing rules we have included two sample protocols and the coding rules that apply to them. Note: Please be aware that these examples are included for educational purposes only. Always consult your Medicare carrier and the CMS website for specific coding guidance.

2006 CPT Coding Exercises

Sample Protocol

 Drug  Dose  Start  Stop  Route
Calcium
Gluconate
1 GM 09:35 10:40 IV
Magnesium 1 GM 09:35 10:40 IV (same bag as calcium gluconate)
Zofran 32 mg 10:40 11:00 IV
Decadron 10 mg 10:40 11:00 IV (same bag as Zofran)
Oxaliplatin 200 mg 11:00 13:00 IV
Leucovorin 1040 mg 11:00 13:00 IV (separate bag)
5-FU 832 mg 13:03 13:05 IV Push
5-FU 4992 mg 13:05   Ambulatory Pump

Assign the codes:

 Drug  Administration Code:
Calcium Gluconate 90761 - Hydration each additional hour

 Rule

  1. Electrolytes whether pre-packaged or added to fluids are billed under hydration codes;
  2. Ea. additional hour code is used because hydration is a secondary service in this patient encounter, the “initial” code will be used for the primary service chemotherapy.

 Drug  Administration Code:
Magnesium Ø

 Rule

  1. No separate administration code because the magnesium was in the same bag as the calcium gluconate. To report the concurrent infusion code the drugs must be in separate bags.

 Drug  Administration Code:
Zofran 90767 – Additional sequential infusion, therapeutic
Diagnostic

 Rule

  1. Infusion time was greater than 15 minutes and drug was administered sequential to the other drugs.

 Drug  Administration Code:
Decadron Ø

 Rule

  1. No separate administration code as this drug was in the same bag as the Zofran.

 Drug  Administration Code:
Oxaliplatin 96413 – chemo admin. IV single or initial
96415 – each additional hour

 Rule

  1. Use the initial code as chemotherapy is the primary service for this encounter;
  2. Bill one unit of 96415 for the 2nd hour of infusion.

 Drug  Administration Code:
Leucovorin 90768 – concurrent infusion

 Rule

  1. Concurrent code is used because leucovorin was administered at the same time as the oxaliplatin in a separate bag. Note: If your carrier has instructed you to bill the leucovorin with the chemotherapy administration codes you will not be able to bill for this administration as there is no concurrent code for chemotherapy.
  2. There is no 2nd hour billed for the leucovorin as the concurrent code is only reportable once per patient per encounter.

 Drug  Administration Code:
5-FU 96411 – chemo IV push, ea additional substance/drug

 Rule

  1. Use each additional IV push code as the initial code was used with oxaliplatin; only 1 initial code is to be billed per patient per encounter.

 Drug  Administration Code:
5-FU 96416 – initiation of prolonged chemotherapy infusion

 Rule

  1. When a drug is administered by different administration techniques bill for each method of administration (as long as it meets medical necessity).

Sample Protocol

 Drug  Dose  Start  Stop  Route
Normal
Saline
1 liter 08:45 10:35 IV
Aloxi 0.25 10:35 10:45 IV
Decadron 10 mg 10:35 10:45 IV (same bag as Aloxi)
VP-16 203 mg 10:45 11:55 IV
Cisplatin 41 mg 11:55 12:55 IV
Bleomycin 30 units 12:55 13:05 IV push

Assign the codes:

 Drug  Administration Code:
Normal Saline 90761 x 2 – hydration each additional hour

 Rule

  1. Hydration administered sequentially to chemo is separately billable (when medically necessary). In this encounter hydration is a secondary service so you would not use the initial code;
  2. NS dripped for 1 hr. 50 minutes, additional infusion time past 1st hour was greater than 30 minutes so it is reported with a 2nd unit of the additional hour code.

 Drug  Administration Code:
Aloxi 90775 – each additional sequential IV push

 Rule

  1. Infusions lasting 15 minutes or less are to be billed with the IV push codes, Aloxi dripped for 10 minutes;
  2. This is a secondary service in this encounter so you would not use the initial code.

 Drug  Administration Code:
Decadron Ø

 Rule

  1. No separate administration code as this drug was in the same bag as the Aloxi.

 Drug  Administration Code:
VP-16 96413 – Chemotherapy administration, IV up to 1 hr. single or initial substance/drug

 Rule

  1. Use the initial code as chemotherapy is the primary service for this encounter;
  2. The infusion ran ten minutes past the 1st hour, you would not bill for an additional hour until 31 minutes past the 1st hour.

 Drug  Administration Code:
Cisplatin 96417 – each additional sequential infusion up to 1 hour, chemo

 Rule

  1. The drug was dripped sequentially to the other drugs; the initial code was already reported with VP-16.

 Drug  Administration Code:
Bleomycin 96411 – chemo IV push, each additional substance/drug

 Rule

  1. The initial code was already reported with VP-16.

Basic Rules to Remember:

  1. Only 1 “initial” code per patient per day – use this for the primary service provided that day irrespective of the order in which the services are provided.

  2. Infusions lasting 15 minutes or less are to be billed with the appropriate IV push code.

  3. Concurrent code can only be billed once per patient per encounter.
FREQUENTLY ASKED BILLING QUESTIONS

Q. We have been coding the bone marrow biopsy and aspiration as 38220-59 and 38221-50. Is this correct?

  • A. Modifier -50 is appended to the bone marrow biopsy code 38221 to report bi-lateral bone marrow biopsies. The modifier -59 is used to report that the bone marrow biopsy and aspiration were performed through separate incisions.
  • For Medicare patients, as of January 1, 2005 if the bone marrow biopsy & aspiration are performed through the same incision you should be billing G0364 (bone marrow aspiration performed on the same date through the same incision as a bone marrow biopsy) with the bone marrow biopsy code, 38221.

    If the biopsy and aspiration are performed through different incisions or different patient encounters on the same day, then Medicare will make separate payments for each procedure. In this case, you would report both the bone marrow aspiration (38220) and bone marrow biopsy (38221) codes and append the modifier -59. It must be medically necessary to perform the procedures through two separate incisions.

Q. Is it necessary to re-stage the patient each time we bill for the 2006 Oncology Demonstration Project?

  • A. No. In the MedLearn Matters document: MM4219 2006 Oncology Demonstration Project CMS states: “Disease status should be based on the best available data at the time of the visit, unless otherwise specified. No additional diagnostic tests or evaluations should be performed for the purposes of further determining disease status for the purposes of this Demonstration Project.”

Q. Where can I find information on billing for concurrent infusions? In particular, I am looking for guidance on drugs infused in one bag.

  • A. The AMA publication, CPT Changes 2006 An Insider’s View states on page 253, “An infusion consisting of three substances in a single bag is not intended to be reported as three separate infusion services, because the parenteral administration codes are intended to report the separate work of administration and IV access and not the inclusion of multiple agents in a bag prepared prior to infusion.” ASCO also addresses this in their FAQs for 2006 Drug Administration.

Q. When giving an injection and port flush on the same day, can you bill the port flush (96523)?

  • A. No. According to the American Medical Association CPT, a port flush 96523 is not separately billable when a drug infusion or injection is provided on the same day. For Medicare patients the port flush is only billable when no other Medicare Physician Fee Schedule service is provided.

President Bush Signs BILL Halting
Physician Payment Cuts

Wednesday February 1, 2006 the House of Representatives passed the Deficit Reduction Act (DRA) of 2005 (S. 1932). On Feb. 8, President Bush signed the bill halting the 4.4 percent reduction in Medicare physician rates that began January 1, 2006. The DRA retroactively freezes the Conversion Factor (CF) at the 2005 level.

CMS announced that Medicare carriers would immediately begin processing claims using the 2005 Conversion Factor and begin reprocessing of those claims that were previously paid at the lower reimbursement level. According to CMS, physicians will not be required to resubmit the claims.

CMS previously stated that Medicare carriers would perform a mass adjustment and issue providers the additional reimbursement in one payment. However, it is now reported that CMS plans to allow carriers to make adjustments in periodic batches in order to avoid falling behind in processing current claims. The target date for completing the reprocessing and for issuing checks for the previously paid claims remains July 1, 2006.

The freeze at the 2005 level does not include the 2005 3% transitional add-on payment mandated by the MMA of 2003. The transitional add-on payment on drug administration services was 32% in 2004, reduced to 3% in 2005 and in accordance with the MMA (Medicare Modernization Act); it was eliminated altogether in 2006.

Congress has not fixed the flawed formula that will continue to result in yearly reductions in physician payments but the bill does provide relief from the cuts in 2006 allowing Congress time to determine the new payment methodology. Note: Read the article “Medicare Physician Fee Schedule 2006” in the December Issue for details on the flaw in the current formula.

Imaging Services Addressed in Deficit Reduction Act

The Deficit Reduction Act (DRA) includes a new provision effective January 1, 2007, that caps the technical component for imaging services provided in the physician office to the lesser of the Medicare Physician Fee Schedule (MPFS) or the Hospital Outpatient Department rate (HOPD) rate. Consistent with the Physician Fee Schedule Final Rule, payments for multiple imaging procedures performed in physician offices on contiguous body parts on the same day are reduced by 25% in 2006 and 50% in 2007. Reimbursement rates for the same imaging services provided in the HOPD are not reduced in 2006.

The Congressional Budget Office (CBO) estimates that the imaging cuts will result in a savings of $2.8 billion over 5 years but the American College of Radiology estimates the impact to be a reduction of $6 billion over 5 years. Efforts to contain these cuts are already underway.

The Comprehensive Cancer Care Improvement Act

The National Coalition for Cancer Survivorship is an advocacy organization led by cancer survivors. The NCCS is currently working with Members of Congress to develop a legislative proposal that they believe would improve cancer care. This proposal, the Comprehensive Cancer Care Improvement Act, focuses on how cancer care providers address the side effects of cancer and its treatment and cancer patients’ quality of life.

The stated goal of their proposal is to promote comprehensive care for patients including, appropriate management of pain, nausea, vomiting, fatigue and depression.

The key provisions outlined by the NCCS are:

  • Establish Medicare payment for development of a cancer care plan at the beginning of treatment and explanation of that plan with the patient.
  • Establish Medicare payment for development of a treatment summary when patients finish treatment that would outline follow-up care for survivors.
  • Encourage the development of model programs that integrate active treatment and cancer symptom management.

The NCCS is currently conducting a survey of cancer survivors, their families, friends and others who are interested in promoting comprehensive care for cancer patients. The survey includes a question asking participants to vote on the components of the bill that are most important to them. The listed choices are:

  • Grants should be made available to expand existing palliative care and symptom management programs
  • Grants should be provided to The Centers for Medicare and Medicaid Services to evaluate the impact of palliative care
  • Grants should be provided for professional training for medical personnel in the field of cancer symptom management
  • Oncologists should be paid to develop comprehensive treatment plans that would be communicated to their patients

Those interested in taking the survey can access it here: Cancer Advocacy Now Survey

The NCCS expects the Comprehensive Cancer Care Improvement Act to be introduced within the next week or so.

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IMPORTANT NOTICE
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.

Using the Medicare Advance Beneficiary Notice

What is it?
The Medicare Advance Beneficiary Notice (ABN) is a written notice that is given to a Medicare beneficiary before providing an item or service that you expect Medicare will deny. The use of the ABN is in accordance with the Limitation on Liability (LOL) provision under Section 1879 of the Social Security Act (the Act). A Quick Reference to these regulations is available on the CMS website.

The ABN is also commonly referred to as a Medicare waiver. CMS has developed specific forms that must be used. The Advance Beneficiary Notice - General Use (ABN-G) (Form No. CMS-R-131-G) may be used by providers for all situations where Medicare payment is expected to be denied including laboratory tests. The Advance Beneficiary Notice - Laboratory Use (ABN-L) (Form No. CMS-R-131-L) is only used for laboratory services. Both of these forms are available in English and Spanish on the CMS website.

When & How Is It Used?
ABNs are only necessary for services which are normally covered by Medicare, but which in a specific circumstance the physician believes will be denied as not reasonable or necessary.

For example, in medical oncology we would use an ABN before treatment with a drug that while usually covered is not indicated for the patient’s diagnosis. The ABN would specify the drug and drug administration that the provider believes will be denied and the specific reason for the denial i.e., "this drug is not indicated for your diagnosis, since the drug is not covered the administration of the drug would not be covered."

The ABN is used to allow the beneficiary to make an informed decision to receive the items or services even though Medicare may not pay for it and it transfers financial responsibility for the service to the beneficiary either out-of-pocket or through other insurance coverage.

The Completed ABN will contain:

The specific items or services that are expected to be denied
The reason for the expected denial
The estimated cost of the services to the patient in case of a denial
The election by the patient to either receive the service & acceptance of financial responsibility for the services or to decline to receive the services
The date & signature of the patient or person acting on the patient’s behalf

The ABN must be provided to the Medicare beneficiary before the service is provided.

Obtaining a signed ABN is not necessary when the services are statutorily excluded (not a covered service) from Medicare coverage.

What Modifiers Are Used for These Services?
When a signed ABN has been obtained, the provider will bill for the services appending the modifier GA Waiver of liability statement on file to the particular service or services. This modifier tells Medicare that you have a signed copy of the ABN on file. If the service is denied, you can bill the patient for the service.

If you did not obtain an ABN, do not append modifier GA to the service. If Medicare denies the service, the patient will not be responsible for payment.

Use modifier GY for items or services that you expect to be denied because they are statutorily excluded or do not meet the definition of any Medicare benefit.

No Medicare ABN is necessary for services that are statutorily excluded. The GY modifier is used to receive a Medicare denial so the claim can be submitted to a secondary payer.

Modifier GZ is used when you provide an item or service that you expect to be denied as not reasonable and necessary and you did not obtain a signed ABN from the beneficiary. If Medicare denies the claim, you are not allowed to bill the patient.

What if the Patient Will Not Sign the ABN?
On assigned physician claims, no signature is required to make the ABN effective. If the beneficiary refuses to sign, physicians may annotate and sign the form, indicating the beneficiary’s refusal to sign, and have a witness sign the form. Then if Medicare denies the claim, the patient may be billed for the service.

However, it is important to note that in the absence of a signed ABN, CMS states, “If a beneficiary’s signature is absent, in case of a dispute as to the agreement, the beneficiary’s allegations regarding the notice will be given credence.”

On the other hand, if the provider can prove that the beneficiary received proper written notice or that the provider did not know, and could not reasonably have been expected to know that Medicare would deny the item or service, and there is no evidence to the contrary, the carrier must find that the provider is not liable.

Read the Quick Reference - Medicare Rulings of the Administrator with respect to Financial Liability Protections provisions: Limitation On Liability (LOL) & Refund Requirements (RR) for more information.

For unassigned claims, the beneficiary or his representative must agree to be financially responsible by signing the ABN. In this case, if the beneficiary is unable to sign the ABN the provider must obtain the signature of the beneficiary’s authorized representative.

Can The ABN Be Used With Bundled Services?
Certain services are considered “bundled” by Medicare. These services are listed with a B status on the Medicare Physician Fee Schedule. It would never be appropriate to obtain an ABN and bill the beneficiary for these services. Payment for these services are included in the RVUs (Relative Value Units) of other procedures performed that day.

Calendar of Events

FEBRUARY 2006

Wednesday Feb 8th
Thursday Feb 9th
Friday Feb 10th

Community Oncology Conference
Reed Medical Education
Washington, D.C.
phone: 888.799.2995
www.CommunityOnc.com

Thursday Feb 16th
Friday Feb 17th
Saturday Feb 18th
Sunday Feb 19th
APOS Annual Conference
American Psychosocial Oncology
Amelia Plantation Island, Fla.
phone: 434.293.5350
www.apos-society.org

Monday Feb 20th
Tuesday Feb 21st
Wednesday Feb 22nd
ACE 12th Annual Meeting
Association of Cancer Executives
Las Vegas, Nev.
phone: 630.323.1170
www.cancerexecutives.org

Thursday Feb 23rd
Friday Feb 24th
Saturday Feb 25th
ACRO 2006
American College of Radiation Oncology
Orlando, Fla.
phone: 301.718.6515 x 6536
www.acro.org

MARCH 2006

Wednesday Mar 8th
Thursday Mar 9th
Friday Mar 10th
Saturday Mar 11th
Sunday Mar 12th
NCCN Clinical Practice Guidelines in Oncology Summit
National Comprehensive Cancer Network
Hollywood, Fla.
phone: 215.690.0300
www.nccn.org

Tuesday Mar 14th
Wednesday Mar 15th
Thursday Mar 16th
Friday Mar 17th
ACCC 31st Annual National Meeting
Association of Community Cancer Centers
Arlington, Va.
phone: 301.984.9496
www.accc-cancer.org

Thursday Mar 23rd
Friday Mar 24th
Saturday Mar 25th
Sunday Mar 26th
59th Annual Cancer Symposium
Society of Surgical Oncology
San Diego, Calif.
phone: 847.427.1400
www.surgonc.org

APRIL 2006

Sunday Apr 2nd
Monday Apr 3rd
Tuesday Apr 4th

Wednesday, Apr 5th
MGMA Administrators in Oncology & Hematology Conference
Medical Group Management Association
Las Vegas, Nev.
phone: 877.275.6362
www.mgma.com

Friday Apr 28th
Saturday Apr 29th
Sunday Apr 30th
Monday May 1st

ASPH/O 19th Annual Meeting
American Society of Pediatric Hematology/Oncology
San Francisco, Calif.
phone: 847.325.4869
www.aspho.org

MAY 2006

Wednesday May 3rd
Thursday May 4th
Friday May 5th
Saturday May 6th

AOSW 22nd Annual Conference
Association of Oncology Social Workers
Minneapolis, Minn.
phone: 215.599.6093
www.aosw.org

JUNE 2006

Friday Jun 2nd
Saturday Jun 3rd
Sunday Jun 4th
Monday Jun 5th
Tuesday Jun 6th

ASCO 2006 Annual Meeting

American Society of Clinical Oncology
Atlanta, Ga.
phone: 703.299.1000
www.asco.org

AUGUST 2006

Wednesday Aug 9th
Thursday Aug 10th
Friday Aug 11th

Thirty-first World Congress of the International Society of Hematology Imedex
Puerto Rico Convention Center,
Puerto Rico
phone: 770.751.7332
www.imedex.com

OCTOBER 2006

Sunday Oct 22nd
Monday Oct 23rd
Tuesday Oct 24th
Wednesday Oct 25th

MGMA Annual Conference
Medical Group Management Association
Las Vegas, Nev.
phone: 877.275.6462 x 875
www.mgma.com

NOVEMBER 2006

Sunday Nov 5th
Monday Nov 6th
Tuesday Nov 7th
Wednesday Nov 8th
Thursday Nov 9th

ASTRO 48th Annual Meeting
American Society for Therapeutic Radiation and Oncology
Philadelphia, Pa.
phone: 703.502.1550
www.astro.org

Friday Nov 10th
Saturday Nov 11th
Sunday Nov 12th

ONS Institutes of Learning
Oncology Nursing Society
Pittsburgh, Pa.
phone: 866.257.4667
www.ons.org

DECEMBER 2006

Saturday Dec 9th
Sunday Dec 10th
Monday Dec 11th
Tuesday Dec 12th

ASH 48th Annual Meeting
& Exposition

American Society of Hematology
Orlando, Fla.
phone: 202.776.0544
www.hematology.org

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CONTACT US
Risë Marie Cleland
Rise@Oplinc.com
Oplinc
300 West 8th Street, Unit 419
Vancouver, WA 98660-3440
580.695.0632 phone
360-993-5065 fax
www.Oplinc.com

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