Practice Management Series

1. ASCO Clinical Practice Series Practice Management Series

2. Practice Management Curriculum Adapting to Changes in Medicare Generating Practice Efficiencies Health Information Technology in Practice

3. Adapting to Changes in Medicare…2006 Topics for today: • The 2006 Oncology Demonstration Project • Physician fee schedule changes • Drug administration coding • Part D

4. 2006 Oncology Demonstration Project • A one-year demonstration project, effective 1/1/06 • Purpose is to identify and assess, in office-based oncology practices, certain oncology services that positively affect outcomes in the Medicare population. • Capture the spectrum of services oncologists provide to Medicare beneficiaries with certain cancer diagnoses • Determine the extent to which practice guidelines parallel care that hematologists/oncologists provide

5. 2006 Oncology Demonstration Project • Replaces the 2005 chemotherapy demonstration project • Calendar year 2005 G-codes (G0921 – G0932) have been eliminated, effective 12/31/05

6. G-Codes • CMS has established 81 new G-codes in three reporting categories 1. Primary focus of the E & M visit (G9050 – G9055) 2. Whether current patient management adheres to clinical practice guidelines (G9056 – G9062) 3. Current disease state (G9063 – G9130) • Reporting is no longer specific to chemotherapy administration services; now associated with E & M services for established patients with cancer

7. Who Can Participate? • Office-based hematologists and oncologists • Medicare-designated physician specialties hematology (specialty code 82), medical oncology (specialty 83), and hematology/oncology (specialty 90) • Check with your carrier to be sure your physicians are identified with the correct specialty designation

8. Who Can Participate? • Midlevel providers (NPs, PAs) who may bill independently for Medicare services are not eligible to participate in the demonstration • ASCO’s interpretation of the carrier instructions is that visits performed in compliance with Medicare’s incident-to rules may be billed under the demonstration

9. How Does it Work? • Office-based hematologists and oncologists can participate for services furnished in 2006 when … • E & M services level 2 thru 5 (99212 – 99215) are provided to established patients with a primary diagnosis of cancer in one of 13 major diagnostic categories • Participation is voluntary and the physician participates by filing a claim for services with their Medicare carrier

10. 13 Diagnostic Categories • Head & Neck Cancer (140.0 – 149.9, 161.0 – 161.9) • Esophageal Cancer (150.0 – 150.9) • Gastric Cancer (151.0 – 151.9) • Colon Cancer (153.0 – 153.9) • Rectal Cancer (154.0, 154.1) • Pancreatic Cancer (157.0, 157.1, 157.3, 157.8, 157.9) • Lung Cancer (both non-small cell and small cell) (162.2 – 162.9) • Female breast cancer (invasive) (174.0 – 174.9) • Ovarian Cancer (183.0) • Prostate cancer (185) • Non-Hodgkin’s Lymphoma (202.00 – 202.08, 202.80 – 202.98) • Multiple Myeloma (203.00, 203.01) • Chronic myelogenous leukemia (205.10, 205.11)

11. Payment Requirements • To qualify for payment, providers must submit one G-code from each of the three reporting categories when billing for an E & M service for established patients, 99212 – 99215 • Claims must be assigned • Place of service must be “office” (place of service code 11) • Patients enrolled in Medicare Advantage plans are not eligible

12. Payment Requirements • Providers reporting data for all three categories with a qualifying visit will receive demonstration payment of $23 • Allowances are as follows: • G9050 – G9055 $7.67 • G9056 – G9062 $7.67 • G9063 – G9130 $7.66 • The usual Part B coinsurance and deductible apply • Effective date is 1/1/06; carrier implementation date is 1/17/06; carriers will hold claims until 1/17/06

13. E & M Visits • The demonstration applies to E & M visits with patients who have a diagnosis in one of the 13 listed categories where the primary focus of the visit is management of the cancer, its complications, and the complications of its treatment • Eligible visits should have an ICD-9 code on the claim for one of the included cancers; that cancer should be the first listed cancer diagnosis on the claim form • The cancer does not need to be the first list diagnosis of any kind

14. E & M Visits • The E & M service may be furnished on the same day that chemotherapy is provided to a patient or it may be the only service a patient receives on that day • If a medically necessary E & M service is provided on the same day as chemotherapy administration, attach modifier -25 to the E & M service

15. E & M Visits • As always, the physician should appropriately document the patient’s record to support the level of E & M service billed • E & M visits should not be “upcoded” because of the additional documentation required by the demonstration project

16. Documentation Requirements • For each qualifying visit, physicians must identify three appropriate G-codes, one from each category: • Primary focus of visit (G9050 – G9055) • Adherence to guidelines (G9056 – G9062) • Current disease state (G9063 – G9130)

17. Documentation Requirements • Physician must also supply documentation in the patient chart to support billing for the demonstration project • The primary requirement is to identify the source of the guideline consulted • The title of the specific guideline that was consulted is not required

18. Documentation Requirements • Suggested phrases for documentation: • Demonstration project – ASCO • Demonstration project – NCCN • Demonstration project – ASCO & NCCN, or Both • Demonstration project – No guideline available, or None • Demonstration project – Clinical trial, or CT

19. Documentation Requirements • Physicians do not have to provide additional documentation in the patient chart beyond these elements • Local Medicare carriers have been advised that further documentation requirements are not to be imposed • Notify ASCO if your carrier adds documentation requirements

20. An Alternative Approach • CMS has also suggested using a documentation template, or flowsheet, designed to fulfill all requirements under the demonstration project • http://www.asco.org/asco/downloads/Medlearn_Article_Demo_Documentation_and_Reporting.pdf • If such a template is used, physicians do not have to provide any additional documentation in the patient record • Again, local carriers are instructed not to impose additional documentation requirements

21. Documentation Templates from ASCO • ASCO has prepared 13 diagnosis-specific templates for use with the Demonstration Project • In addition to the codes, each template includes a list of appropriate practice guidelines (both ASCO and NCCN) • To access the ASCO templates, go to • www.asco.org/2006demo

22. Coding Guidance: Primary Focus of the Visit • Physician should determine the single code that best identifies the primary focus of the E & M visit on that particular day • CMS recognizes that many different issues are addressed in most E & M visits; physicians should make what to them seems the best choice for that day

23. Primary Focus of the Visit • G9050 Oncology Work-up Evaluation • G9051 Oncology Treatment Decision/Treatment Management • G9052 Oncology Surveillance for Disease • G9053 Oncology Expectant Management of Patient • G9054 Oncology Supervision Palliative • G9055 Oncology Visit Unspecified

24. Coding Guidance: Guideline Adherence • Treating physician should choose the single code that best reflects whether or not patient management adheres to practice guidelines, and if not, the best listed reason why not

25. Oncology Practice Guidelines • G9056 Management Adheres to Guidelines • G9057 Management Differs from Guidelines as a Result of Enrollment in Clinical Trial • G9058 Management Differs from Guidelines because the Physician Disagrees with the Guidelines • G9059 Management Differs from the Guidelines because the Patient Opts for Different Treatment • G9060 Management Differs from Guidelines for Reasons Associated with Patient Illness • G9061 Patient’s Condition Not Addressed by Guidelines • G9062 Management Differs from Guidelines for Other Reasons

26. G9056 Management Adheres to Guidelines

27. G9056

28. G9057 Management Differs from Guidelines as a Result of Enrollment in Clinical Trial • Code is reserved for patients who are on an IRB-approved clinical trial that dictates the care being provided in that visit • Will most often be relevant to visits in which the primary focus is treatment but may also include clinical trials focused on evaluation, surveillance, expectant management or palliation

29. G9057 • If the primary focus of the visit is the subject of the clinical trial, this code should be submitted; if the primary focus of the visit is other than that being evaluated in the clinical trial, the treating physician should determine if that management adheres to guidelines.

30. G9057 • NOTE: NCCN guidelines specify participation in a clinical trial as a recommended management strategy. For the purposes of this demonstration, if management differs from that specified in guidelines due to the patient’s enrollment on an IRB-approved clinical trial, G9057 should be reported as described above.

31. Coding Guidance: Disease Status • Physician providing the E & M service on that day should determine the single code that best represents the disease status of the patient’s cancer. • Disease status code should be relevant to the cancer that is the first listed cancer diagnosis on the claim form. • Disease status should be based on the best available data at the time of the visit. No additional diagnostic tests or evaluations should be performed for the purpose of further determining disease status for the purposes of this demonstration project.

32. Disease Status Codes

33. Disease Status Codes

34. Demo Project FAQs • How do I enroll in the demonstration project? • There is no separate enrollment process. Reporting one G-code form each category for an E & M visit for a patient with a qualifying diagnosis will automatically enroll you in the demonstration project. Participation is voluntary. • Can I bill for the demonstration project in the hospital outpatient department? • No. CMS has stated that the demonstration can only be billed in the office setting (place of service 11).

35. Demo Project FAQs • Will the patient be responsible for a 20% Medicare co-pay? • Yes. • Will non-Medicare secondary payers recognize the demonstration project and cover the 20% co-pay? • All official Medigap plans will cover the 20% co-pay. Other secondary insurers may cover the co-pay. Check with individual payers.

36. Demo Project FAQs • Is patient consent required for the demonstration project? • No. Physicians are not required to obtain patient consent to participate in the demonstration project. However, physicians may choose to provide some explanation of the additional co-pay to their patients.

37. Demo Project FAQs • Is a physician required to select the G-codes for the demonstration or can this be done by a nurse reviewing the patient’s chart? • CMS has clearly noted its intent to tie the demonstration project to a physician service and has designed reporting requirements around the physicians evaluation and management of the patient. Therefore, ASCO recommends that the physician take primary responsibility for selecting and reporting the appropriate demonstration codes, based on his/her evaluation of the patient. Physicians also need to continue to comply with the E & M documentation requirements for their level 2 – 5 office visits.

38. 2006 Physician Fee Schedule • Conversion factor • Payment for covered outpatient drugs and biologicals • Diagnostic imaging • Physician self-referral prohibition • HCPCS changes

39. Conversion Factor • CF was scheduled to decrease 4.4% on 1/1/06 • Before the holiday break, the House and Senate both approved a conference report to freeze the conversion factor at 2005 levels BUT the Senate struck three unrelated provisions on a point of order and now the House must re-pass the report • House is expected to re-pass the report, but this is not guaranteed • Timing is unclear, probably late January or February • Freeze on CF will likely be retroactive to 1/1/06; impact on claims processing unclear at this time

40. Payment for Covered Outpatient Drugs and Biologicals • Average Sales Price (ASP) • ASP calculation methodology remains unchanged • ASP updates continue to be provided quarterly, generally about 15 days before the beginning of the quarter

41. Payment for Covered Outpatient Drugs and Biologicals • Intravenous infusion of immunoglobulin • Temporary code (G0332) established to describe additional pre-administration services related to IVIG administration • Intended to cover “substantial additional resources that are associated with locating and acquiring adequate IVIG product and preparing for an office infusion of IVIG in the current environment.” • G0332 may be billed once per day in association with a patient encounter for administration of IVIG.

42. Payment for Covered Outpatient Drugs and Biologicals • New J-codes for IVIG • J1566 Injection, immune globulin, intravenous, lyophilized (powder), 500 mg. • J1567 Injection, immune globluin, intravenous, non-lyophilized (liquid), 500 mg. • Codes Q9941, Q9942, Q9943, Q9944 have been deleted

43. Diagnostic Imaging • Multiple procedure payment reduction • CMS finalized a proposal to reduce payment for the 2nd and subsequent imaging procedures within the same “family” • Procedure with the highest payment will be paid at the full amount; payment for the technical component of additional procedures will be reduced • Professional component is not subject to this reduction • Two-year phase-in process; 25% reduction in 2006, 50% reduction in 2007 • Reductions apply to office-based imaging only

44. Physician Self-Referral Prohibition • Nuclear medicine • Effective 1/1/07, nuclear medicine services (including PET scans) will be included in the definition of “designated health services” subject to the Stark law

45. HCPCS Changes • Many new codes and deleted codes • Watch out for new descriptions, new units of measure • Code changes are effective 1/1/06

46. Drug Administration Services • 2005 Medicare G-codes have been deleted effective 12/31/05 and replaced with CPT codes • Definitions for 2006 CPT codes mirror the 2005 Medicare G-codes for drug administration services • ASCO’s coding cross-reference sheet contains the 2006 CPT codes, the 2005 Medicare G-codes, and all definitions

47. Drug Administration Services • 2006 CPT codes should be recognized by private payers as CPT is the standard coding system recognized by HIPAA • Implementation dates may vary by payer • 2006 CPT codes for drug administration services are also being used in the hospital outpatient setting under the hospital outpatient prospective payment system • Combination of CPT codes and new C-codes • Payment still based on APCs

48. Drug Administration FAQs • Did CPT keep the terms “initial,” “each additional,” and “additional sequential” that were used with the Medicare G-codes? • Yes. The CPT book includes these same terms and there have been no changes in their definitions.

49. Drug Administration FAQs • Did CPT make any additional changes to the definition of an intravenous push? • No. The CPT Editorial Panel has defined an intravenous or intra-arterial push as “an injection in which the healthcare professional who administers the substance or drug is continuously present to administer the injection and observe the patient, or an infusion of 15 minutes or less.”

50. Drug Administration FAQs • We are still very confused about concurrent infusions. Has there been any clarification or definition of a concurrent infusion? • The American Medical Association (AMA) defines a concurrent infusion as one in which multiple infusions are provided through the same intravenous line. • The concurrent infusion code (90768) is for non-chemotherapy infusions only.