Implementing Medicare and Commercial Insurance Coding Changes in 2006

Patricia Falconer, MBAPresident, Health Options

650-949-2526 phone650-745-1122 fax

Healthoptions@worldnet.att.net

Strategies For 2006

Financial Issues Medicare Demonstration Project

Fee Schedule Management Operations

Financial Issues Plan for Reduced Cash Flow

Medicare Revenue Loss from Elimination of 2005 Demonstration Project

Medicare Revenue Loss from 3% Reduction in Administration CPT Codes

Delays in Medicare payments due to 1/17/06 implementation date for Demonstration codes

Fee Schedule Reductions from Commercial PPO Insurance Plans

Medicare Demonstration Project 2006

Should you participate? How to facilitate the billing process

Documentation Requirements

Demonstration Project Philosophy “The project builds on the use of G-codes to gather more specific information about patients with particular types of cancer, including information about the primary focus of the visit and the spectrum of care that you provide. It will emphasize practice guidelines as the source for standards of care, permitting CMS to monitor and encourage quality care to cancer patients, and to identify and promote best cancer care practices that should lead to improved patient outcomes”.

MediLearn Matters Number SE0589 Effective Date 1/1/06

Demonstration Project Revenue Projection Calculate the total Number of 99212-99215 visits in 2005.

Estimate the percentage of Medicare patients in the practice.

Estimate the percentage of visits representing the 13 major diagnostic categories.

Multiply each element above and then multiply the number by $23.00

Implement A New Superbill Add all Codes on Superbill.

This will require a two page superbill. First page: E & M codes, Procedure Codes, G-Codes, and Lab

Second page: 2006 Administration CPT codes, supplies, and J-Codes for drugs. G-Codes and 2004 CPT codes may be required for specific contracts.

Patient insurance must be on the superbill

Update all new CPT and J-Codes

Lung Cancer (162.2 – 162.9)

G9063 NSCLC, Stage I, Stable

G9064 NSCLC, Stage II, Stable

G9065 NSCLC, Stage IIIA, Stable

G9066 NSCLC, Stage IIIB-IV or Progression

G9067 NSCLC , Unknown, NOS

G9068 SCLC Limited

G9069 SCLC Extensive or Progression

G9070 SCLC Extent Unknown

Breast Cancer (174.0 – 174.9)

G9071 Breast Stage I-II or T3, N1, M0, ER/PR +, Stable

G9072 Breast Stage I-II or T3, N1, M0, ER/PR -, Stable

G9073 Breast Stage III not T3, N1, M0, ER/PR +, Stable

G9074 Breast Stage III not T3, N1, M0 ER/PR -, Stable

G9075 Breast M1 or Progression

G9075 Breast Extent Unknown NOS

Prostate Cancer (185)

G9077 Prostate T1-T2C Gleason 2-7 and PSA < 20 Stable

G9078 Prostate T2 or T3A Gleason 8-10 or PSA > 20 Stable

G9079 Prostate T3B-T4 Any N Any T N1 Stable

G9080Prostate Rising PSA or Lack of Decline after Initial

Treatment

G9081 Prostate M1 at Diag or Metastatic, Non-Castrate

G9082 Prostate M1 at Diag or Metastatic, Castrate

G9083 Prostate, Extent Unknown NOS

Colon Cancer (153.0 – 153.9)

G9084 Colon T1-3, N0, M0, Stable

G9085 Colon T4, N0, M0, Stable

G9086 Colon T1-4, N1-2, M0, Stable

G9087 Colon M1 or Recurrent with evidence of disease

G9088 Colon M1 or Recurrent with no evidence of disease

G9089 Colon Extent Unknown NOS

Rectal Cancer (154.0, 154.1)

G9090 Rectal T1-2, N0, M0, Stable

G9091 Rectal T3, N0, M0, Stable

G9092 Rectal T1-3, N1-2, M0, Stable

G9093 Rectal T4 Any N M0 Stable

G9094 Rectal, M1 or Recurrent

G9095 Rectal Extent Unknown NOS

Esophageal Cancer (150.0 – 150.9)

G9096 Esophageal T1-3, N0-1, or NX, Stable

G9097 Esophageal T4, Any N, M0, Stable

G9098 Esophageal M1 or Recurrent

G9099 Esophageal Extent Unknown NOS

Gastric Cancer (151.0 – 151.9)

G9100 Gastric Post R0, Resectable, Stable

G9101 Gastric Post R1-2, Resectable, Stable

G9102 Gastric M0, Unresectable, Stable

G9103 Gastric M1 or Recurrent

G9104 Gastric Extent Unknown NOS

Pancreatic Cancer (157.0 – 157.3, 157.8 – 157.9)

G9105 Pancreatic Post R0, Resectable, Stable

G9106 Pancreatic Post R1-2, Resectable, Stable

G9107 Pancreatic M1 or Recurrent

G9108 Pancreatic Extent Unknown NOS

Head & Neck Cancer (140.0 – 140.9, 161.0 – 161.9)

G9109 Head/Neck T1-2, N0, M0, Stable

G9110 Head/Neck T3-4 and/or N1-3, M0, Stable

G9111 Head/Neck M1 or Recurrent

G9112 Head/Neck Extent Unknown NOS

Ovarian Cancer (183.0)

G9113 Ovarian Stage IA-B Grade 1, Stable

G9114 Ovarian Stage 1A-B Grade 2-3 or Stage 1C All Grades or Stage II Stable

G9115 Ovarian Stage III-IV, Stable

G9116 Ovarian Progression, Recurrence, Plat Resistant

G9117 Ovarian Extent Unknown NOS

Non-Hodgkin’s Lymphoma (202.00 – 202.08, 202.80 – 202.98)

G9118 NHL Stage I-II Not Relapsed Not refractory

G9119 NHL Stage III-IV Not Relapsed Not Refractory

G9120 NHL Trans to Diffuse Large B-Cell Lymphoma

G9121 NHL I-IV Relapsed/Refractory

G9122 NHL I-IV Possible Relapse or Non-response or Not listed

Chronic Myelogenous Leukemia (205.10, 205.11)

G9123 CML Chronic Phase Not in Remission

G9124 CML Accelerated Phase Not in Remission

G9125 CML Blast Phase Not in Remission

G9126 CML in Remission

G9127 CML Extent Unknown NOS

Multiple Myeloma (203.00, 203.01)

G9128 Multiple Myeloma Smoldering Stage 1

G9129 Multiple Myeloma Stage II or Higher

G9130 Multiple Myeloma Extent Unknown NOS

Educate Providers

Physicians and Nurse Practitioners who bill as “incident to”

Use Resources Educate Billing Staff Set up Charge Entry and Documentation Audit System

Documentation RequirementsPrimary Focus of VisitG9050 – G9055 Progress note section, chief complaint or primary reason for visit, should match G-Code Work-Up Evaluation Treatment Decision/Management Surveillance for Disease Expectant Management of Patient Supervision Palliative Other- Visit Unspecified

Documentation RequirementsFor Guideline Adherence Codes (G9056 – G9062) Must Document Source of Guideline ASCO NCCN Both No Guideline Available or None Clinical Trials

Documentation Guidelines Current Disease StateG9063- G9130 Choose the single G-Code that best represents the disease status based on the best available data at the time of service

G-Code selected must match ICD-9 code

Staging should be documented in progress note

2006 Fee Schedule- Medicare US House of Representatives passed a federal budget package that stopped the 4.4% Medicare cut in December 2005 but could not obtain final approval before the holiday break. CMA and AMA are now working with congress to pass the payment “freeze”.

Practices should use billed charges or the 2005 Medicare fee schedule for dates of service in 2006 except with the new administration CPT codes.

The new administration CPT codes will be paid using the 2006 fee schedule. These codes are not part of the “freeze”.

If Congress Freezes 2006 Medicare Payments at 2005 Rates...

Medicare carrier will have 2 business days to begin to automatically reprocess claims that were paid under the 4.5 % conversion reduction.

Payments will be issued in one lump sum by July 2006

Additional Medicare payments will increase patients co-payments if they do not have secondary insurance

Decision to recover co-payments from patients is up to the individual practice

Waiving co-payments due to the change in conversion factor would not be viewed as an “inducement”

Fee Schedule- PPO Commercial Lower Contracted Reimbursement Rates for 2006 Administration CPT Codes

Blue Shield of California PPO Default Fee Schedule

Average of 30% Reduction Blue Cross Prudent Buyer PPO Default Fee Schedule

Average of 33% Reduction Monitor PPO Plans rate changes through their websites

Electronic Claim Clearing House Edits Can you submit 2004 CPT codes or 2005 G-codes if your payer contracts require them?

Commercial Default Fee Schedule Change ExamplesCPT 2006 CPT

20052006 Allowable

2005 Allowable

2006 Medicare Allowable

Blue Cross Prudent Buyer PPO

96409 G0357 $117.66 $186.12 $173.95

Blue Shield PPO

96409 96408 $173.95 $236.88 $173.95

Fee Schedule - HMO Commercial HMO Plans

Take this opportunity to renegotiate your IPA HMO contracts to include 2006 CPT codes.

Find out if your IPAs carved out the financial responsibility for drug reimbursement for 2006

Who pays you for drugs and procedures for each health plan?

What rate? Any other changes?

Managing Drug Purchasing Compare Quarter 1 2006 ASP with your current practice acquisition costs

Manage your drug distributors Use Distributors Website for Drug Purchasing Monitor price changes with each order Order from multiple distributors

Review drugs within therapeutic classes to maximize purchase power

Growth Factors Antiemetics Bisphosphonates

Operations Implement Automated Functions wherever possible Electronic Claim Submission for all payers that will accept them. Can your software submit three digit units?

Electronic Remittance Electronic Patient Statements

Reduce Accounts Receivable days to match or beat drug distributor payment terms

Resources www.anco-online.org www.asco.org www.nccn.org www.medicarenhic.com www.bluecrossca.com www.mylifepath.com www.cigna.com www.aetna.com www.unitedhealthcareonline.com www.practicemanagerinsider.com www.caring4cancer.com