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Dec. 14, '04
Vol. 1, No. 40
Weekly news and analysis
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| EXEC CORNER |
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Contractors to scrutinize documentation, code usage
CMS will force contractors starting next year to collect more detailed information from providers in an effort to reduce payment errors, according to a Medicare-reform mandate CMS announced Monday. Contractors will have to scrutinize provider claims for medical necessity and documentation as part of the effort. Contractors will officially be required to do the following: (1) Develop corrective action plans that include efforts to educate providers about the importance of submitting thorough and complete medical records; (2) Identify where additional review of claims and education on submitting claims is needed, based on information that shows where the highest percentage of errors on overused billing codes are occurring; (3) Use the performance results to develop local efforts to lower their error rates by addressing the cause of the errors and outlining corrective steps.
Source: CMS press office.
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| QUOTABLES |
| "The [Medicare-reform law's voluntary] chronic care program represents huge potential for the disease management industry. It's an unmatched opportunity to essentially double the size of the market in the relatively near term--and to create clear prospects for continuing substantial and long-term growth by serving not only the 36 million people participating in traditional Medicare today, but also the pending demographic wave that the Baby Boom population represents."
--Ben Leedle, Jr., president and CEO, American Healthways, Nashville |
| DATEBOOK |
| December 30--The public has until December 30 to comment on the Centers for Medicare and Medicaid Services' (CMS) draft Medicare prescription drug formulary guidance, which was released on Dec. 3. To encourage more comments and questions before that deadline, CMS held a special open door forum via telephone on Dec. 13 to answer questions and hear comments. Final formulary guidelines will be published in early 2005. "Keep in mind that as we put these guidelines together, they were not put in a glass bubble," said Babette Edgar, PharmD, MBA, who is director of CMS' division of science and operations within the Center for Beneficiary Choices in Baltimore. CMS wants to give "as much flexibility as possible to plans that will allow them to negotiate good prices from a rebate standpoint, while protecting beneficiaries from discrimination," Edgar said.
To view and comment on draft Medicare drug benefit materials, see www.cms.hhs.gov/pdps. A recording of the Dec. 13 open door teleconference can accessed through Dec. 17 by calling 1-800-642-1687 (conference ID number 2660577).
January 1--Independent Health has introduced a new Encompass 65 plan for Medicare beneficiaries living in Western New York that has no monthly premium beyond the monthly Medicare Part B premium. The plan, pending federal approval, will begin January 1, 2005. The new $0 premium plan includes office visits for $20, emergency care services for $50, and the company's Medicare-approved Prescription Drug Discount Card, which provides up to a 25% discount on most Tier 1 and Tier 2 drugs on the Independent Health formulary. |
© 2004 HCPro, Inc. |
HOSPITALS: New drug money available for 6 codes
Due to a coding misclassification related to the Medicare-reform law, hospitals have a new opportunity this month to send their fiscal intermediary (FI) a payment adjustment request for any claims containing HCPCS codes J7310, C9412, J9031, C9416, Q3002, or C9434, with dates of service on or after January 1, 2004. Make sure these claims were processed and paid between January 1, 2004 and October 4, when CMS updated the outpatient prospective payment system (OPPS). The reason for the opportunity is that earlier this year CMS misclassified Ganciclovir Long Act Implant (Ganciclovir), Bcg Live Intravesical Vac (Bcg), and Gallium ga 67 (Gallium) as multiple-source products and, as a result, implemented codes for generic and brand name forms of each drug, a spokesman confirmed. CMS corrected the error in the October 2004 OPPS update by deleting the brand name codes for Bcg and Gallium (C941! 6 and C9434) from the OPPS Outpatient Code Editor and correcting the payment rates for all three drugs. The correct code assignments and payment rates for 2004 are now as follows:
- J7310--APC 0913; Ganciclovir, 4.5 mg, Long-Acting Implant; Payment rate, $4,400.00; Minimum adjusted copayment, $880.00
- J9031--APC 0809; BCG (Intravesical) per Instillation; $148.33; $29.67
- Q3002--APC 1619; Supply of radiopharmaceutical diagnostic imaging agent, Gallium GA 67, per mCi; $28.73; $5.75
Adjustment requests submitted after implementation of the January 2005 OPPS update that contain C9412 will be returned to the provider. Hospitals will need to change the HCPCS code on adjustment requests submitted after installation of the October 2004 OPPS update from C9416 to J9031 for Bcg and from C9434 to Q3002 for Gallium. For Ganciclovir, hospitals will need to change the HCPCS code on adjustment requests submitted after installation of the January 2005 OPPS update from C9412 to J7310.
NOTE: All of these changes will be implemented starting December 28. E-mail Melissa Dunn at CMS (mdehn@cms.hhs.gov) for more information or specific questions.
| MEDICAREMURMURS |
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- Lab billing: Medicare carriers will continue to pay independent labs through 2006 for the technical component of physician pathology services furnished to patients of a covered hospital, according to rules set in place by section 732 of the Medicare-reform law. Coverage officially begins for the two-year period starting January 3. A CMS spokesman said the agency will post full details on its Web site before January. Look for Transmittal 382.
- Inpatient Rehabilitation Facilities (IRF): IRFs may get additional payments for treating a disproportionate share of low-income patients, according to an announcement December 10. An IRF may use the ratio provided at the Web site below as part of the formula to estimate its adjustment for low income patients. Click here www.cms.hhs.gov/providers/irfpps/ssidata_ratios.asp to access the data. Medicare contractors will implement these changes starting January 10. If you have questions before then, contact CMS' August Nemec (410) 786-0612, or e-mail Nemec at anemec@cms.hhs.gov (Source: CMS, change request 3567; Transmittal 392).
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G code revisions released
On December 10, CMS' press office clarified the 2005 drug administration coding revisions. CMS must evaluate existing drug administration codes for physician services to ensure accurate reporting, billing, and resource consumption, according to section 303 of the Medicare-reform law. These interim codes are effective until 2007. The CPT drug administration codes approved by the CPT Editorial Panel are grouped into three code categories: hydration (e.g, codes G0345 and G0346); therapeutic or diagnostic injections and intravenous infusions other than hydration (e.g, codes G0347 to G0354 and CPT codes 90783, 90788); and chemotherapy administration (e.g, codes G0355 to G0363, CPT codes 96405-96406, 96420-96520, and 96530-96549). The allowances for these codes reflect the application of the 2005 transitional payment adjustment of 3% under the Medicare-reform law, which is applicable only to drug admin! istration codes. These changes are retroactive to January 1, as contractors will begin implementing the changes on January 17. In the final physician fee schedule rule published in the November 15, 2004 Federal Register, CMS announced it would adopt G codes for 2005 that correspond to the new CPT drug administration codes that will take effect in 2006. Note: E-mail bcote@hcpro.com for the full transmittal billing instructions.
Source: CMS, change request 3631; Transmittal 129.
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Providers lined up for chronic care pilot
Medicare announced last week the nine healthcare organizations that will participate in the three-year Phase 1 pilot stage of its Voluntary Chronic Care Improvement Program. The program, introduced in April, was authorized under the Medicare Modernization Act to help about 150,000 to 300,000 Medicare beneficiaries with multiple chronic conditions-including complex diabetes, congestive heart failure, and chronic obstructive pulmonary disease-in fee-for-service plans better manage their conditions.
The chronic care organizations and the locations they will be serving are as follows: Aetna Health Management in Chicago; American Healthways in the District of Columbia and Maryland; CIGNA HealthCare in Georgia; Health Dialog Services Corp. in Pennsylvania; Humana in Central Florida; LifeMasters Supported SelfCare in Oklahoma; McKesson Health Solutions in Mississippi; Visiting Nurse Service of New York in partnership with United HealthCare Services Evercare in Queens and Brooklyn in New York City; and XLHealth in Tennessee. The first program is expected to open operations by this upcoming spring.
Medicare said it will use historical claims data to identify Medicare beneficiaries by geographic area and then screen them for eligibility in a disease management program. Those beneficiaries targeted will be assigned to either an intervention group or a control group. Since the program is voluntary, those who are contacted by one of these organizations will be given the option to decline participation. Beneficiaries will not be charged for the program's services, and they will not be required to change physicians.
Each of the local chronic care organizations will offer self-care guidance and support to beneficiaries. The programs will be responsible for promoting increased adherence to evidence-based care, reducing unnecessary hospital stays and emergency department visits, and avoiding costly complications. However, to receive payment, the programs will have to achieve a 5% reduction in overall patient costs.
One of the companies-Nashville-based American Healthways (which will provide services directly to beneficiaries in Maryland and the District of Columbia and will collaborate with CIGNA HealthCare in Georgia)-said it is not daunted by this payment structure. "We know what we're actually getting into with these projects from real-life experiences, and we are confident of our prospects for success," said President and CEO Ben Leedle Jr., at a teleconference the day after the Medicare announcement.
The Health and Human Services secretary is authorized by the MMA to precede with Phase II expansion within two to three years after Phase I if it determines that the conditions for expansion are met. The program components that need to be successfully met are improved clinical outcomes, increased beneficiary satisfaction, and fulfillment of Medicare spending targets for an assigned population.
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Part B deductible updates for Medicare notices
Section 629 of the Medicare-reform law increased the Medicare Part B deductible from $100 to $110 and on Friday CMS gave its carriers and fiscal intermediaries information both will use to update their 2005 Medicare Summary Notice (MSN) forms. CMS had not provided these instructions back in September when the agency first released the new deductible. Changes to the MSNs must be in place by January 1. Carriers, for example, will have to change the back of their MSNs so that the forms include the following language:
YOUR RESPONSIBILITY: The amount in the You May Be Billed column is your share of cost for the services shown on this notice. You are responsible for:
- annual deductible: taken from the first Medicare Part B approved charges each calendar year
- coinsurance: 20% of the Medicare approved amount, after the deductible has been met for the year
- the amount billed, up to the limiting charge, for unassigned claims
- charges for services/supplies that are not covered by Medicare. You may not have to pay for certain denied services. If so, a NOTE on the front will tell you.
Contact Joe Bryson at jbryson2@cms.hhs.gov or 410-786-2986 if you have questions.
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Poll shows Medicare education low on new benefits
Just one year after the Medicare Modernization Act (MMA) was signed into law, many beneficiaries still appear to be in the dark about what benefits are available to them--particularly regarding prescription drug and preventive health care benefits, according to a new survey prepared after the election for the Washington-based Federation of American Hospitals (FAH).
The poll, conducted Nov. 17-21 by American Viewpoint of Alexandria, VA, surveyed 1,000 registered voters and 478 voters age 65 older. When asked if they were aware of the prescription drug benefit, 37% of all respondents said yes, and 62% said no. Among those age 65 years or older, the response was 53% yes and 44% no. "Physicians, hospitals and pharmaceutical companies can play a big part in reversing these stats," says public relations consultant Shannon White.
Poll highlights:
- Only 33% of those age 65 or older said they were likely to sign up for the Medicare prescription drug benefit
- 61% said they were not likely or would not sign up for the benefit
- 49% of all respondents said they would be likely to sign up, while 45% said not likely or not at all
These percentages point to the work ahead for health plans and plan administrators to get beneficiaries to sign up, said FAH President Chip Kahn. "Those numbers have to be a lot higher."
Similarly, the percentage of beneficiaries aware of preventive benefits available in 2005 under Medicare was low. For instance, when respondents were told of three new benefits--a one-time initial awareness exam, a screening blood test for early detection of cardiovascular disease, and a diabetes screening test--only 31% of those over age 65 said they were aware of those benefits. Among all respondents, only 18% said they aware of the benefits. For more information on the survey, see www.fah.org.
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Chemo payment demonstration rules released
On December 10, CMS released billing instructions to practitioners interested in participating in the 2005 chemotherapy project to help cancer patients control pain, minimize nausea and vomiting, and reduce fatigue (see below for how to receive the full instructions in easy-to-read bullet format). CMS will use the data to evaluate how these symptoms affect quality of life. Practitioners must bill one of 12 applicable G codes for each patient status factor assessed during a chemotherapy encounter in order to receive a payment under the demonstration. A patient chemotherapy encounter is defined as chemotherapy administered through intravenous infusion or via the push technique. During the demonstration, an additional payment of $130 per encounter will be paid to participating practitioners for submitting the patient assessment data. These services are paid on an assignment basis, and the usu! al Part B deductible and coinsurance apply. The rules here take effect January 1.
A spokesperson from CMS shared several payment tips with Medicare Reform Advisor, including the following:
TIP: If you bill more than one symptom assessment code from the same category for the same date of service on a claim-for example, if the provider bills for G9021 and G9022 for the same date of service-carriers will reject the claim as unprocessable. Use remittance advice reason code 16 and remark code N185 for this. Use the remark code generated for the service that is least intensive; in the scenario above, generate N185 for code G9021.
Payment
During the demonstration, CMS will pay providers based on 80% of the actual service charge or the allowance by code (whichever is less). Contractors must use the following allowances for the symptom G codes: G9021-G9024 ($43.34); G9025-G9028 ($43.33); G9029 to G9032 ($43.33).
For a full list of the acceptable G codes and the full CMS instructions, e-mail bcote@hcpro.com and write "Chemo Demonstration Request" in the subject line.
Source: CMS change request 3654, Transmittal 12.
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Case studies clarify new hospice counseling benefit
Part I of II
Effective January 1, 2005, section 512 of the Medicare-reform law allows hospices a one-time payment for evaluation and counseling services furnished by physicians. The physicians must be either the medical director of or employee of a hospice agency. To be eligible for the payment under this MMA section, make sure the beneficiary
- Has a terminal illness
- Has not made a hospice election to this point
- Has not previously received the preelection hospice services under this benefit
These preelection hospice services include a physician evaluating the individual's need for pain and symptom management and counseling the individual regarding hospice and other care options and may include advising the individual regarding advanced care planning.
The services that comprise this benefit are currently available through other Medicare benefits. For example, evaluation and counseling are often provided by an individual's physician as well as by other sources such as discharge planners, case managers, social workers and nonphysician providers; therefore, the service may not be reasonable and necessary for all individuals. Depending upon the extent that beneficiaries have already received Medicare-covered evaluation and counseling with respect to end-of-life care, the hospice preelection benefit would seem duplicative.
However, if a beneficiary or the beneficiary's physician deem it necessary to seek the expertise of a hospice medical director or physician employee, this benefit is available to ensure that a beneficiary's end-of-life options for care and pain management are addressed.
Because the decision to utilize this benefit is determined by the beneficiary or the beneficiary's physician, the evaluation and counseling service may not be initiated by the hospice-that is, the entity receiving payment for the service. Payments by hospice agencies to physicians or others in a position to refer patients for services furnished under this provision may implicate the federal anti-kickback statute.
If the beneficiary's physician is also the medical director or physician employed by a hospice or possesses expertise in the provision of palliative or hospice care, CMS believes that this physician already possesses the expertise necessary to furnish end-of-life services. CMS further believes that this physician will have received payment for these services through the use of evaluation and management codes.
The following are five cases to help you figure out under what circumstances to use the new hospice benefit:
Case I: A thoracic surgeon has diagnosed a patient hospitalized in an acute care facility, with end-stage lung cancer with a prognosis of six months or less, if the disease runs its normal course. The patient has been informed of this diagnosis. The physician, with the patient's concurrence, requests a consult by the hospital's palliative care team. The team meets with the patient, discusses options, evaluates the patient's pain and symptoms, and makes recommendations including hospice care.
CMS assessment: Utilization of the evaluation and consultation benefit is not appropriate.
Case II: A patient with terminal cervical cancer has been receiving aggressive curative care as an outpatient, which has not been successful. The patient's physician, nurse and social worker have discussed the possibility of hospice. The patient decides to seek information from a hospice.
CMS assessment: Utilization of the evaluation and consultation benefit is appropriate.
Coding and reimbursement
Since the evaluation and counseling provision is not a service within the hospice benefit, payment for these services are not included in the hospice payment cap. Payment to the hospice agency for the provision of this evaluation and counseling service is made using HCPCS code G0337. The national payment amount for this service for FY 2005 will be $54.57. Future changes in the rate will be identified in the physician fee schedules.
Editor's note: Part II will appear next week with additional case studies.
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NEED TO CONTACT US?
Bryan Cote
Executive Editor
860-232-6367
E-mail address: bcote@hcpro.com |
