Medical Oncology Services and External Infusion Pumps. Part B Provider Outreach and Education February 2016

Transcription

1 Medical Oncology Services and External Infusion Pumps Part B Provider Outreach and Education February 2016

2 DISCLAIMER This information release is the property of Noridian Healthcare Solutions, LLC. It may be freely distributed in its entirety but may not be modified, sold for profit or used in commercial documents. The information is provided as is without any expressed or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide legal advice. All models, methodologies and guidelines are undergoing continuous improvement and modification by Noridian and CMS. The most current edition of the information contained in this release can be found on the Noridian website at and the CMS website at The identification of an organization or product in this information does not imply any form of endorsement. CPT codes, descriptors, and other data only are copyright 2016 American Medical Association. All rights reserved. Applicable FARS/DFARS apply. February

3 Agenda Overview Drugs and Biologicals Evaluation and Management Services Administration Hydration Therapeutic, prophylactic, diagnostic injections and infusions Chemotherapy External Infusion Pumps Durable Medical Equipment Minimize Common Errors CERT Reminders Resources February

4 Helpful Acronyms ABN CERT ESA IOM LCD MPFS NCCI OCM RA SADs Advance Beneficiary Notice of Noncoverage Comprehensive Error Rate Testing Erythropoiesis-Stimulating Agents Internet Only Manual Local Coverage Determination Medicare Physician Fee Schedule National Correct Coding Initiative Oncology Care Model Recovery Auditor Self-Administered Drugs February

5 Overview

6 Medical Necessity Document medical necessity within medical records Authenticated medical records Records must provide clear evidence of the need for treatments Ongoing significant benefit Objective measurements Complexity of skill required by treating practitioner must be clear February

7 Oncologist Role 125 Treatment Counseling Diagnosis Disease dynamics Treatment options Recommended course of treatment February

8 Oncology Disciplines Surgical oncology Radiation oncology Medical oncology February

9 Medical Oncology Drugs and Biologicals

10 Office Chemotherapy Charges 126 Cost of drug(s) Incident to guidelines Administration cost Other covered services February

11 Providing Drugs Incident To Provision May not instruct patients to purchase drugs then bring to provider s office for administration Drug charge included in physician s bill and cost represents expense to physician Pharmacies can not bill Medicare Part B for drugs furnished to a physician for administration to a Medicare beneficiary Pharmacies, suppliers and providers can not bill Medicare Part B for drugs dispensed directly to a beneficiary for administration incident to a physician service, such as refilling an implanted drug pump February

12 Donated or Free of Charge Patient Supplied Drug To avoid drug administration denial, drug code must be on same or prior claim Include the following information: Item Description 19 (Narrative) Drug Donated with description, strength and dosage when billing Not Otherwise Classified (NOC) HCPCS 24D Drug (J code) HCPCS 28 Billed amount of $0.00 or $0.01 February

13 Medicare Drug Benefit 127 Not self administered Incident to physician service Reasonable and necessary Not excluded FDA approved February

14 Medicare Drug Pricing Percent of the Average Sales Price (ASP) Updated quarterly (CR9351) March 2015 February

15 Top Adjudication Issues Unlisted codes or NOC J3490, J9999, and J3590 Name of the drug, NDC number and dosage Block 19 Electronic equivalent Bill the correct number of units Claims not providing adequate information deny unprocessable February

16 Unlabeled Use for Anti-Cancer Drugs Use not included as an indication on drug s label as approved by the FDA May be covered if contractor determines to be medically accepted Consideration include: Major drug compendia Authoritative medical literature Accepted standards of medical practice 129 February

17 Off-Label Use in Anti-Cancer Regimen Regimen is a combination of anti-cancer agents clinically recognized to treat specific cancers Supported in compendia or peer-reviewed medical literature Contractor may maintain its own subscriptions for consideration Contractor may request literature supporting off-label use from the physician February

18 ESA for Cancer Patients 132 Stimulate formation of new red blood cells Decrease anemia Decrease need for transfusions Epoetin Alfa anemia in patients on chemotherapy Darbepoetin Alfa - anemia due to effects of chemotherapy in patient with non-myeloid malignancies February

19 Billing Erythropoietin (EPO) 133 J0881 = Darbepoetin alfa J0885 = Epoetin Alfa ICD-10: Review Local Coverage Determinations: JE: JF: February

20 Required Reporting of the Hematocrit or Hemoglobin Reading Administration of an ESA J0881, J0882, J0885, J0886 and Q4081 Administration of Part B anti-anemia drug Test Readings in Loop 2400 MEA01 segment Hemoglobin: MEA02=R1 Hematocrit: MEA02=R2 Test results: MEA03 (3 digit plus decimal point numeric test result) Examples: 2400/MEA/TR/R1/10.5 (hemoglobin) or TR/RT/32.3 (hematocrit) 133 February

21 Medical Oncology & Evaluation & Management Services

22 Established Patient Office or other outpatient visit for E/M of an established patient, which requires at least two of these three key components History Exam Decision making Levels depend on problems presented Records should tell a complete story of the patients condition February

23 E /M Code Based on Time % of time or more Counseling Coordination of care Select code level by time Medical record Note counseling time Note total time of visit February

24 Medical Record 136 Document Diagnosis Prognosis Treatment options Treatment plan Side effects Recovery February

25 Administration Coding

26 Administration Services 139 Hydration Therapeutic, prophylactic, and diagnostic injections and infusions (excluding chemotherapy) Chemotherapy administration February

27 Administration Coding Hydration

28 Hydration Infusion, initial, up to 1 hour Minimum time duration of 31 minutes is required to report each additional hour List separately in addition to primary service Hydration provided secondary or subsequent to initial service Use With 96360, 96365, 96374, 96409, February

29 Hydration Time Billing Total Time of Hydration Infusion Billing Example minutes only minutes x 1 and x minutes x 1 plus x minutes x 1 plus x 3 February

30 Administration Coding Therapeutic, prophylactic diagnostic injections and infusions (excluding chemotherapy)

31 Infusion Codes Other than Chemotherapy IV infusion, initial, up to 1 hour Each additional hour List with primary code or For > 30 minutes beyond 1 hour Additional sequential infusion, 1 hour Concurrent infusion List with primary code 96365, 96366, 96374, 96413, 96415, 96416, 96422, Report only once per date of service February

32 Injections Codes Other than Chemotherapy Injection, subcutaneous or intramuscular Intra-arterial IV push, single/initial drug Each additional IV push, new drug List with primary code (96365, 96374, 96409, 96413) Unlisted February

33 Included in Administration 142 Local anesthesia IV start Access to indwelling IV, subcutaneous catheter, or port Flush at conclusion of infusion Standard tubing, syringes and supplies Preparation of chemotherapy agent(s) February

34 E/M and Injections/Infusions 142 Modifier 25 on E/M code with Significant identifiable problem Clearly document February

35 Administration Coding Chemotherapy Administration

36 96401 Chemotherapy administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic Chemotherapy administration, subcutaneous or intramuscular; hormonal antineoplastic Chemotherapy administration; intralesional, up to and including 7 lesions Chemotherapy administration; intralesional, more than 7 lesions Chemotherapy administration; intravenous, push technique, single or initial substance/drug Chemotherapy administration; intravenous, push technique, each additional substance/drug (list separately in addition to code for primary procedure) Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug Chemotherapy administration, intravenous infusion technique; each additional hour (list separately in addition to code for primary procedure) Chemotherapy administration, intravenous infusion technique; initiation of prolonged chemotherapy infusion (more that 8 hours), requiring use of a portable or implantable pump February

37 96417 Chemotherapy administration, intravenous infusion technique; each additional sequential infusion (different substance/drug), up to 1 hour (list separately in addition to code for primary procedure Chemotherapy administration, intra-arterial; push technique Chemotherapy administration; intra-arterial; infusion technique, up to 1 hour Chemotherapy administration; intra-arterial; infusion technique, each additional hour (list separately in addition to code for primary procedure) Chemotherapy administration; intra-arterial; infusion technique, initiation of prolonged infusion (more than 8 hours), requiring the use of a portable or implantable pump Chemotherapy administration into pleural cavity, requiring and including thoracentesis Chemotherapy administration into peritoneal cavity via indwelling port or catheter Chemotherapy administration, into CNS (e.g. Intrathecal), requiring and including spinal puncture February

38 Other Chemotherapy Administrations Injection, subarachnoid or intraventricular via subcutaneous reservoir, single or multiple agents Unlisted procedure February

39 IV or Intra-Arterial Push 144 Healthcare professional continuously present Administer the drug Observe patient OR Infusion of 15 minutes or less February

40 Bundled into Chemotherapy Administration 144 Local anesthesia IV start Access to indwelling IV, subcutaneous catheter or port Flush at conclusion of infusion Standard supplies Tubing, syringes Saline used in mixing drug(s) Preparation of chemotherapy agent(s) February

41 Additional Services 145 Office visit only for line maintenance Line irrigation & inspection of skin site Bill IOM 100-4, Chapter Declotting a catheter or port Bill February

42 CPT Not allowed with or without the modifier 25 on the same day as non-chemotherapy or chemotherapy administration codes. Not allowed for: Phone calls to patients Drawing of blood for laboratory analysis or when performing other diagnostic tests Administration of medications when an injection or infusion code is submitted separately February

43 Chemotherapy Documentation Patient name, date of birth, and date of service Name and dosage of drug administered Infusion start and stop times for each drug to support length of time infusion was administered Signed and dated physician order for drug(s) administered, dosage, frequency and duration of treatment Progress notes to support medical necessity Staff documentation matches codes billed Staff administering must sign, date/time and credentials the admin sheet February

44 Chemotherapy Billing Tips 145 Specific administration service(s) CPT codes Specific drug(s) or biological(s) used HCPCS codes Dosage Report code(s) for each method of administration Report only 1 initial service code Drugs given independently or sequentially to chemo Use 96360, 96361, 96365, February

45 Additional Billing Tips 148 Report 1 initial service code Unless protocol requires 2 separate IV sites Modifier 76 if simultaneously Modifier 59 if different encounter Saline, anti-nausea or non-chemo drugs Same day sequentially covered Same day, same time - bundled February

46 External Infusion Pumps Presented by the DME MAC for Jurisdiction D Local Coverage Determination L33794 and Policy Article A52507 National Coverage Determination

47 DMEPOS Payment Categories Capped rental item E0779, E0781, E0791 Paid on monthly basis Caps at 13 months Ownership transfers to beneficiary Inexpensive and Routinely Purchased items E0780 Can be rented or purchased February

48 External Infusion Pump Reminders Beneficiary must use same pump during entire rental period Cannot change pumps for each round of chemotherapy Pump cannot be used on multiple beneficiaries Must comply will all supplier standards February

49 Required Documentation Dispensing Order Detailed Written Order (DWO) DME Information Form (DIF) Medical records supporting condition requiring therapy Proof of refill requirements Proof of Delivery (POD) February

50 Basic elements Beneficiary s name Physician s name DWO Date of the order and the start date, if start date is different from the date of the order Detailed description of the item(s) Physician signature and signature date February

51 DWO Additional Elements Item(s) to be dispensed Dosage or concentration, if applicable Route of administration Frequency of use Duration of infusion, if applicable Quantity to be dispensed Number of refills February

52 Revised DIF Drug changes Drug added DIF Include existing drugs listed along with all drugs used with pump February

53 DMEPOS Resources LCD/Policy Article /lcd/active Supplier Manual on/supplier-manual Documentation Checklist /documentation-checklists DME Information Form (DIF) February

54 Minimize Errors, Maximize Revenue Get it done right the first time!

55 Place of Service Document the place of service Reimbursement tied to the place of service; it varies between the facility outpatient department (22) and non-facility, such as the physician s office (11) February

56 Advanced Beneficiary Notice (ABN) An ABN is required for payment prior to drug administration if the treatment is known to be noncovered by Medicare Remember that completion of an ABN must contain the drug as well as potential cost February

57 Drug Formulation Be exact in reporting which drug formulation oral or IV was ordered and billed Example: Oral anti-emetic drug Zofran (Q0162) is ordered but the IV formulation of Zofran (J2405) is documented and billed on claim The reverse is common as well: the IV formulation is ordered and documented, but the claim form indicates an oral formulation was billed Verify correct units of service based on code February

58 Discarded Drug- Modifier JW If after administering a dose/quantity of the drug or biological to a Medicare patient, a provider must discard the remainder of a single use vial or other single use package, the program provides payment for the amount of drug or biological discarded as well as the dose administered, up to the amount of the drug or biological as indicated on the vial or package label Multi use vials not subject to payment Detailed instructions regarding use of JW modifier on Noridian website Guidance/Guidance/Manuals/Downloads/clm104c17.pdf February

59 Insufficient Documentation Submitted Does not support beneficiary was seen for a significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service Submitted progress note states: Patient is here for chemo. No new problems. Same as last visit February

60 Common Documentation Error Signature Requirements Legible full signature or first initial and last name Legible signature over typed or printed name Letterhead indicates name of signer Initials over typed or printed name, signature log Stamped signature never acceptable Additional information: Education/Medicare-Learning-Network- MLN/MLNMattersArticles/downloads/MM6698.pdf Attestation Statement available on our website February

61 Electronic Signatures Providers using electronic systems need to recognize there is potential for misuse or abuse with alternate signature methods The individual whose name is on the alternate signature method and the provider bears the responsibility for authenticity of information being attested Signature Requirements FAQs February

62 Resources

63 CMS Resources IOM Publication , Medicare Benefit Policy Manual, Chapter 15, Sections and 60 Incident to, Covered Medical Services, Off-label drugs IOM Pub , Medicare Claims Processing Manual, Chapter 17, Sections 40, 80.8 and Drugs and Biologicals IOM Pub , Medicare Claims Processing Manual, Chapter 12, Sections 30.5 Chemotherapy Administration February

64 Noridian Resources Browse by oncology specialty: JE: ology-hematology JF: logy-hematology Patients Supplying Their Own Drugs: JE: JF: February

65 E/M Guide 89 pages November /1997 guidelines February

66 Upcoming Part B Webinars Date Time (CT/PT) Webinar Title 2/18/16 1:00 pm/11:00 am Global Surgery Modifiers 2/23/16 1:00 pm/11:00 am Influenza and Pneumonia Roster Billing 2/23/16 3:00 pm/1:00 pm Anesthesia Services 2/24/16 3:00 pm/1:00 pm Outpatient Therapy Services 2/29/16 11:00 am/9:00 am Appeals I The Basics 2/29/16 1:00 pm/11:00 am Chiropractic Basics REGISTER NOW! JE JF February

67 CEU Reminder Attend entire workshop to earn CEU(s) Take short polling survey Pops up after closing out of webinar CEU ed 3 days after presentation Earn 1 CEUs today No password/index number needed for AAPC PDF presentation ed again with CEU Q/A posted after 30 business days February

68 Questions? Thank you! Thank you!