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NEWS

CODING & BILLING G & BILLING

Oncology Code Update 2011

by Cindy Parman, CPC, CPC-H, RCC

New Codes and Updated Descriptors

hegoodnews:therearefew procedurecodechangesaffectingradiationandmedicaloncologyfor2011,soitshouldbeeasy toupdatechargeticketsandfee schedules.Theonlychangetodrug administrationcodingfor2011 involvesthedeletionofcode96445 (chemotherapyadministrationinto peritonealcavity,requiringand includingperitoneocentesis).This codehasbeenreplacedwith: 96446: Chemotherapyadministrationintotheperitonealcavity viaindwellingportorcatheter. Bydefinition,thephysicianprovidesdirectsupervisionandis immediatelyavailableforany problemsrelatedtoaccessingthe intraperitonealportreservoir.The physicianalsoassessesthepatient's responsetotreatmentandperforms anynecessarysymptommanagement.Theadministrationofdilutionalfluidsisincludedinthiscode andisnotseparatelyreportedas intraperitonealhydration. Ashasbeenseeninprioryears, twomorecodeshavebeenaddedfor theplacementoffiducialmarkers: +49327: Laparoscopy,surgical; withplacementofinterstitial device(s)forradiationtherapy guidance(e.g.,fiducialmarkers, dosimeter),intra-abdominal, intrapelvic,and/orretroperitoneum,includingimageguidance, ifperformed,singleormultiple. (Listseparatelyinadditionto codeforprimaryprocedure.) +49412: Placementofinterstitial device(s)forradiationtherapy guidance(e.g.,fiducialmarkers, dosimeter),open,intra- abdominal,intrapelvic, and/orretroperitoneum, includingimageguidance,if performed,singleormultiple. (Listseparatelyinadditionto codeforprimaryprocedure.)

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appyNewYear!And onceagain,therearecode changes,newregulations,andthousandsofpagesof rulesandguidelinestodigestand incorporateintoourhospitals, physicianpractices,andcancer programs. Inadditiontotheregulatory issueslistedbelow,themore than4,400pagesoftheHospital OutpatientProspectivePayment System(HOPPS)andMedicare PhysicianFeeSchedule(MPFS) finalrulesalsoincludethe implementationofcertainitems fromtheAffordableCareAct (ACA),suchasthewaiverof beneficiarycost-sharingfor preventiveservicesinallsitesof service,paymentforanannual wellnessvisit,coverageofbone densitytests,andtheintentto considerapaymentadjustmentfor certaincancerhospitals.

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Asindicatedinthecodedescriptors,bothoftheseprocedurecodes are"add-on"codesbilledinaddition tothelaparoscopicoropensurgical procedurewhenfiducialmarkersare placedduringthesamesurgicalsession.Imageguidanceisincludedwhen performedandnotseparatelybilled witheitherofthesesurgerycodes. Inaddition,oneofthecodesfor fiducialmarkerplacementhasan updateddescriptioneffectiveJan.1, 2011: 55876: Placementofinterstitial device(s)forradiationtherapy guidance(e.g.,fiducialmarkers, dosimeter),prostate(vianeedle, anyapproach),singleormultiple. Thecodedescriptornolonger includestheword"percutaneous" andinsteadidentifiesfiducialmarker placementintotheprostatebyany approach. Thereisalsoanewprocedurecode fortheplacementofabrachytherapy applicator: 57156: Insertionofavaginalradiationafterloadingapparatusfor clinicalbrachytherapy. Procedurecode57155(insertionof uterinetandemand/orvaginalovoids forclinicalbrachytherapy)underwentaminimalchangeinverbiage: "tandem"isnowsingular,instead ofthepriorlistingof"tandems."In addition,procedurecode57156was addedtothecodeclassificationto reporttheinsertionofavaginalcylinderorsimilardevicepriortothe administrationofbrachytherapy.As withallprocedurecodes,thephysicianwhoperformsanddocuments theprocedurewillreportthecorrect surgicalservice. The2011CPT Manualalso includesupdatedinstructionssurroundingthereportingofprocedure code77427(radiationtreatment management,5treatments).This

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PhotograPhs/bigstock Photo

codespecificallyincludes: Radiationtreatmentmanagementrequiresand includesa minimumofoneexamination ofthepatientbythephysician formedicalevaluationand management(e.g.,assessment ofthepatient'sresponseto treatment,coordinationofcare andtreatment,andreviewof imagingand/orlabtestresults withdocumentation)foreach reportingoftheradiationtreatmentmanagementservice. Thisupdatedinstructionclarifies thatiftheradiationoncologistdoes not performtherequiredface-to-face patientevaluationduringa5-fraction weekoftherapy,code77427 cannot bechargedforthatweekoftherapy. ChangestoHCPCSLevelII codesalsoincludetherevisionof onemodifierandtheadditionofa modifiertoreporttheprovisionof AdvanceBeneficiaryNoticesand waiversofliability: GA:Waiverofliabilitystatement issuedasrequiredbypayerpolicy, individual case.

GU:Waiverofliabilitystatement issuedasrequiredbypayerpolicy, routinenotice.

Thefollowingnewcodeshavebeen establishedforhematologyand oncologydrugs: C9279: Injection,ibuprofen, 100mg. J1559:Injection,immuneglobulin (Hizentra),100mg. J1599:Injection,immuneglobulin, intravenous,non-lyophilized(e.g., liquid),nototherwisespecified, 500mg. J7185:Injection,FactorVIII(antihemophilicfactor,recombinant) (Xyntha),perIU. J9328:Injection,temozolomide, 1mg. Inthepast,somedrugshavebeen listedwithmultipleHCPCScodes todescribevariousquantitiesof thespecificdrug.Forcalendaryear 2011,manyoftheseHCPCScodes havebeendeleted,leavingonlythe codedescriptorwiththelowest quantity.Forexample,ninecodes forcyclophosphamidearedeleted

effectiveJan.1,2011,leavingonly codeJ9070(cyclophosphamide, 100mg)forreportingpurposes. Oncologydrugcodesthatare deletedfor2011canbefoundin Table1,below). Table2(below)isalistofagents thatwerereportedwithdifferent codesduring2010,andwhichhave nowbeendeletedandreplacedwith anewHCPCScodefor2011. Finally,Medicareremovedprior coveragelimitsontobaccocessationcounselingeffectiveJan.1, 2011,andnowprovidesreimbursementforapatient: Whousestobacco,regardless ofwhetherthepatienthassigns orsymptomsoftobacco-related disease; Whoiscompetentandalertat thetimethatcounselingisprovided;and Whosecounselingisfurnished byaqualifiedphysicianorother Medicare-recognizedpractitioner. Asaresultofthischange,HCPCS codesC9801andC9802havebeen deleted,andtherearenewcodes todescribecounselingprovided toasymptomaticpatients: G0436:Smokingandcessationcounselingsessionforthe asymptomaticpatient;intermediate,greaterthan3minutes, upto10minutes. G0437:Intensive,greaterthan 10minutes. Rememberthattheexistenceofa procedureorsupplycodedoes not guaranteereimbursement;paymentforaservicedependsonthe patient'sinsurancepolicy,medical necessity,andotherdetermining factors.

Table 1. Oncology Drug Codes Deleted for 2011

Code J0128 J0970 J1390 J2321 J2322 J9080, J9090-J9097 J9110 J9140 J9290 J9291 J9375 J9380 Definition Injection,abarelix,10mg Injection,estradiolvalerate,upto40mg Injection,depo-estradiolcypionate,upto5mg Injection,nandrolonedecanoate,upto100mg Injection,nandrolonedecanoate,upto200mg Cyclophosphamide Injection,cytarabine,500mg Dacarbazine,200mg Mitomycin,20mg Mitomycin,40mg Vincristinesulfate,2mg Vincristinesulfate,5mg

Table 2. New or Revised HCPCS Codes for 2011 and Deleted Codes

New or Revised Code J1826:Injection,interferonbeta-1A,30mcg J7184:Injection,VonWillebrandfactorcomplex (human)Wilate,per100IU J9307:Injection,pralatrexate,1mg J9302:Injection,ofatumumab,10mg J9315:Injection,romidepsin,1mg J9351:Injection,topotecan,0.1mg J8562:Fludarabinephosphate,oral,10mg J9060:Injection,cisplatin,powderorsolution,10mg Deleted Code J1825:Injection,interferonbeta-1A,33mcg C9267:njection,VonWillebrandfactorcomplex I (human)Wilate,per100IU C9259:Injection,pralatrexate,1mg C9260:Injection,ofatumumab,10mg C9265:Injection,romidepsin,1mg J9350:Injection,topotecan,4mg C9292, Q2025:Fludarabinephosphate,oral,1mg J9062:Cisplatin,50mg

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AL CORNER

NEWS

Direct CODING & BILLING supervision. CMShasalso modifiedthedefinitionofdirect supervisionforallhospitaloutpaING & BILLING tientservicestorequire"immediate

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Hospital Regulatory Update

heCentersforMedicare&MedicaidServices(CMS)projects thathospitalswillreceive$39billionin2011foroutpatientservices furnishedtoMedicarebeneficiaries. TheHOPPSfinalruleestimatesa 2.35percentincreasetoMedicare paymentratesformostservicesthat wouldbepaidundertheHOPPS tomorethan4,000hospitalsin 2011. However,forhospitalsthat donotmeetqualityreportingdata requirements,the2011hospitaloutpatientupdateis0.35percent(2.35 percentmarketbasketupdateminus 2.0percentfornotreportingdata). Therearestillquestionsrelating tophysiciansupervisioninthehospitaloutpatientdepartment,soCMS hasonceagainrevisedandclarified theregulations.Theagencycontinuestorecognizesupervisionofhospitaloutpatienttherapeuticservices performedbymidlevelproviders, includingphysicianassistants,nurse practitioners,clinicalnursespecialists,certifiednurse-midwives,and licensedclinicalsocialworkers.

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availability"withoutreferencetothe boundariesofaphysicallocation.The agencywillbeestablishing--through futurerulemaking--anindependent committeeandaprocesstoconsider industryrequestsonanannualbasis forsupervisionlevelsotherthan directsupervisionforcertainindividualservices,andtomakerecommendationstotheagency.However, thedefinitionof"immediatelyavailabletofurnishassistanceanddirectionthroughouttheperformanceof theprocedure"hasnotchanged.The supervisormustnotbeperforming anotherprocedureorservicethathe orshecouldnotinterruptandthe supervisormustnotbesophysically farawayfromthelocationwherethe servicesarefurnishedthatheorshe couldnotintervenerightaway. Inaddition,theHOPPSfinal ruleprovidesthefollowingspecific guidance: AswehavestatedintheMedicare Benefit Policy Manual (Pub.No.100-02),Chapter6, Section20.5.24,"thesupervisory physicianornonphysicianpractitionermusthave,withinhisor herStatescopeofpracticeand hospital-grantedprivileges,the knowledge,skills,ability,and privilegestoperformtheservice orprocedure.Speciallytrained

ancillarystaffandtechnicians aretheprimaryoperatorsof somespecializeddiagnostic ortherapeuticequipment,and whileinsuchcasesCMSdoes notexpectthesupervisorypractitionertooperatetheequipmentinsteadofatechnician, CMSdoesexpectthephysician ornonphysicianpractitioner thatsupervisestheprovisionof theservicemustbeknowledgeableaboutthetestandclinically appropriatetofurnishthetest. Thesupervisoryresponsibilityismorethanthecapacityto respondtoanemergency,and includesfurnishingassistance anddirectionthroughoutthe performanceofaprocedureand, asappropriatetothesupervisoryphysicianornonphysician practitionerandthepatient,to changeaprocedureorthecourse ofcareforaparticularpatient. CMSwouldnotexpectthatthe supervisorypractitionerwould makealldecisionsunilaterally withoutinformingorconsulting thepatient'streatingphysician ornonphysicianpractitioner." Wedonotbelieveitissufficient orconsistentwithourrulesfor directsupervisionfortheindividualonsitetobecapableof onlyemergencymanagement. Thesupervisoryphysicianor nonphysicianpractitionerwho isphysicallypresentshouldhave

Table 3. Hematology and Oncology Drugs with Pass-through Status for 2011

Brand Name

Folotyn Arzerra Istodax Wilate Gammaplex Xgeva Provenge Cysview Jevtana Temodar Fusilev Mozobil Hycamtin Firmagon Fludara Feraheme

Code

J9307 J9302 J9315 J7184 C9270 C9272 C9273 C9275 C9276 C9279 J9328 J0641 J2562 J8705 J9155 J8562 Q0138

Definition

Injection,pralatrexate,1mg Injection,ofatumumab,10mg Injection,romidepsin,1mg Injection,vonWillebrandfactorcomplex(human),per100IU Injection,immuneglobulin,intravenous,non-lyophilized(e.g.,liquid),500mg Injection,denosumab,1mg S ipuleucel-T,minimumof50millionautologousCD54+cellsactivatedwithPAPGM-CSFin 250mlofLactatedRinger'sincludingLeukopheresisandallotherpreparatoryprocedures, perinfusion Injection,hexaminolevulinatehydrochloride,100mg,perstudydose Injection,cabazitaxel,1mg Injection,ibuprofen,100mg Injection,temozolomide,1mg Injection,levoleucovorincalcium,0.5mg Injection,plerixafor,1mg Topotecan,oral,0.25mg Injection,degarelix,1mg Fludarabinephosphate,oral,10mg Injection,ferumoxytol,fortreatmentofirondeficiencyanemia,1mg(non-esrduse)

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Oncology IssuesJanuary/February 2011

thetrainingandknowledgeto clinicallyredirecttheserviceor provideadditionalorders. Forcalendaryear2011,CMShasidentifiedas"extendeddurationservices" alimitedsetofserviceswithasignificantmonitoringcomponentthatcan extendforasizableperiodoftime, thatarenotsurgical,andthattypically havealowriskofcomplicationafter assessmentatthebeginningoftheservices. Forthesespecificservices,there isarequirementfordirectsupervision attheinitiationoftheservice,followedbygeneralsupervisionforthe remainderoftheservice.CMSstates thatthepointoftransitionfromdirect supervisiontogeneralsupervision shouldbe"documentedprominently inprogressnotesorinthemedical record."Extendeddurationservices thatmaybetransitionedtogeneral supervisionincludehydration(96360, 96361)andtherapeuticdrugadministration(96365-96376,C8957). Last,CMSissuedinstructionsto contractorstonotenforcethedirect supervisionrequirementinCritical AccessHospitals(CAHs)forcalendar year2011andisexpandingthisnonenforcementtoincludesmallrural hospitalswith100orfewerbeds. Drugs and biologicals. Forcalendaryear2011,CMSwillpayforthe acquisitionandpharmacyoverhead costsofseparatelypayabledrugsand biologicalswithoutpass-throughstatusattheaveragesalesprice(ASP)+5

percent. ThepaymentrateofASP+5 percentisbaseduponthecostof separatelypayabledrugsandbiologicals,calculatedfromhospitalclaims andcostreports,withanadjustment forpharmacyoverheadcosts. This methodologyreflectstheredistributionof$200millionofthepharmacy overheadcostcurrentlyattributed topackageddrugsandbiologicalsto separatelypayabledrugsandbiologicalswithoutpass-throughstatus. For2011,CMSwillcontinueto includeantiemeticdrugsinthedrug packagingrules.Theywillbepaid separatelyonly iftheiraveragecost perdayisgreaterthan$70,which isthe2011HOPPSdrugpackaging threshold.Currently,theonly5-HT3 antiemeticthatmeetsthecriteriafor separatepaymentispalonosetron HCl(codeJ2469).Thisantiemetic drugwillcontinuetobepaidseparatelyincalendaryear2011. CMSannouncedthatantiemetic drugfosaprepitant(J1453),immune globulinPrivigen(J1459),romiplostim(J2796,usedtotreatthrombocytopenia),andantineoplasticdrugs bendamustine(J9033)andixabepilone (J9027)arelosingtheirpass-through statuseffectiveDec.31,2010.Once pass-throughstatusexpires,thedrug willbepaidseparatelyonlyiftheestimatedcostperdayisgreaterthanthe OPPSpackagingthresholdof$70. Table3onpage12 liststhehematologyandoncologydrugsthatCMS hasgrantedpass-throughstatusfor

2011.Hospitalswillreceiveseparate reimbursementforthesedrugsin 2011. APCs.Thereareseveralchanges toAmbulatoryPaymentClassification(APC)assignmentsfor 2011,andakeychangeaffectscode 77338(multi-leafcollimatorIMRT treatmentdevice).CMSinitially proposedtocontinuetoassign procedurecode77338toAPC 303 (TreatmentDeviceConstruction), whichhadaproposedpayment of$198.12.Theagencyreceived numerouspubliccommentsthat clarifiedthiscodeisusedtoreport alldevicesthatarenecessaryforan IMRTtreatmentandthatatypical treatmentrequires3to9devices. Usingahypotheticalcostperunit forcode77338,CMSdetermined thatthiscodeshouldbeassigned toAPC 310(LevelIIItherapeutic radiationtreatmentpreparation) for2011,whichreimburses$926.74. However,CMSstatedthatnext yeartheagencywillreviewclaims datatodetermineifthisAPC assignmentremainsappropriatefor calendaryear2012. For2011,CMSwillcontinueto payseparatelyforbrachytherapy sourcesonaprospectivebasis, withpaymentratesbasedonthe 2009claims-basedmediancost persourceforeachbrachytherapy product.Inaddition,CMSwillpay forthestrandedandnon-stranded continued on page 14

Table 4. Separately Payable Brachytherapy Sources for 2011

HCPCS Code

A9527 C1716 C1717 C1719 C2616 C2634 C2635 C2636 C2638 C2639 C2640 C2641 C2642 C2643 C2698 C2699

Definition

IodineI-125,sodiumiodidesolution,therapeutic,permillicurie Brachytherapysource,non-stranded,Gold-198,persource Brachytherapysource,non-stranded,HighDoseRateIridium-192,persource Brachytherapysource,non-stranded,Non-HighDoseRateIridium-192,persource Brachytherapysource,non-stranded,Yttrium-90,persource Brachytherapysource,non-stranded,HighActivity,Iodine-125,greaterthan 1.01mCi(NIST),persource Brachytherapysource,non-stranded,HighActivityPalladium-103,greaterthan 2.2mCi(NIST),persource Brachytherapylinearsource,non-stranded,Palladium-103,per1MM Brachytherapysource,stranded,Iodine-125,persource Brachytherapysource,non-stranded,Iodine-125,persource Brachytherapysource,stranded,Palladium-103,persource Brachytherapysource,non-stranded,Palladium-103,persource Brachytherapysource,stranded,Cesium-131,persource Brachytherapysource,non-stranded,Cesium-131,persource Brachytherapysource,stranded,nototherwisespecified,persource Brachytherapysource,non-stranded,nototherwisespecified,persource

APC

2632 1716 1717 1719 2616 2634 2635 2636 2638 2639 2640 2641 2642 2643 2698 2699

Payment

$21.65 $190.12 $218.87 $28.07 $16,568.83 $56.24 $28.65 $37.15 $41.62 $36.55 $72.73 $65.56 $124.28 $66.57 $41.62 $28.07

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NEWS

CODING & BILLING ING & BILLING

"nototherwiseclassified"codes (C2698andC2699)basedonthe rateequaltotheloweststranded ornon-strandedprospective paymentrateforsuchsources, respectively,onapersourcebasis. Table4onpage13showsthe separatelypayablebrachytherapy sourcesforcalendaryear2011, theirAPCassignments,andthe nationalreimbursementamount (notadjustedforgeographicarea). Packaging and bundling.For 2011,CMScontinuestopackage paymentforitemsandservices insevencategoriesintothepaymentfortheprimarydiagnostic ortherapeuticmodalitytowhich theseitemsandservicesaretypicallyancillaryandsupportive. Thesevencategoriesinclude guidanceservices,imageprocessingservices,intraoperative services,imagingsupervision andinterpretation,diagnostic radiopharmaceuticals,contrast media,andobservationservices. Thefollowingradiationtherapy guidanceservicescontinuetobe packagedfor2011: 77421(stereoscopicguidance) 77014(CTguidance) 77011(CTguidanceforstereotacticlocalization) 77417(portfilms) 76950(ultrasoundguidance fortheplacementofradiation fields) 76965(ultrasoundguidance forinterstitialradioelement application) 0197T(intra-fractionlocalizationandtracking). CMScontinuestostressthat hospitalsshould"reportall HCPCScodesthatdescribe packagedservicesthatwere provided,unlesstheCPTEditorialPanelorCMSprovideother guidance."Theagencystated thatfailuretoreportcodesfor packagedservicesmakesitdifficulttotrackutilizationpatterns andresourcecosts.

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Physician and Freestanding Center Regulatory Update

heMedicarePhysicianFee Schedule(MPFS)specifiespaymentratestophysiciansandother providers,includingfreestanding radiationoncologycenters,for morethan7,000healthcareservices andprocedures,rangingfromsimpleofficevisitstocomplexsurgery. TheAffordableCareAct amendsthein-officeancillary servicesexceptiontothephysician self-referrallawasappliedtomagneticresonanceimaging(MRI), computedtomography(CT),and positronemissiontomography (PET),torequireaphysicianto disclosetoapatientinwritingat thetimeofthereferralthatthe patientmayobtaintheseservices fromanothersupplier. CMSwill requirethatthereferringphysicianprovidethepatientwithalist ofatleastfivealternativesuppliers withina25-mileradiusofthephysician'sofficelocationatthetimeof thereferralwhoprovidethediagnosticimagingservicesordered. Ofimportance,CMShas removedprocedurecode77014 (computedtomographyguidance forplacementofradiationtherapy fields)fromthislistofprocedures becausetheserviceisalwaysintegraltoandperformedduringa non-radiologicalmedicalprocedure.Thiscodewillnotbesubject tothedisclosurerequirement. New, revised, and potentially misvalued codes.TheAffordable CareActrequiresCMStoperiodicallyreviewandidentifypotentiallymisvaluedcodesandmake appropriateadjustmentstotherelativevaluesoftheservicesthatmay bemisvalued.Theagencyhasbeen engagedinavigorouseffortover thepastseveralyearstoidentify andrevisethesepotentiallymisvaluedcodes. Thefinalruleidentifies additionalcategoriesofservices thatmaybemisvalued,including

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codeswithlowworkrelativevalue units(RVUs)commonlybilledin multipleunitspersingleencounter andcodeswithhighvolumeandlow workRVUs. Specificcodesincluded onthelistforreviewincalendaryear 2011include 77334(complextreatmentdevice) 77290(complexsimulation) 77300(basicdosimetrycalculation). For2011,CMSreceivedAMArecommendationsfor325new,revised, andpotentiallymisvaluedCPT codesand93recommendeddeletions.Ofthe325codes,84were identifiedaspotentiallymisvalued, 125asnew,and116asrevised.The AMARelativeValueScaleUpdate Committee(RUC)providedphysicianworkRVUrecommendations for291codes.Ofthe291codes, CMSaccepted207(71percent)ofthe AMARUCrecommendedvalues andprovidedalternativevaluesfor theremaining84codes(29percent), whichisasignificantlyloweracceptanceratethaninprioryears.In responsetocomments,CMSstates thattheagencyhasintensifiedits scrutinyoftheworkvaluationsof new,revised,andpotentiallymisvaluedcodes.Table5onpage15isa listofselectmisvaluedworkRVUs. (Table53intheMPFSfinalrule includesacompletelistingofallmisvaluedworkRVUs.) Oneofthebiggestpayment reductionsimpactsCPTcode77427 (radiationtreatmentmanagement,5 treatments).For2011,theAMARUC reviewedthespecialtysurveyresults andagreedthatthesurveyedphysiciantimeof7minutespre-service,70 minutesintra-service,and10minutes immediatepost-serviceisappropriate.Uponreview,theAMARUC recommended3.35to3.45work RVUsforCPT77427.However, CMSmodifiedoneofthebuilding

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Table 5. Select Misvalued Work RVUs for 2011

CMS Decision AMA RUC Interim Work RVUs 2011 Final Code CPT Short Descriptor Recommended Work RVUs

49327 49412 55876 57155 57156 77427

Lapinsertdeviceforradiationtherapy Insertdeviceforradiationtherapyguideopen Placeradiationtherapydevice/markerprostate Insertuterinetandem/ovoids Insertvaginalbrachytherapydevice RadiationtreatmentmanagementX5

2.38 1.50 1.73 5.40 2.69 3.35or3.45

Agree Agree Agree Disagree Disagree Disagree

2.38 1.50 1.73 3.37 1.87 2.92

Table 6. 2011 Total Allowed Charge Impact by Specialty*

Specialty Work RVU Changes PE RVU Changes PE RVU Changes FULL MEI Rebasing TRAN Total FULL Total TRAN

Hematology/Oncology 0% RadiationOncology -2% RadiationTherapyCenters 0%

-4% -9% -13%

-2% -3% -5%

2% 4% 8%

-2% -7% -6%

0 -1% 3%

*Thesepercentagesdonotincludethe-24.9%potentialCostFactorreduction.

blocksthattheRUCusedtocalculatetheworkRVUsandassignedan alternativevalueof2.92workRVUs toCPT77427onaninterimfinal basisfor2011,whichrepresentsa26 percentreimbursementreduction. Inaddition,CPTcodes77785, 77786,and77787(remoteafterloadinghigh-doserateradionuclide brachytherapy)wereidentifiedby theFive-YearReviewIdentification Workgroupthroughthe"CMSFastestGrowing"and"HighVolume Growth"potentiallymisvaluedcodes screens.Duetochangesinthepractice expenseallocationoftheIridium-192 brachytherapysourceandcorrection ofthephysicistlabortime,thesecodes willhaveincreasedreimbursementfor calendaryear2011. PQR. ThePhysicianQuality ReportingSystem(formerly,thePhysicianQualityReportingInitiative orPQRI)isavoluntaryreporting program,firstimplementedin2007, thatprovidesanincentivepaymentto identifiedeligibleprofessionals(EPs) whosatisfactorilyreportdataon qualitymeasuresforcoveredMPFS servicesfurnishedtoMedicarePart Bbeneficiariesduringaspecified reportingperiod. TheAffordable CareActmakesanumberofchanges tothePhysicianQualityReporting (PQR)System,includingauthorizing incentivepaymentsthrough2014,and

Oncology IssuesJanuary/February 2011

requiringapenaltybeginningin2015 forEPswhodonotsatisfactorilysubmitqualitydata. For2011,participantsmayearnan incentivepaymentof1percentofthe EP'sestimatedtotalallowedcharges forcoveredMPFSservicesunder MedicarePartBprovidedduringthe reportingperiod.CMSismakinga numberofkeychangesin2011for PQR,including: Adding20individualmeasures andonenewmeasuresgroup Increasingthenumberofmeasuresthatcanbereportedthrough electronichealthrecordssystems (EHRs)to20 Reducingtheclaims-basedreportingsamplerequirementsofindividualmeasuresfrom80percent to50percent CreatinganewGroupPractice ReportingOption(GPRO). Inaddition,EPsandgrouppractices whoaresuccessfule-prescribersfor 2011mayearnanincentivepayment of1percentoftheEP's(orgroup practice's)estimatedtotalallowed chargesforMPFSservicesunder MedicarePartBprovidedduring thereportingperiod. Thereporting periodforincentivepaymentsunder theeRxIncentiveProgramfor2011 willbetheentirecalendaryear(January1throughDecember31,2011).

Beginningin2012,theprogram willimposepaymentadjustments onEPswhoarenotsuccessful e-prescribersduringtheapplicable reportingperiod. CMSestimates thattheincentivepaymentsfor the2011eRxIncentiveProgram (whichwillbepaidin2012)willbe approximately$148million. Thecombined2011total allowedchargeimpactbyspecialty canbefoundinTable6,above. Cindy Parman, CPC, CPC-H, RCC, is a principal at Coding Strategies, Inc., in Powder Springs, Ga.

Followingisalistofresourcesused whencompilingthesecodingand regulatoryupdates: 1.2011MedicarePhysicianFee ScheduleFinalRule.Available onlineat:http://www.cms.gov/PhysicianFeeSched/PFSFRN/itemdetail. asp?filterType=none&filterByDID=99&sortByDID=4&sortOrder=descen ding&itemID=CMS1240932&intNum PerPage=10.LastaccessedDec.2,2010. 2.2011MedicareOPPSFinal Rule.Availableonlineat:http:// www.cms.gov/HospitalOutpatientPPS/HORD/itemdetail. asp?filterType=none&filterByDID=99&sortByDID=3&sortOrder=descen ding&itemID=CMS1240960&intNum PerPage=10.LastaccessedDec.2,2010. 15

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