2014 nuclear medicine cr&p 4-12-2014€¦ · implemented march 7, 2014 non-shared systems and...

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©2013 Merlino Healthcare Consulting Corp.Office & Cell: 1-888-60M-HCCC (1-888-606-4222)

Fax: 1-888-606-4223 – Email: [email protected]

April 13, 2014

Presented by: Denise A. Merlino, MBA, CNMT,CPC

President, Merlino Healthcare Consulting Corp. SNM Coding Advisor

2014 Nuclear MedicineCoding, Policy and Reimbursement

April 13, 2014

Presenter

Denise Merlino, MBA, CNMT, FSNMMI, CPC President, Merlino Healthcare Consulting Corp.Gloucester, MA

[email protected]

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April 13, 2014

Agenda

“Obama Care” aka The Affordable Care Act – How it affects Nuclear Medicine Coding & Payment Policy

• New, Revised and Deleted Codes for 2013 & 2014

• Important Policies, Coding Tips & Updates

• CY 2014 Hospital Outpatient Policies (HOPPS)

• CY 2014 Physician Office and IDTF Policies (MPFS)

• Questions

3

Affordable Care Act (ACA)aka - Obama Care

• Provide affordable health insurance to all US citizens• Most Americans will be required to have insurance in 2014• Insured Americans will increase by 32 million by 2019• Assistance will be provided through a Health Insurance Exchange

• Prevents insurance companies from denying coverage or raising premium based on gender or health

• Does not replace Private Insurance, Medicare or Medicaid• Expands Medicaid• Improve Community Health Care Centers• Addresses Fraud and Abuse • Establishment and expansion of Accountable Care Organizations

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April 13, 2014

CMS Authority Expanded Under ACA

• In some cases, ZPIC works with CMS to issue payment suspension and CMS has new authority under ACA to suspend payments based on “credible allegations of fraud” (which are defined to include contractor data mining)

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CMS Stepping Up Efforts to Reduce Improper Payments

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April 13, 2014

Contractor and Enforcement Landscape

• Medicare Administrative Contractors (MAC)

• Zone Program Integrity Contractors (ZPIC)

• Program Safety Contractors (PSC)

• Medicare Drug Integrity Contractors (MEDIC)

• Medicare/Medicaid Recovery Audit Contractors (RAC)

• Qualified Independent Contractors (QIC)

• Medicaid Integrity Contractors (MIC)

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Audit TriggersImproper or inaccurate billing

• High claim rejection rates

• High claim recoupment rates

• Utilization screens

• Higher utilization than neighboring providers

• High clinical case mix assignment

• Medicare admission patterns

• Claim Mismatch with medical record

• Lengths of stay outside industry norm

• Use of data mining

• Beneficiary complaints

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April 13, 2014

Medicare's anti-fraud toolsObama’s Budget Proposal Save $32.3 billion over the next 10 years

• Enhanced screening and enrollment protections requiring high-risk health care professionals, such as new medical equipment providers, to face a greater level of scrutiny when signing up for Medicare.

• The ability for CMS to stop payment of suspect claims immediately when a credible allegation of fraud arises.

• $350 million over the decade to fund new program integrity resources, such as more law enforcement agents to track down fraud.

• Expanded use of recovery audit contractors in Medicare Advantage, Medicare part D and Medicaid.

• Data analytics and increased data-sharing among federal agencies that will allow the government to analyze claims for aberrant activity in real time.

Source: Centers for Medicare & Medicaid Services 9

AMA CPT 2013

2013 CPT Additions - Endocrine

CPT Category I Descriptor Comments

78012Thyroid uptake, single or multiple quantitative measurement(s) (including stimulation, suppression, or discharge, when performed)

Replaces 78000, 78001, 78003

78013Thyroid imaging (including vascular flow, when performed)

Replaces, 78010, 78011

78014

Thyroid imaging (including vascular flow, when performed); with single or multiple uptake(s) quantitative measurement(s) (including stimulation, suppression, or discharge, when performed)

Replaces 78006, 78007

CPT ® is a registered trademark of the American Medical Association

© 2010 MEDICAL LEARNING INCORPORATED / SLIDE 10Slide 10

Tip: Similar to other nuclear medicine services, if the bundled services are performed over multiple (one or more) days (e.g. different radiopharmaceuticals), the codes billed remain the same. DO NOT UNBUNDLE these services when performed over two days.

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April 13, 2014

AMA CPT 2013

2013 CPT Additions/Revisions - Endocrine


78070Parathyroid planar imaging (including subtraction, when performed);

Modified 78070

78071Parathyroid planar imaging (including subtraction, when performed); with tomographic (SPECT)

Combines 78070 with 78803

78072

Parathyroid planar imaging (including subtraction, when performed); with tomographic (SPECT), and concurrently acquired computed tomography (CT) for anatomical localization

Combines 78070 with 78803 when CT is used for AC.NM first SPECT/CT code

CPT ® is a registered trademark of the American Medical Association© 2010 MEDICAL LEARNING INCORPORATED / SLIDE 11

Slide 11

®CPT is a registered trademark of the American Medical Association

CPT Code Description

78226 Hepatobiliary system imaging, including gallbladder when present;

78227 with pharmacologic intervention, including quantitative measurement(s) when performed

June 11, 2012

Both codes, includes pre treatment with morphine. Intervention refers to a “drug” administered DURING the procedure. Fatty meals & water are not considered pharmacologic, use 78226 for these services, do not report with

78827. See SNMMI Q&A in the coding corner for details.

Hepatobiliary ImagingClarification- during Sincalide shortage

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April 13, 2014

AMA CPT® Category III Codes

2013 CPT Additions - New July 1, 2013New in the 2014 CPT Book


0331T Myocardial sympathetic innervation, imaging, planar qualitative and quantitative assessment; Sunset January 2019

0332TMyocardial sympathetic innervation, imaging, planar qualitative and quantitative assessment; with tomographic SPECT

Sunset January 2019

CPT ® is a registered trademark of the American Medical Association© 2010 MEDICAL LEARNING INCORPORATED / SLIDE 13

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Do not use CPTs 78466-78469 for cardiac use of AdreView.78466-78469 are for Myocardial infarct Avid imaging, typical Radiopharmaceutical is 99mTc Pyrophosphate.

Radiopharmaceutical Billing Code

HCPCSLevel II

DescriptionUnits Billed

A9520Technetium Tc 99m tilmanocept, diagnostic, up to 0.5 millicuries

1

A9541Technetium Tc 99m sulfur colloid, diagnostic, per study dose, up to 20 millicuries

1

Billing Codes & Units: Sulfur Colloid & Lymphoseek

If a nuclear pharmacy supplies several syringes of a radiopharmaceutical, the billing unit remains (1) as units for these codes are defined by a study not per syringe. The fact that the new code A9520 does not have this language would not change the billing rules.

Source: SNMMI Coding Committee Consensus Opinion14

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April 13, 2014

2013-2014 HCPCS Level II Codes

Additions - Deletions

HCPCSLevel II

Trade/Common

NameDescription

C1204December 31, 2013

Lymphoseek™Technetium Tc 99m tilmanocept, diagnostic, up to 0.5 millicuries

J0152 Adenosine Injection, Adenosine, 30 mg

J0151 (New) Adenosine Injection, Adenosine, 1 mg

© 2010 MEDICAL LEARNING INCORPORATED / SLIDE 15

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Prior units for J0152 were 1, 2 or 3 based on vial size and drug administered.

“JW” Modifier Requirements

Use “JW” to Identify Unused Units of Adenosine

HCPCS Level II Modifier

HCPCSModifier

Descriptor Comment

JW Drug amount discarded/not administered to any patient

Medicare only covers discarded drugs for single use vials; multi-use vials are not subject to payment for discarded amount of drugs. Use “JW” modifier to identify discarded “units” of Adenosine (J0151) from single use vials.

Bill for unused amounts of Adenosine in units of 1 mg on a separate line on the claim form by appending modifier “JW” to the HCPCS code, i.e., J0151-JW.

Note: Check payer requirements regarding use of “JW” modifier.

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April 13, 2014

August 21, 2013

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NDC Numbers for New FDA Approved Radiopharmaceuticals

January 2014HCPCSLevel II

Trade Name

DescriptionNDC # for

Claim Form

C9399 followed by

permanent codeXofigo™

Radium Ra-223 dichloride, therapeutic, per treatment dose

NDC #50419-0208-01

A9520* Lymphoseek™Technetium TC 99m tilmanocept, diagnostic, up to 0.5 millicuries

NDC #52579-1600-05

A9599 Vizamyl™Radiopharmaceutical, diagnostic, for beta-amyloid positron emission tomography (pet) imaging, per study dose

F-18 flor------ -G.E.NDC #17156-067-10 orNDC #17156-067-30

A9599Neuraceq

Radiopharmaceutical, diagnostic, for beta-amyloid positron emission tomography (pet) imaging, per study dose

F-18 florbetaben -PiramalNDC # 54828-001-30

Please note that A9520 years ago was an active code for 99mTC SCdescribed per millicurie and then later deleted and changed. If you do aGoogle search for A9520 it lists the deleted code.

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April 13, 2014

FDG-PET (CAG-00181R4) Final Decision Summary

Limitation on Coverage:• Three (3) FDG-PET scans will be nationally

covered for oncologic indications when used to guide subsequent physician management of anti-tumor strategy after initial anticancer therapy.

• Additional scans will be permitted at MAC or MA Plan Contractor discretion. (New Instructions)

• Append KX modifier for imaging past (3) maintain and provide if requested, good documentation to prove medical necessity.

• Obtain ABN and append GA modifier if singed

• If ABN not obtained append GZ modifier19

PET Frequency Limit ModifierBypasses MAC Edit

.

HCPCS Level II Modifiers

HCPCSModifier

Descriptor CMS Billing Instructions

KX Requirements specified in the medical policy have been met

Modifier applies to PET claims for PI post (1) and for PS (post (3) to allow payment for non surveillance and medically appropriate PET imaging

Appropriate use: When additional documentation is available to support the medical necessary service under a medical policy

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April 13, 2014

FDG PET Claim SubmissionsDOS post June 11, 2014 NOPR

February 6, 2014 Transmittal 162 & 2873 Change Request 8468 Implemented March 7, 2014 non-shared systems and July 7th 2014 Shared System Edits

Denials –(PS) FDG exceeds 3 and no KX:• CARC 96: “Non-Covered Charge(s). Note: Refer to the 835 Healthcare Policy

Identification Segment (loop 2110 Service Payment Information REF), if present."

• RARC N435: “Exceeds number/frequency approved/allowed within time period without support documentation.”

• MSN 23.17: “Medicare won’t cover these services because they are not considered medically necessary.”

MACs will report Group Code PR assigning financial liability to the beneficiary, if a claim is received with a GA modifier indicating a signed ABN is on file.

Contractors shall use Group Code CO assigning financial liability to the provider, if a claim is received with a GZ modifier indicating no signed ABN is on file.

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Denials –(PS) when no initial (PI) claim is present in history when appropriate:

CWF shall create an edit for oncologic FDG PET scan claims to begin a new count with each initial treatment strategy (-PI) and a different/new dx than what is present in history for that beneficiary. • CARC B5: "Coverage/program guidelines were not met or were exceeded."

• RARCN640: "Exceeds number/frequency approved/allowed within time period."




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April 13, 2014



Denials –(PS) when no initial (PI) claim is present in history when appropriate:

CWF shall create an edit for oncologic FDG PET scan claims to begin a new count with each initial treatment strategy (-PI) and a different/new dx than what is present in history for that beneficiary. • CARC B5: "Coverage/program guidelines were not met or were exceeded."

• RARCN640: "Exceeds number/frequency approved/allowed within time period."




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SEQUESTRATION – – MPFS & HOPPSEffects on Medicare Payments CMS Article PE201303-02

Medicare Fee-for-Service (FFS) program (i.e., Part A and Part B). In general, Medicare FFS claims with dates-of-service or dates-of-discharge on or after April 1, 2013, will incur a two (2) percent reduction in Medicare payment.

The claims payment adjustment shall be applied to all claims after determining coinsurance, any applicable deductible, and any applicable Medicare Secondary Payment adjustments.

• Beneficiary payments for deductibles and coinsurance are not subject to the two (2) percent payment reduction, Medicare's payment to beneficiaries for unassigned claims is subject to the two (2) percent reduction.

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April 13, 2014

FINAL 2014

Hospital Outpatient Prospective Payment System (HOPPS)

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Device & RP to Procedure Edits Are Eliminated For CY 2014

• From CMS:

“We believe that hospitals have now had several years of experience reporting procedures involving radiolabeled products and have grown accustomed to ensuring that they code and report charges so that their claims fully and appropriately reflect the costs of those radiolabeled products.

As with all other items and services recognized under the OPPS, we expect hospitals to code and report their costs appropriately, regardless of whether there are claims processing edits in place.

After consideration of the public comments we received, we are finalizing our proposal to no longer require the nuclear medicine procedure-to-radiolabeled product edits. Hospitals will still be expected to adhere to the guidelines of correct coding and append the correct radiolabeled product code to the claim when applicable.”

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April 13, 2014

Use of New Cost Centers to Calculate APC Relative Weights

1 2 3 4 5 6 7

APC APC Description4Q 2013 APC Rate

Table 3 % Change Proposed from Cost Center

1Q 2014 APC Rate

% Total Change Final

includes all policy changes

$ Change in APC Rate

0378 Level II Pulmonary Imaging $336.40 15.2% $430.87 28.1% $94.470396 Bone Imaging $261.68 15.5% $323.94 23.8% $62.260390 Level I Endocrine Imaging $150.04 15.8% $183.40 22.2% $33.360395 GI Tract Imaging $256.76 16.2% $323.78 26.1% $67.020402 Level II Nervous System Imaging $458.34 16.2% $533.18 16.3% $74.840398 Level I Cardiac Imaging $308.99 16.3% $383.10 24.0% $74.110377 Level II Cardiac Imaging $679.68 17.0% $1,153.62 69.7% $473.940406 Level I Tumor/Infection Imaging $300.09 17.4% $382.77 27.6% $82.680403 Level I Nervous System Imaging $264.09 18.9% $162.68 ‐38.4% ‐$101.41

Column 4: AFFECTED BY USE OF THE NEW STANDARD COST CENTER CCRs IN THE CMS FORM 2552-10 COST REPORTS

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HOPPS Expanded Packaging Policy

• CMS proposed to package an additional 7 different categories of services that it believes to be “integral, ancillary, supportive, dependent, or adjunctive” to other services.

• CMS modified its proposal and finalized 5 of the 7 categories for CY 2014 – Addendum P lists specific CPT codes

1. Drugs, biologicals, and radiopharmaceuticals that function as supplies in a diagnostic test or procedure; “Stress Agents”

2. Drugs and biologicals that function as supplies or devices in a surgical procedure; “Skin Substitutes”

3. Certain clinical laboratory tests

4. Certain procedures described by add-on codes; and

5. Device removal procedures

• CMS is updating its list of OPPS packaged items and services in 42 CFR 419.2(b)

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April 13, 2014

Packaging Expands for Nuclear Medicine in CY 2014

Stress Agents (J0151 & J2785) & Ancillary Services (93017)

Finalized Packaged for CY 2014:

Myocardial Perfusion Imaging (MPI)p.311 of the final rule; CMS states, “78452 is the highest cost nuclear medicine procedure in the OPPS, with total payments exceeding $800 million in CY 2012.” OPPS payments for the two separately payable stress agents totaled approx. $111 million in CY 2012.

• 96 percent of MPI is billed with 78452

• 96 percent of MPI is performed under stress 93017 p. 370

CPT ® is a registered trademark of the American Medical Association 29

• Stress Agents HCPCS codes J0151 (replacing J0152) and J2785 are finalized to be unconditionally packaged. CMS is treating these agents as functioning as supplies, therefore packaged into the primary procedure.

• CPT code 93017 (Cardiovascular stress test…) finalized for conditional packaging since it is often performed as a part of myocardial perfusion imaging (MPI). CMS believes that, because stress testing is both integral and ancillary to MPI, it should be packaged into MPI when a stress test accompanies MPI.

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Packaging Expands for Nuclear Medicine in CY 2014

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April 13, 2014

HOPPS CMS Packaging PolicyCMS Example

Service or Supply

CY 2013Separate

Payment for MPI

Components

CY 2013Separate

Payment for MPI

Components

CY 2013Separate

Payment for MPI

Components

CY 2013Separate

Payment for MPI

Components

CY 2014Final

Packaged Paymentfor MPI

78452** $680 $680 $680 $680 $1,154

93017 $177 $177 $177 $177 P€

Exercise or Stress Agent¥ Exercise-$0 J1245-P J2785-$215 J0152-$219* P

Radiopharmaceutical P P P P P

Total $857 $857 $1,072 $1,076 $1,154

% diff compared to CY 2014 35% 35% 8% 7%

P = Packaged. € The stress test described by CPT code 93017 is conditionally packaged as a result of the final rule. ¥April 2013 ASP Drug Pricing File. *70 kg patient.

CY 2013 SEPARATE PAYMENT VS CY 2014 FINAL PAYMENT MPI

Cost center changes have impacted the payments, CMS states 17 percent for APC 0377


Diagnostic Nuclear Cardiology HOPPS National Rates

APC Status Description 4Q 2012 4Q 2013 1Q 2014

0398 S

Level I Cardiac Imaging

78414, 78428, 78466, 78468, 78469, 78472, 78473, 78481, 78483, 78494, 78499

$297.85Incl Dx Rp

$308.99Incl Dx RP

$383.10Incl Dx RP

0377 S

Level II Cardiac Imaging

0331T, 0332T, 75563, 78451, 78452, 78453, 78454, 78483

$673.07Incl Dx Rp,WM & EF

$679.68Incl Dx Rp,WM & EF

$1,153.62Incl DX Rp, WM, EF, 93017, Stress Agent

0100X /

Q1

Cardiac Stress Test

93017+ (Q1-packaged)$178.37 $176.82

$244.21 or $0.00(if not conditionally

packaged)

APC rates will vary geographically. Figures are National hospital payment rates.

This is the ONLY cardiac stress code which is Technical only. Therefore, it is the only cardiac stress code used by hospitals on the UB 92/UB04 claim form.


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April 13, 2014

Diagnostic– Cardiac & Non-Cardiac PET HOPPS National Rates


0307 SMyocardial Positron Emission Tomography (PET) imaging

78459, 78491, 78492

N/A (could have been $809.00)

(CMS combined

into 0308 see below)

NA NA

0308 S

Positron Emission Tomography (PET) Imaging

78459, 78491, 78492, 78608, 78811, 78812, 78813, 78814, 78815, 78816

$1,037.87Incl Dx Rp

$1,056.12Incl Dx RP


0100X /

Q1

Cardiac Stress Tests

93017+ (Q1-packaged)$178.37 $176.82


packaged)




HOPPS CY 2013 Compared to CY 2014Other Services & Stress Agents

HCPCS Code S.I. Descriptor 4Q 2013 1Q 2014

Percent Difference

93017 X / Q1Conditional

Stress Test $176.82$244.21

conditionally packaged

38% or

-100%

96413 SChemo infusion up to one hour

$230.50 $299.53 30%

J0151 N Adenosine, 1mg New Code Packaged -100%

J0152 D Adenosine, 30 mg $109.38 *Discontinued Deleted

J2785 N Regadenoson, .1 mg $53.43 Packaged -100%

*J0152 replaced by J0151, Charge Master Alert!



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April 13, 2014

Diagnostic– Cardiac & Non-Cardiac PET HOPPS National Rates


0307 SMyocardial Positron Emission Tomography (PET) imaging

78459, 78491, 78492

N/A (could have been $809.00)

(CMS combined

into 0308 see below)

NA NA

0308 S

Positron Emission Tomography (PET) Imaging

78459, 78491, 78492, 78608, 78811, 78812, 78813, 78814, 78815, 78816

$1,037.87Incl Dx Rp

$1,056.12Incl Dx RP


0100X /

Q1

Cardiac Stress Tests

93017+ (Q1-packaged)$178.37 $176.82


packaged)




Diagnostic – Oncology HOPPS National Rates


0406 S

Level I Tumor / Infection Imaging

78015, 78016, 78018, 78800, 78801

$280.39Incl Dx Rp

$300.09Incl Dx Rp

$382.77Incl Dx Rp

0408 SLevel III Tumor / Infection Imaging

78075, 78607, 78804

$985.17Incl Dx Rp

$955.60Incl Dx Rp

$1,157.42Incl Dx Rp

0414 S

Level II Tumor / Infection Imaging

78801, 78802, 78803, 78805, 78806, 78807

$493.07Incl Dx Rp

$502.54Incl Dx Rp

$656.97Incl Dx Rp

APC rates will vary geographically. Figures are National hospital payment rates.36


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April 13, 2014

HOPPS CY 2013 Compared to CY 2014Includes the Diagnostic Radiopharmaceutical(s)

HCPCS Code

Descriptor 4Q 2013 1Q 2014Percent

Difference

78014 Thyroid uptake & scan $232.94 $286.94 23%

78071 Parathyroid planar & SPECT $322.04 $738.69 129%

78075 Adrenal Imaging $955.60 $1,157.42 21%

78195Lymphatics and lymph nodes imaging $279.95 $346.34** 24%

78206-78227Liver SPECT with vascular flow – Hepatobiliary with pharm agent

$314.39 $372.57 19%

78306 Bone imaging whole body $261.68 $323.94 24%

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**C1204 Lymphoseek Oct 2013 (A9520 CY 2014) on pass-through per statute off-set applies, CY 2013 offset APC 0400, $49.16, 0392 $52.49; CY 2014 offset APC 0400, $61.41, 0392 $71.31




HCPCS Code


Difference

78472 Gated Blood Pool $308.99 $383.10 24%

78492 Cardiac PET, MPI, multiple $1,056.12 $1,310.60 24%

78582 Lung vent and perfusion $336.40 $430.87 28%

78600 Brain Imaging, less than 4 $264.09 $162.68** -38%

78607 Brain Imaging SPECT $458.34 $1,157.42** 153%

78707Kidney imaging, single w/o pharm agent $332.91 $417.02 25%

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**A9584 DatScan packaged for CY 2014, off pass-through per statute.



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April 13, 2014


Does not include therapeutic Rp(s)

HCPCS Code


Difference

78800 Tumor/distribution limited $300.09 $382.77 28%

78801 Tumor/distr., multi area $502.54 $382.77 -24%

78802 Tumor/dist. WB, single day $502.54 $659.97 31%

78804Tumor/distribution WB, two or more days $955.60 $1,157.42 21%

78815 PET/CT torso $1,056.12 $1,310.60 24%

79005-79101

Therapy, oral or IVRP for services separate $236.71 $255.81 8%

79403Therapy, IV infusion antibody $301.01 $356.68 18%



AMA CPT® Category III CodesNew July 1, 2013

*CPT Category

III

APC Assign

edS.I. Descriptor

July 1, 2013 / Proposed 2014 Payment Rate

1QCY 2014

0331T0398/0377

S

Myocardial sympathetic innervation, imaging, planarqualitative and quantitative assessment;

$308.99 / $391.36

$1,153.62

0332T0398/0377

S

Myocardial sympathetic innervation, imaging, planarqualitative and quantitative assessment; with tomographic SPECT

A9582 --- NIodine I-123 iobenguane, diagnostic, per study dose, up to 15 millicuries

Packaged Packaged

Final Rule CY 2014 using 2012 Medicare Claims Data:A9582 mean cost $1,331.73; median cost is $1,160.71.



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April 13, 2014

2014 HCPCS Level II Codes

Continues in CY 2014

HCPCSLevel II

Trade/Common

NameDescription

Q996995 percent NON-HEU Product

Tc-99m from non-highly enriched uranium source, full cost recovery add-on, per study dose

© 2010 MEDICAL LEARNING INCORPORATED / SLIDE 41

Comments: HOPPS ONLY ADD-ON PAYMENT - Total Payment $10.00, Per Study Dose, patient co-insurance is $2.00. If two study doses are administered may bill (2) units and be paid $20 dollars, $16 from Medicare and $4.00 from the patient. APC = 1442 status indicator “K”

41

HOPPS CY 2013 Compared to CY 2014Deletion of Policy Requirement

“FB” Modifier Used in CY 2013 for “Free / Full Credit” RPs.

HCPCS Level II Modifiers

HCPCSModifier

Descriptor CMS HOPPS Rule

FB Item provided without cost to provider, supplier or practitioner, or credit received for replacement devices

Modifier applies to RadiopharmaceuticalsPlace “token charge” on claimProcedure payment reduced by “offset amount”

CY 2014, CMS deleted this requirement for Radiopharmaceuticals.

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April 13, 2014

Looking Ahead…Expect More Packaging

• CMS says the packaging finalized here is not “exhaustive” and that it will continue analyzing other services

• It is likely that for CY 2015, we’ll see more packaging proposals possibly for the areas that CMS did not finalize for CY 2014 including the packaging of imaging services with associated surgical procedures in CY 2015.

• Comprehensive APCs coming in 2015

• Beyond 2015…even more bundles, packaging, and comprehensive style APCs…

43

Basics of a Charge MasterWhen to Update the CDM?

• Minimum Annual Update with Coding Changes• October thru December each year

• Changes in Payer Guidelines or Instructions

• Changes in Technology

• Department Provides New Services or New Product Lines

• CMS Quarterly Updates (HCPCS & APC) Updates• January, April, July, October

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April 13, 2014

Basics of a Charge Description Master (CDM) Was your CDM Updated for MPI in January 2010?

• Department # -specific to dept.

• Item # - specific to site

• Short / Limited Description

Dept # Item # Limited Description CPT/HCPC RC PriceActive Code

Deactivation / Date

302 18490 MPI wall motion 78478-TC 0341 $300.00 N 1/1/2010

302 18491 MPI ejection fraction 78480-TC 0341 $200.00 N 1/1/2010

302 55401 MPI, SPECT, Multiple 78465-TC 0341 $1,500.00 N 1/ 1/2010

302 55423 MPI SPECT Multiple WM&EF 78452-TC 0341 $2,000.00 Y New

302 40325 99mTc MIBI, PSD A9500 0343 $120.00 Y

302 40330 201Thallium, Per mCi A9505 0343 30.00 Y

302 60235 Inj, regadenoson, per 0.1 mg J2785 0636 $80.00 Y

302 36751 Stress test 93017 0341 $350.00 Y

PSD = per study dosePrice = example to show math and not derived from actual data

®CPT is a registered trademark of the American Medical Association

• CPT/HCPCS Code (previous and new)

• Revenue Code (RC) (hospitals only)

• Price (develop based on your facility costs)

45

Dept # Item # Limited Description CPT/HCPC RC PriceActive Code

Deactivation/ Date

302 55486 Tumor SPECT – (Parathyroid) 78803-TC 0341 $3,200.00 Y Maybe

302 55450 Parathyroid Imaging (planar) 78070-TC 0341 $1,800.00 Y Modified

302 55490 Parathyroid Planar + SPECT 78071-TC 0341 $3,200.00 Y New

302 55410 Parathyroid Planar + SPECT/CT 78072-TC 0341 $4,200.00 Y New

302 40335 Tc99m pertechnetate, per mCi A9512 0343 $100.00 Y

302 40350 Tc99m sestamibi, PSD A9500 0343 $500.00 Y

Charge Description MasterParathyroid Imaging Effective 1/2013

PSD = per study dosePrice = example to show math and not derived from actual data

TIP: Maintain the tumor SPECT code unless you priced it differently from other tumor imaging. Price for SPECT without CT should be different from SPECT with CT for attenuation correction (AC) service Watch units for RPs.

®CPT is a registered trademark of the American Medical Association 46

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April 13, 2014

Several MPFS PoliciesContinued in CY 2014

• Drugs paid at ASP plus 6 percent

• Radiopharmaceuticals are paid at Invoice cost; or at a limit set by each local contractor

• Imaging accreditation requirement

• DRA Cap

• Multiple Procedure Reduction – no changes

• Scrutiny of Potentially Misvalued Codes

47

MAC- Novitas Solutions - L and HRadiopharmaceuticals Paid at Acquisition Cost

Article Revision Effective Date January 24, 2014

Effective December 1, 2013 for Jurisdictions L and H(not applied retroactively, click on above for link to take you to full article.)

• Claims without Radiopharmaceutical acquisition cost will be denied.

• Actual invoice is not required on each claim• Random audits will occur, if audited, invoice to verify will be necessary

• Acquisition cost should be reported in Block 19 or Block 24D of the claim form 1500 and in the 2400 loop NTE segment of an EMC claim.

• Codes affected: A4641, A4642, A4648, A9500-A9551, A9552, A9553-A9572, A9580-A9582, A9584, A9600-A9605, and A9698-A9700.

• Note, the codes listed in this article are not all-inclusive and the guidelines outlined in this article apply to all radiopharmaceutical codes

• Not Otherwise Classified (NOC) codes must report terminology, i.e., description of radiopharmaceutical.

• NOC codes include: A4641, A9698, A9699 and A9700

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April 13, 2014

FINAL 2014

Medicare Physician Fee Schedule (MPFS)

49

Two-year Budget Agreement Three-month SGR fix

• This extends by two years (through 2023) the 2% sequester cut for Medicare providers under the Budget Control Act;

• Extends Medicare policies important to small and rural hospitals.

• The law increased Medicare payment for physicians under the Physician Fee Schedule by 0.5% from January through March, which temporarily averts a 20.1% payment cut effective Jan. 1 under the Sustainable Growth Rate formula for fee schedule updates.

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Pg. 26



April 13, 2014

Protecting Access to Medicare Act of 2014 - April 1, 2014

• 17th Patch since 1997- Prevents 24 percent cut scheduled for April 1, 2014; provides a .5 percent update through Dec. 31, 2014, and a 0 percent update from Jan. 1 - March 31, 2015

• Requires consultation with appropriate use criteria and clinical decision support for advanced diagnostic imaging, beginning 2017

• Delays the transition to ICD-10 for one year, Oct 1. 2015

• Requires all CT services to be provided by equipment adhering to NEMA dose standards, beginning January 2016

• Consolidates the 2 percent Medicare sequester cut scheduled for full-year 2024 into a 4 percent cut in the first six months of 2024.

51

Protecting Access to Medicare Act of 2014 - April 1, 2014

• Allows the Health and Human Services (HHS) Secretary to revise payments for potentially misvalued codes within the physician fee schedule beginning in 2017 based on information collected from providers

• Extends HHS Secretary's medical review activities regarding the "Two Midnight Rule" for the first six months of 2015, delaying enforcement of the rule

• Extends funding for the National Quality Forum for measure endorsement through July 2015

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April 13, 2014

SGR UPDATES:What will happen for April 1, 2015? MPFS

53

Absent LegislationDoctors would have seenA 20.1 percent Decrease in rates April 2014

Patch for rest of 2014.5% update 0% update

First Jan-March 2015

Legislation also brings us:• ICD-10 DELAY toOctober 1, 2015By 2017• Misvalued codes $$ savings from MPFS• Appropriate use criteria

“Sunshine” Rule Increases TransparencyFinal Rule Announced February 1, 2013

Called the “National Physician Payment Transparency Program: Open Payments”: https://www.federalregister.gov/public-inspection

• Affordable Care Act provision to create greater transparency

• Goal: Reduced potential for conflicts of interest

• Public awareness to be increased• Financial relationships to be disclosed between:

• Manufacturers of drugs, devices, biologicals and medical supplies covered by Medicare, Medicaid or the Children’s Health Insurance Program (CHIP), and

• Certain Health Care Providers

• Data Reporting and Collection:• Applicable to Manufactures and GPOs

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April 13, 2014

CMS Advancing Transparencyin Physician Payments

MPFS

55

http://www.nytimes.com/interactive/2014/04/09/health/medicare-doctor-database.html

Transparency in Physician PaymentsMPFS

56

http://www.nytimes.com/interactive/2014/04/09/health/medicare-doctor-database.html

Pg. 29



April 13, 2014

Slide 57

DRA Deficit Reduction Act of 2005

Medicare Physician Fee Schedule – Affects Physician Offices & Independent

Diagnostic Testing Facilities (IDTF)

Section 5102(b) of the Deficit Reduction Act of 2005 requires a payment cap on

the technical component (TC) of certain diagnostic imaging procedures and

the TC portions of the global diagnostic imaging services. This cap is based

on the Outpatient Prospective Payment System (OPPS) payment (aka HOPPS).

To implement this provision, the physician fee schedule amount is compared to

the OPPS payment amount and the lower amount is used in the formula below

to calculate payment.

• One-way CAP

Final - MPFS CY 2014Tweaking Continued

• Medicare Economic Index (MEI)• Revisions to calculation using MEI, re-distributing some

payment from Practice Expense to physician work, by changing the percent distribution

• Interest Rates linked Small Business Administration (SBA), max rates, loan size, and useful life.

• Liability of Overpayments finalized from three years to five years, this means CMS can go back further to recoup provider overpayments. – PET is a concern.

58

Technical RVUs decreased by 4 to 8 percent for mostNuclear medicine services, while professional RVUs are unchangedCMS lists cumulative impact to nuclear medicine as 0 percent radiology -2

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April 13, 2014

Several MPFS PoliciesContinued in CY 2014

• Drugs paid at ASP plus 6 percent

• Radiopharmaceuticals are paid at Invoice cost; or at a limit set by each local contractor

• Imaging accreditation requirement

• DRA Cap

• Multiple Procedure Reduction – no changes

• Scrutiny of Potentially Misvalued Codes

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Potentially Misvalued CodesSpecified in the Affordable Care Act

In response CMS has entered into two contracts:

• One 2-year contract was awarded to the RAND Corporation

• One contract was awarded to the Urban Institute, with partners Social and Scientific Systems and Research Triangle Institute (RTI)

Contractors will:

• Develop a model for the valuation of work under the PFS

• Test the model by creating work RVUs for PFS services

• Consult with practicing physicians as a part of valuation process

• Acquire or develop clinical information and other data sources, including data on physician time, for use in the model.

Update: Research performed under these two contracts continues

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April 13, 2014

Potentially Misvalued CodesThe Affordable Care Act requires CMS to examine potentially

misvalued codes in seven categories:

1. Codes & families of codes for which there has been the fastest growth,

2. Codes & families of codes that have experienced substantial changes in practice expenses,

3. Codes that are recently established for new technologies or services,

4. Multiple codes that are frequently billed in conjunction with furnishing a single service,

5. Codes with low relative values, esp. those that are billed multiple times for a single service,

6. Codes which have not been reviewed since the implementation of the RBRVS (the so-called “Harvard-valued codes”),

7. Other codes to be determined by the Secretary.

61

Medicare Physician Fee Schedule MPFS FINAL Rule for 2014

CMS Rule Summary:

62

CY 2014 Medicare Physician Fee Schedule Final Rule

CY 2014 New, Revised, and Potentially Misvalued Code Decisions

HCPCS Code Short Descriptor

CY 2012 Work RVU

AMA RUC/HCPAC

Recommended Work RVU*

CY 2014 Final Work RVU

Agree/Disagree with AMA

RUC/HCPAC Recommended

Work RVU*

CMS Refinement to AMA/HCPAC

Recommended Time*

78012 Thyroid uptake measurement New 0.19 0.19 Agree No

78013 Thyroid imaging w/blood flow New 0.37 0.37 Agree No

78014 Thyroid imaging w/blood flow New 0.50 0.50 Agree No

78070 Parathyroid planar imaging 0.82 0.80 0.80 Agree No

78071 Parathyrd planar w/wo subtrj New 1.20 1.20 Agree No

78072 Parathyrd planar w/spect&ct New 1.60 1.60 Agree No

78278 Acute gi blood loss imaging 0.99 0.99 0.99 Agree No

78472 Gated heart planar single 0.98 0.98 0.98 Agree No

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April 13, 2014

Nuclear Medicine - CardiacMPFS Professional National Rates (26)

HCPCSCPT

Status Description2013 National

PFS Professional*4Q 2013 Rates

2014 National PFS Professional**/***2014 Rates

Jan - Dec No SGR Fix

78451-26 A MPI, SPECT, Single Study $65.32 $68.06 $51.68

78452-26 AMPI, SPECT, Multiple Studies

$76.55 $79.88 $60.66

78453-26 A MPI, Planar, Single Study $47.63 $50.51 $38.35

78454-26 A MPI, Planar, Multiple Studies $63.62 $66.99 $50.87

RBRVS rates will vary geographically. Figures used are not actual payment rates.63

*4Q 2013 rates based upon CF=$34.0230 (American Taxpayer Relief Act of 2012)**Jan - Mar 2014 rates based upon CF=$35.8228 (Pathway for SGR Reform Act of 2013)***No SGR Fix CF=$27.2006

Nuclear Medicine - CardiacMPFS Technical National Rates (TC)

HCPCSCPT

Status Description2013 National PFS Technical*4Q 2013 Rates



78451-TC A MPI, SPECT, Single Study $294.98 $282.64 $214.61

78452-TC AMPI, SPECT, Multiple Studies

$425.63 $406.59 $308.73

78453-TC AMPI, Planar, Single Study

$265.38 $262.58 $199.38

78454-TC AMPI, Planar, Multiple Studies

$386.50 $378.65 $287.51

RBRVS rates will vary geographically. Figures used are not actual payment rates.

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April 13, 2014

Nuclear Medicine - Cardiac PETMPFS Professional National Rates (26)

HCPCSCPT




78459-26 AMyocardial imaging, positron emission tomography (PET), metabolic evaluation $70.09 $73.79 $56.03

78491-26 AMyocardial imaging, positron emission tomography (PET), perfusion; single study at rest or stress

$71.45 $74.51 $56.58

78492-26 AMyocardial imaging, positron emission tomography (PET), perfusion; multiple studies at rest and/or stress

$88.80 $92.42 $70.18

78499-26 C Cardiac Unlisted Nuclear Medicine Carrier Priced Carrier Priced

Technical & Global Rates for PET codes are Carrier Priced.


PET NCD is an “only” policy, wall motion studies and determination of ejectionfraction are NATIONALLY NON-COVERED with MPI or Viability PET studies for Medicare Patients.

65


Nuclear Cardiology – Cardiac Stress TestingMPFS National Rates

(PC/TC split does not apply to these codes as the CPTs are descriptive.)

HCPCSCPT



Jan – Dec No SGR Fix

93017 A

Cardiovascular stress test using maximal or submaximal treadmill or bicycle exercise, continuous electrocardiographic monitoring, and/or pharmacological stress; tracing only, without interpretation and report

$43.89 $39.05 $29.65

93016 ACardiovascular stress test …; physician supervision only, without interpretation & report

$21.43 $22.21 $16.86

93018 ACardiovascular stress test …; interpretation and report only $14.29 $14.69 $11.15

93015 ACardiovascular stress test …; with physician supervision, with interpretation and report $79.61 $75.94 $57.67

RBRVS rates will vary geographically. Figures used are not actual payment rates.66


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April 13, 2014

Pharmacological Stress Agents and Drugs

MPFS ASP plus 6%Drugs are paid by ASP methodology, changes occur quarterly.

HCPCS Code

Description 2012*4Q 2012

2013**4Q 2013

2014***1Q 2014

J0151 Inj, Adenosine, 1 mg New Code New Code $3.31

J0152 Inj, Adenosine, 30 mg $109.40 $109.38Discontinued

Code

J0280 Inj, Aminophyllin up to 250 mg $0.60 $1.19 $1.40

J1245 Inj, Dipyridamole, per 10 mg $0.81 $0.82 $0.83

J1250 Inj, Dobutamine HCL, per 250 mg $6.20 $8.30 $5.70

J1265 Inj, Dopamine HCL, per 40 mg $0.40 $0.51 $0.55

J2785 Inj, Regadenoson, per 0.1 mg $53.67 $53.43 $53.13

J2805 Inj, Sincalide, 5 mcg $67.01 $83.11 $82.68

67

**Rate effective October 1st through December 31st, 2013, CMS ASP Web Site***Rate effective January 1st through March 31st, 2014, CMS ASP Web Site

*Rate effective October 1st through December 31st, 2012, CMS ASP Web Site

Nuclear Medicine – Diagnostic & Therapeutic MPFS Professional National Rates (26)

HCPCSCPT




78306-26 A Bone and/or joint imaging; whole body $40.49 $42.99 $32.64

78320-26 A Bone and/or joint imaging; tomographic (SPECT) $48.31 $50.87 $38.62

78579-26 A Pulmonary ventilation imaging (eg, aerosol or gas) $24.50 $24.36 $18.50

78580-26 APulmonary perfusion imaging, particulate (eg, particulate) $34.70 $36.90 $28.02

78582-26 APulmonary ventilation (eg, aerosol or gas) and perfusion imaging $52.74 $53.38 $40.53

78597-26 AQuantitative differential pulmonary perfusion, including imaging when performed $36.40 $35.82 $27.20

78598-26 AQuantitative differential pulmonary perfusion and ventilation (eg, aerosol or gas), including imaging when performed

$41.51 $41.55 $31.55

RBRVS rates will vary geographically. Figures used are not actual payment rates. 68

*4Q 2013 rates based upon CF=$34.0230 (American Taxpayer Relief Act of 2012)**Jan - Mar 2014 rates based upon CF=$35.8228 (Pathway for SGR Reform Act of 2013)

***No SGR Fix CF=$27.2006

Pg. 35



April 13, 2014

Nuclear Medicine – Diagnostic & Therapeutic MPFS Technical National Rates (TC)

HCPCSCPT




78306-TC A Bone and/or joint imaging; whole body $217.75 $213.50 $162.12

78320-TC A Bone and/or joint imaging; tomographic (SPECT) $184.74 $181.62 $137.91

78579-TC A Pulmonary ventilation imaging (eg, aerosol or gas) $198.35 $166.22 $126.21

78580-TC APulmonary perfusion imaging, particulate (eg, particulate) $209.92 $207.41 $157.49

78582-TC APulmonary ventilation (eg, aerosol or gas) and perfusion imaging $339.21 $289.45 $219.78

78597-TC AQuantitative differential pulmonary perfusion, including imaging when performed $207.54 $170.52 $129.47

78598-TC AQuantitative differential pulmonary perfusion and ventilation (eg, aerosol or gas), including imaging when performed

$322.54 $272.25 $206.72

RBRVS rates will vary geographically. Figures used are not actual payment rates. 69

*4Q 2013 rates based upon CF=$34.0230 (American Taxpayer Relief Act of 2012)**Jan - Mar 2014 rates based upon CF=$35.8228 (Pathway for SGR Reform Act of 2013)

***No SGR Fix CF=$27.2006

Nuclear Medicine - PET OncologyMPFS Professional National Rates (26)

HCPCSCPT

Status Description2013 National

PFS Professional*4Q 2013 Rates



78608-26 ABrain Imaging, PET; Metabolic evaluation

$70.43 $56.58 $74.51

78811-26 A PET imaging; Limited Area $76.55 $61.47 $80.96

78812-26 A PET imaging; skull base to mid thigh $92.88 $73.99 $97.44

78813-26 A PET imaging; whole body $96.63 $77.79 $102.45

78814-26 A PET/CT imaging; Limited Area $106.83 $85.68 $112.84

78815-26 A PET/CT torso $118.06 $94.39 $124.31

78816-26 A PET/CT imaging; whole body $119.08 $95.20 $125.38


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April 13, 2014

Nuclear Medicine - PET OncologyMPFS Technical National Rates (TC OPPS CAP)

HCPCSCPT

Status Description

2013 National PFS Technical*4Q 2013 Rates

(OPPS CAP)

2014 National PFS Technical

**/***2014 Rates(OPPS CAP)


*78608-TC ABrain Imaging, PET; Metabolic evaluation

$1,056.07 $1,310.52 $1,310.76

*78811-TC A PET imaging; Limited Area

*78812-TC A PET imaging; skull base to mid thigh

*78813-TC A PET imaging; whole body

*78814-TC A PET/CT imaging; Limited Area

*78815-TC A PET/CT torso

*78816-TC A PET/CT imaging; whole body

*Technical & Global Rates for PET codes are Carrier Priced.


71

*4Q 2013 rates based upon CF=$34.0230 (American Taxpayer Relief Act of 2012)**Jan - Mar 2014 rates based upon CF=$35.8228 (Pathway for SGR Reform Act of 2013)***No SGR Fix rates based upon HOPPS CY 2014 Final Rule CF=$27.2006

Your Questions

Denise Merlino, MBA, CPC President, Merlino Healthcare Consulting Corp.Gloucester, [email protected]

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2014 nuclear medicine cr&p 4-12-2014€¦ · implemented march 7, 2014 non-shared systems and...

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