medicare 2011 omf march, 2011. agenda what’s going on right now medicare pfs final rule 1/1/2011...

Medicare 2011OMF

March, 2011

onPoint Oncology LLC 2

AgendaWhat’s Going On Right Now

Medicare PFS Final Rule 1/1/2011

PQRI and E-Prescribing 2010-2011

Meaningful Use Final Rule 7-13-2010

Coding 2011

Follow Up Items For Practices


DISCLAIMER

Much is not known about Health Reform and The Final Rule for Physician Services in 2011. This is what we know right now.

Payers differ on their guidelines. Please verify coding for each payer and claim.

All Medicare and RAC information is literally changing on a daily basis. What is presented herein may or may not be valid for 2010.

This is not legal or payment advice.

This content is abbreviated for Medical Oncology. It does not substitute for a thorough review of code books, regulations, and Carrier guidance.

This information is good for the date of the information and may contain typographical errors.

CPT is the trademark for the American Medical Association. All Rights Reserved.


MEDICARE PHYSICIAN PAYMENT BASICS

Payments are based on RVUs for each code (WRVUs+PERVUs+MalRVUs)

RVUs are multiplied times GPCIs for your area. There is a work GPCI floor in some areas of 1.00. (W*WGPCI+PE*PEGPCI+Mal*MalGPCI)

The Medicare conversion factor determines the overall level of Medicare payments (W*WGPCI+PE*PEGPCI+Mal*MalGPCI) times CF = $Your Total Allowable for your area

A formula spelled out in the Medicare statute determines the annual update to the conversion factor and that has been a disaster.


History of the Debacle

http://www.ama-assn.org/ama/pub/physician-resources/solutions-managing-your-practice/coding-billing-insurance/medicare/the-medicare-physician-payment-schedule.shtml


The Medicare Fee Schedule Nightmare

We had 5 different conversion factors in 2010!Started off with last year’s conversion factor--

$36.0666Went to $36.0864 in JanuaryWent to $28.3895 when Congress was deliberating

and then will be (?) paid back—Could return December 1.

Went to $36.8729 June 1This was renewed for DecemberAnd, this year…


SGR Fix For One YearCongress passed a one-year patch to SGR

(Medicare and Medicaid Extenders Act of 2010 or MMEA)Signed by President Obama on 12/15/10 Congress is expected to work on a permanent

solution to the ongoing SGR crisis in 2011Congress is expected to also finalize a funding

mechanism for items left out of the SGR PatchBut, we can relax a little bit…or can we?


MMEA (Signed into Law 12-15-2010)

Physician fee schedule update will be 0%

Changes to relative value units (RVUs) used to calculate fee schedule rates must be budget neutral To make these changes budget neutral, the conversion factor

must be adjusted for 2011

CMS released the 2011 MPFS to implement the 0% update and RVU changes– “We expect all 2011 claims to be processed timely, in compliance with the new legislation” CF = $33.9764 Some PE RVUs changed slightly


MMEAAlso extends the existing 1.0 floor on the

physician work geographic practice cost index (GPCI) through 12/31/11 Will be reflected in the revised 2011 MPFS

Medicare Physician Fee Schedule FINAL Rule

November 2, 2010


FINAL MPFS 2011On November 2, 2010, the Centers for Medicare &

Medicaid Services (CMS) posted a proposed notice for Medicare payments in the physician fee schedule for calendar year (CY) 2011.

Many of these provisions were specified in Health Reform (“ACA”). The final rule (CMS-1502-P) affects physicians and office payment for services paid under the resource-based relative value scale/system (RBRVS), also known as, the Medicare Physician Fee Schedule.

Here are the highlights of Rule which becomes effective for dates of service on or after 11-2-2010.

https://www.cms.gov/PhysicianFeeSched/PFSFRN/list.asp#TopOfPage


FINAL MPFS 2011Practice Expense: CMS continues for the

second year (at a 50/50 blend), the phasing-in over four years the implementation of the American Medical Association (AMA) Physician Practice Information Survey (PPIS) data administered in 2007/08 for practice expense (PE) indirect per hour rate. Oncology is still using the AMA SMS data series. Of interest is this year's calculation of practice expense for drug administration because many of our codes were bumped up slightly to include some supplies.



FINAL MPFS 2011 Related –TC of Imaging Codes Get Cuts: Well, of course,

this is happening in July 2010. But, what it means is that, as of July 6, you will get a cut of 50% for secondary –TCs of related procedures in the same family of imaging procedures. This has been expanded to include more and unrelated procedures. SEE ADDENDUM F of the fee schedule for additional procedure reduction codes.

Telehealth Services: To perform telehealth services, there must be two-way communication between provider and patient, plus you must be in HPSA (Health Provider Shortage) area or outside an MSA. Additional services proposed as allowable in 2011 are 99231-99233 (every three days) and 99307-99310 every 30 days along with services that are unrelated to Oncology.


FINAL MPFS 2011 Physician Extenders: They are sometimes known as NPs and

PAs. They can now perform certification and periodic re-certification for SNF patients.

Bone density payment: The proposal calls for these to be paid 70% of the 2006 RVUs at the 2006 conversion factor with this year’s GPCIs for codes 77080-77082. This is retroactive to January 1, 2010.

Payment for Biosimilars: Here is the payment formula for drugs that are ‘similar’ to today’s biologics. Down the road, we will see lots of these in cancer treatment for sure… A biosimilar is a product approved under an abbreviated application

for a license of a biological product that relies on a license of another biologic.

The payment for these biosimilar products will be the sum of all ASPs assigned to a biosimilar products divided by all applicable units plus six percent of the REFERENCE PRODUCT…how does that work?


FINAL MPFS 2011 Waiver of Cost Sharing for Preventive Services: The ACA

requires that CMS establish regulations that will waive the deductible and coinsurance requirements for some preventive services, including the following (there are others that would not be performed by most cancer practices): Annual wellness visits, Initial preventive physician examination, depending upon CMS feed-back, Screening mammography, Pneumococcal, influenza, hepatitis B vaccinations, PAPs/pelvics, Prostate screening, Colorectal screening, even if a screening exam becomes therapeutic (e.g.

removal of polyps), Bone mass measurement, And, smoking screening and cessation (asymptomatic) in the absence of

disease or treatment reasons to administer smoking cessation.



FINAL MPFS 2011Primary Care Bonus Payments: Primary Care in

certain areas is getting a bonus under certain conditions. The ACA (Health Reform) requires that CMS implement a 10% bonus for providers designated as family medicine, internal medicine, geriatrics, or pediatrics that furnish primary care services effective January 1, 2010. The ACA limits the bonus payments to practitioners whose allowed charges consist of 60% or more of primary care services (codes 99201-99215, 99304-99340, and 99341-99350). There is also a 10% bonus for surgeons performing procedures in a HPSA area 2011-2016.



FINAL MPFS 2011 Self-Referral Disclosure Law: Effective for dates of service after

January 1, 2011 for CAT, MRI, and PET: A list of FIVE (not ten) alternative ‘suppliers’ (not a hospital)

within a 25-mile radius of the physician’s office who provide the same imaging services. If there are not five, you must list all.

The list must include, name, address, phone number of other facilities. If there is no one they can go to, tell the patient they can get these tests in other facilities.

The list is to be given to the patient at the time of referral. EACH time the patient is referred it must be given.

No signature or form retention is required. Make a note in the chart or get a stamp for charts---but there should be a notation that it was given.

Must be written in a way that patients can understand. Emergency situations are not an exception. Exceptions include patients who are not on Medicare at the time of

the referral.


FINAL MPFS 2011 Drugs: This rule maintains the current average sales price (ASP) + 6% reimbursement for

Part B drugs; however, it includes proposed changes to ASP reporting, thresholds, and vial amounts. Among other provisions, if the manufacturer is late with quarterly reporting, the CMS

proposes to update ASPs by carrying over the previously reported manufacturer ASP for applicable national drug code(s) (NDC(s)). This is called the “carry over” methodology. This method will not be implemented if there are not a significant number of involved NDCs. But, manufacturers are still subject to Civil Monetary Penalties, if they make a habit of not submitting ASPs.

CMS also proposes to update the regulations to clearly state that Medicare will not pay for amounts of “overfill”, i.e. product in excess of the amount reflected on the FDA-approved label. The ASP plus 6% will be paid for FDA-approved amounts in the vial, but practices may not bill for and/or pool their overfill.

Partial quarter ASPs for new drugs were also discussed in the proposed rule. Single-source drugs will be priced at WAC, plus 6% for that quarter and multisource and line extension drugs will be added to the weighted average of applicable NDCs.

CMS also proposes to maintain the applicable threshold percentage for price substitution of WAMP or AMP for two consecutive quarters at 5%. CMS also finalizes the proposal to maintain the applicable threshold percentage for price substitution at 5%, however did not finalize a new proposal for price substitution at 103% of average manufacturer price (AMP) in certain circumstances when the ASP exceeds the AMP.


What is Overfill?An amount in the vial that is not indicated on

the label.

It is an amount not included in what you paid for in terms of vial size.

Under ‘incident to’, practices may not be reimbursed for anything which does not represent an expense to them.

Prior to the final rule, overfill was statutorily excluded from payment. But, the FR reinforced this.


FINAL MPFS 2011 Signature on Requisition: CMS will require a physician’s or a

non-physician practitioner’s signature on requisitions for clinical diagnostic laboratory tests paid under the Clinical Lab Fee Schedule. This has gotten very negative comments in the past. CMS believes that signatures are already required on orders for clinical

diagnostic laboratory tests paid under the Clinical Lab Fee Schedule and there is confusion about the difference between an order and a requisition.

The proposed policy will also be consistent with the requirement that orders for diagnostic tests paid under the MPFS must be signed by a physician or appropriate non-physician practitioner.

CMS has updated this policy to state that it will not be enforced First Quarter 2011. There are also very public rumors that this will go away before April 1.

One-year filing for Part B claims: There has already been a transmittal about this. But, starting January 1, 2010, there will be a one-year filing deadline for claims.


PQRI Goes Away CMS is changing the name of the Physician Quality

Reporting Initiative (PQRI) to the Physician Quality Reporting System (PQRS).

The PQRS as it will now be known will pay bonuses equal to 1% of your Medicare PFS charges for 2011, and a 0.5% bonus for reporting years in 2012 through 2014.

In 2015, providers who don't participate in PQRS will suffer a payment decrease. Beginning in 2015, EPs who do not satisfactorily report Physician Quality Reporting System measures will be subject to payment adjustments

2015: -1.5% payment adjustment 2016 and beyond: -2% payment adjustment


FINAL Fee Schedule 2011 PQRI for 2011: This year, there are 194 measures in the rule. Like last year, there

are 2 reporting periods: 6 months and 12 months. Other proposed changes to PQRI applicable to office-based cancer practices include: Registries: CMS once again emphasized that Registries are the way to go for more accuracy

in PQRI data submission. CMS wants to get away from claims submissions ASAP. New cancer registry: [email protected].

Success Criteria: It is PROPOSED for claims ONLY that you report on at least 3 measures (if applicable) AND you report on at least 50% of applicable patients, instead of 80%---which would still be the rate for EMR/EHR or Registry submission.

Group Practices: Two types of group practices are proposed to report in 2011. First are practices over 200 eligible providers called GPROI. Then there are groups 2-199 eligible providers called GPROII. To report as a GPROII, you must self-nominate; be in the first 500 practices to do so after the beginning of the year 2011; and, you must report at least one of GPROII groups, which do not apply to many cancer practices. CMS is looking for specialty measures groups for GPROII.

Deleted Measures: These measures used by cancer folks are leaving (maybe) in 2011: Measures 114 and 115 for Tobacco Use (more later about this); Measure 136 for Melanoma

Measures Reportable by Registry Only: These are the same as last year: 137-138: Melanoma 143-144: Pain In Cancer Measures


GPRO IIHow to Participate in GPROII in 2011

Potential participants mustMeet group practice definitionHave billed Medicare B between 1/1 – 10/29/10Self-nominate between 1/3 – 1/31/11

Provide group practice’s TIN Agree to attend/participate in mandatory training

sessions and kick-off meeting Reporting requirements vary by size of group practice/#

of eligible professionals


FINAL MPFS 2011PQRS 2011

New Measures:#224 Melanoma: Overuse of Radiation in Stages 0-1AMammography: Reminder System#226 Tobacco: Screening/ Cessation/ Interventions

EHR Reporting: If you have a certified (by CMS) EHR/EMR that can submit data to CMS for you, you can report using your EMR. Here are some :Immunizations: Influenza and pneumoniaScreening MammographyTherapy or screening for osteoporosisColorectal screeningEHR Use (duh—obvious if you are submitting by EHR)Tobacco use and cessationAdvance care planAlcohol screening (on the patients, not the staff)


FINAL MPFS 2011 PQRS 2011

MOCP (Maintenance of Certification) Adjustment: Certain certifying agencies board-certify physicians and their facilities. If you meet these criteria. This is a health reform provision. Beginning in 2011, provides an additional 0.5% PQRI bonus for 3 years (2011-2014) if physicians and other eligible professionals report quality data to the PQRI through a maintenance of certification (MOC) process, and after 2014, the Secretary could require participation in an MOC as part of the physician cost/quality index under section 3007 of ACA.

Public Reporting: the “Medicare Compare” web site was supposed to be up and running 1/1/2011 with all the PQRI and E-Rx success stats for providers. That deadline will now be 2012. Um, whoops…

Integration of PQRS and “Meaningful Use” ARRA incentive: It is proposed that, in 2012, there will be measures that obviate use of EHR, plus quality of care. This reportedly is to avoid duplication, as you will not be able to get ARRA incentives along with e-prescribing.

Appeals: For the first time in 2011, it is proposed that the determination of whether or not EPs qualify for the incentive may be appealed through an ‘informal’ appeal through ever-popular [email protected].

Interim Feedback: CMS proposes to provide feedback to participating providers in June 2011 about their PQRI incentive status. Maybe, they should have done this when the incentive was 2%.https://www.cms.gov/PhysicianFeeSched/PFSFRN/list.asp#TopOfPage

mailto:[email protected]


FINAL E-Prescribing 2011E-Prescribing: E-prescribing will pay 1% of the

providers’ billed and allowed fee schedule services (all services paid by RVUs) in 2011. 2011 is the last year where you will not be penalized, if you do not participate if you qualify. BUT, 2011 is the year that those that should be penalized will be identified. The penalty only exists for those who do not have at least 100 cases in the denominator codes (mostly E/M); who do not report at least 10 encounters by mid-2011, or, do not qualify as a physician or physician extender who has at least 10% of fee schedule revenue in the denominator codes.



E-Rx Reporting For successful claims-based reporting in 2011,a single code

should be reported (numerator) G8553 – At least one prescription created during the encounter was generated and transmitted electronically using a qualified e-Rx system

Must be on the same claim (denominator)–90801, 90802, 90804, 90805, 90806, 90807, 90808, 90809, 90862, 92002, 92004, 92012, 92014, 96150, 96151, 96152, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99315, 99316, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, G0101, G0108, G0109

Combination is reported on at least 25 encounters


FINAL E-Prescribing If you participate in the HIT incentive, you may not receive

the e-prescribing incentive, but you must e-prescribe AND FOR NOW YOU MUST REPORT!

IncentiveReporting period: Calendar year, but data 1/1/2011-

6/30/2011 will be used to identify those who should be penalized. So, you must report at least 10 encounters per NPI before 6/30/11.

Reporting mechanisms: CLAIMS ONLY!!Hardship exceptions—there will be new G-codes for

these: Rural practices with no high speed internet ORProviders near pharmacies that do not process e-rx.


2009 PQRI PaymentsEffective January 2010, CMS revised the manner in which incentive payment information is communicated to eligible professionals receiving electronic remittance advices. CMS has instructed Medicare contractors to use a new indicator of LE to indicate incentive payments instead of LS. LE will appear on the electronic remit. In an effort to further clarify the type of incentive payment issued (either PQRI or eRx incentive), CMS created a 4-digit code to indicate the type of incentive and reporting year. For the 2009 PQRI incentive payments, the 4-digit code is PQ09. This code will be displayed on the electronic remittance advice along with the LE indicator. For example, eligible professionals will see LE to indicate an incentive payment, along with PQ09 to identify that payment as the 2009 PQRI incentive payment. Additionally, the paper remittance advice will read, "This is a PQRI incentive payment." The year will not be included in the paper remittance.

If you have questions about the status of your PQRI incentive payment (during the distribution timeframe), please contact your Provider Contact Center. The Contact Center Directory is available on the CMS website. The QualityNet Help Desk is available Monday through Friday from 8:00 AM - 8:00 AM EST at 1-866-288-8912 or via [email protected] . They can also assist with program and measure-specific questions.

http://click.broadcastemail.asco.org/?ju=fe1d16787d6506757c1d73&ls=fde91372736202747417767d&m=ff311d707460&l=fe5e1575706c067d7d10&s=fdfb15757764027a741d7070&jb=ffcf14&t=

http://us.mc1125.mail.yahoo.com/mc/[email protected]


Imaging ReductionTransmittal 694, CR 6965, effective July 1 and

implemented July 6, 2019 Implements Health Reform ProvisionReduction of –TC increased from 25% to 50% for

additional procedures done in the same session on the same day.

Many experts thought this would not happen until 2011. However, you will see more of this in 2011!


Claims Filing Transmittal 697, CR 6960, effective January 1, 2010 and

implemented October 4, 2010

Claims must be filed within one calendar year. Implementation will be according to this schedule: 1) claims with dates of service prior to October 1, 2009 will be

subject to pre-PPACA timely filing rules and associated edits; 2) claims with dates of service October 1, 2009 through

December 31, 2009 received after December 31, 2010 will be denied as being past the timely filing statute and;

3) claims with dates of service on or after January 1, 2010 received more than 1 calendar year beyond the date of service will be denied as being past the timely filing statute (ex: claim DOS = 3/15/10, claim must be received by COB 3/15/11).

One exception is a mistake by CMS or agents thereof.


Signatures: Review Criteria

Auditors: MACs, CERTs, and RACs, just to name a few. CMS requires that orders for healthcare services and the services that were provided be authenticated by the author using either a handwritten or electronic signature. CMS has made it clear that stamped signatures are not an acceptable form of authentication.

The previous language in the CMS Program Integrity Manual required a “legible identifier”. The recent CMS Transmittal 327 has added additional clarification and signature assessment requirements.

Any auditor can use this rule, unless other laws or regulations supersede this rule.

http://www.medicarefind.com/Transmittal.aspx?TransmittalNo=R327PI&DocumentType=Transmittals/Program%20Memoranda&FileLink=R327PI.pdf


SIGNATURES: CMS AUDITS If the signature is missing from any other medical documentation, excluding the

order, the reviewer should accept a signature attestation from the author of the medical record entry. Providers should not add late signatures to the medical record “beyond the short delay that occurs during the transcription process” and should instead use the signature attestation process. Other providers in the same group may not attest to the original author’s signature.

In addition, if the Medicare policy is “silent” on whether a signature must be dated, the reviewer has been instructed to ensure that the rest of the documentation contains enough information to determine the date when the service was ordered and/or performed. For example, the reviewer finds that the first and third order on a page have a specific date; however, the second order on the same page is not dated. It could be assumed that the second order occurred on the same date.

All providers should be reviewing all documentation for dates and signatures in a timely manner and prior to considering the medical record complete. Also, review all request letters for any additional language the reviewer might add reminding you that a signature log or attestation can be submitted with the copies as part of the Additional Documentation Request (ADR).


National Coverage Analyses (NCAs)

Tobacco Cessation (8/25/2010) The Centers for Medicare and Medicaid Services (CMS) has determined that the evidence is

adequate to conclude that counseling to prevent tobacco use, which is recommended with a grade of A by the U.S. Preventive Services Task Force (USPSTF) for all adults and pregnant women who use tobacco, is reasonable and necessary for prevention of illness or disability and is appropriate for individuals entitled to benefits under Part A or enrolled under Part B.

Therefore CMS will cover tobacco cessation counseling for outpatient and hospitalized Medicare beneficiaries: Who use tobacco, regardless of whether the patient has signs or symptoms of tobacco-related

disease; Who are competent and alert at the time that counseling is provided; and Whose counseling is furnished by a qualified physician or other Medicare-recognized practitioner.

CMS will cover two individual tobacco cessation counseling attempts per year. Each attempt may include a maximum of four intermediate or intensive sessions, with the total annual benefit thus covering up to eight sessions per Medicare beneficiary who uses tobacco. The practitioner and patient have the flexibility to choose between intermediate (more than three minutes) or intensive (more than ten minutes) cessation counseling sessions for each attempt.

This decision memorandum does not modify existing coverage for minimal individual cessation counseling (three minutes or less), which is already covered as part of each Evaluation and Management (E&M) visit and is not separately billable.

FOUR ENORMOUS INITIATIVES

WILL BEGIN OR HAVE BEGUN THIS YEAR

Is Your Organization Prepared?

Incentive Payments are for “Adoption and Meaningful Use of Certified EHR Technology”

*Applies to Medicare ONLY – US Hospitals; Physicians on January 1, 2011

2009 ARRA / HITECH Act

I.A. Beginning in October 2010*

Medicare / Medicaid

Incentive Payments

MEANINGFUL USE of

CERTIFIED EHRsProviders / Hospitals

Division A, Title XIII - Subtitle D:

1996 HIPAA Title II--Administrative Simplification Standards Modifications The Confidentiality and Privacy Standards The Security Standards

*HHS’ OCR begins to enforce Privacy Rule only after a rule is in place; Privacy’s Breach Rule already in place

Applies to ALL (new / existing) HIPAA CEs

2009 ARRA / HITECH ActI.B. Began in February 2010*

HIPAA “TWO” Confidentiality/

Privacy and

Security Standards

II. Compliance on January 1, 2012

The EDI Transactions Set

Version 5010 and D.0 Transactions

Applies to ALL (new /existing) HIPAA Covered Entities and ALL Accredited Standards Committee (ASC) X12 and National Council for Prescription Drug Program (NCPDP) transactions

1996 HIPAA Title II--Administrative Simplification Standards Modifications

HIPAA 5010 COMPLIANCE DATES

HIPAA 5010 EFFECTIVE DATE: March 17, 2009

LEVEL I COMPLIANCE BY: December 31, 2010 CMS Medicare Fee-for-Service Schedule:

April 1, 2010 through December 31, 2010

LEVEL II COMPLIANCE BY: December 31, 2011 CMS Medicare Fee-for-Service Schedule:

January 1, 2011 through December 31, 2011

ALL CEs FULLY COMPLIANT ON: January 1, 2012

All Other

Physician

Long Term Healthcare

Laboratory

Behavioral HealthHospital

Outpatient

ICD-10-CM CPT / HCPCS


ICD-10-CMCPT / HCPCS


ICD-10-CMICD-10-PCS

ICD-10-CM / PCS



Inpatient

III. Beginning on October 1, 2013

Medicare & Medicaid EHR Incentives Final Rule

Implementing the American Reinvestment & Recovery Act of 2009

onPoint Oncology LLC

Overview• American Reinvestment & Recovery Act –

February 2009

• EHR Incentive NPRM on Display – December 30, 2009; published January 13, 2010

• NPRM Comment Period Closes – March 15, 2010

• Final Rule Published 7/13/2010

42

Stage 12011*

Stage 22013*

Stage 3TBD*

1. Capturing health information in a coded format

2. Using the information to track key clinical conditions

3. Communicating captured information for care coordination purposes

4. Reporting of clinical quality measures and public health information

Capture information….

1. Disease management, clinical decision support

2. Medication management3. Support for patient access to

their health information4. Transitions in care 5. Quality measurement 6. Research7. Bi-directional communication

with public health agencies

Report information…

1. Achieving improvements in quality, safety and efficiency

2. Focusing on decision support for national high priority conditions

3. Patient access to self-management tools

4. Access to comprehensive patient data

5. Improving population health outcomes

Leverage information to improve outcomes…

*Indicates “payment year” in which each Stage is first introduced. Actual compliance timeframe depends on an EP’s first payment year.

Eligible Professional (EP) defines those providers eligible for incentives

“Certified EHR” Based on set of standards, implementation specifications,

and certification criteria EHR vendors must meet---certified in EMR in Oncology Altos’ OncoEMR and MOSAIQ

“Meaningful Use” A set of measures for using a certified EHR which EP’s must

meet Continuous 90 day reporting period (first payment year) Reporting period = All year (each subsequent year)

Choose a program Medicare or Medicaid Must choose one (may switch programs once)

eligible professionals (EP’s)Medicare

Doctor of medicine or osteopathy

Doctor of dental surgery or dental medicine

Doctor of podiatric medicine

Doctor of optometry

Chiropractor

Medicaid

Physicians

Dentists

Certified nurse midwives

Nurse practitioners

Physicians assistants (in rural health clinic or FQHC led by a physician assistant)

eligible professionals (EP’s)EP’s who see patients in multiple practices but

do not have a certified EHR at each practice are eligible if more than 50% of encounters occur at an EHR-enabled practice

Starts in calendar year 2011

EP’s may receive payments up to $44,000 over five years

Incentive based on percentage of Medicare allowable

Meaningful Use must be demonstrated for all patients (not just Medicare)

Incentive payments end in 2015

Penalties - reduction in Medicare reimbursements for EP’s not demonstrating Meaningful Use starting in 2015

• Maximum payments based upon 75% of Medicare Part B fee schedule payments up to the maximum incentive amount per year.

• e.g., Minimum of $24,000 per year to be eligible for maximum $18,000 bonus

2011 2012 2013 2014 2015 2016 2017 TOTAL

Adopt 2011

$18,000 $12,000 $8,000 $4,000 $2,000 $0 $0 $44,000

Adopt 2012

---------- $18,000 $12,000 $8,000 $4,000 $2,000 $0 $44,000

Adopt 2013

---------- ----------- $15,000 $12,000 $8,000 $4,000 $0 $39,000

Adopt 2014

---------- ----------- ----------- $12,000 $8,000 $4,000 $0 $24,000

Adopt 2015

+

---------- ----------- ----------- ---------- $0 $0 $0 $0

• In 2015, reduction in Medicare reimbursement begins for physicians who are not meaningful EHR users (1% per year, capped at a 3% reduction).

• Statute allows for exceptions for “significant hardship” as determined by the Secretary.

First Payment YearReduction in Medicare Fee Schedule for non-adoption

of certified EHR

2011 $0

2012 $0

2013 $0

2014 $0

2015 -1%

2016 -2%

2017 and thereafter -3%

Starts in calendar year 2011—some payments have gone out.

EP’s may receive payments up to $63,750 over six years

Incentive based on up to 85% of state-calculated global average costs for EHR

1st yr cost no later than 2016

No payments made after 2021 or more than 5 years

No Medicaid penalty for failure to demonstrate Meaningful Use

PaymentComponent

Base YearMaximum of 85% of

EHR Acquisition and Implementation

Costs

Year 2 Year 3 Year 4 Year 5 Year 6 TOTAL

Physician $21,250 $ 8,500 $ 8,500 $ 8,500 $ 8,500 $ 8,500 $63,750

Certified Nurse Mid-Wife

$21,250 $ 8,500 $ 8,500 $ 8,500 $ 8,500 $ 8,500 $63,750

Dentist $21,250 $ 8,500 $ 8,500 $ 8,500 $ 8,500 $ 8,500 $63,750

Nurse Practitioner $21,250 $ 8,500 $ 8,500 $ 8,500 $ 8,500 $ 8,500 $63,750

Physician Assistant

$21,250 $ 8,500 $ 8,500 $ 8,500 $ 8,500 $ 8,500 $63,750

Requires minimum 30% Medicaid patient mix (20% for Pediatrics)

Patient mix percentage based on EP-selected 90 day average within previous 12 months, calculated by encounters or by patient panel

Group practice claim volume can used to calculate eligibility

Encounters defined as “services rendered”

Medicaid does not require M.U. in first year if an EP can demonstrate that they are:AdoptingImplementingUpgrading

…their Certified EHR technology


Medicare or Medicaid?If an eligible provider opts to receive incentives

under MedicareMay collect PQRI and HITECH incentives May NOT collect e-Rx incentives

If an eligible provider opts to receive incentives under MedicaidMay collect PQRI, HITECH, and e-Rx incentives

2011 – self-reporting (attestation) via CMS web portal---was supposed to be registered in PECOS but, for now, you don’t…

2012 & beyond – if available, report information directly from certified EHR using: Integrated web portalLocal HIERegistries

… Specifics TBA

HOW:

A single, consolidated annual incentive paymentMedicare: paid by CMS (not via claims Fiscal

Intermediary)Medicaid: paid by State Medicaid program, or their

designated intermediary

Payments will be made once an EP: – Demonstrates Meaningful Use for the reporting period

and reaches the threshold for maximum payment, within 15-46 days after attestation

EP’s can reassign their Medicare or Medicaid payment, with guidelines

Incentives are calculated individually per EP, group affiliations are not considered in 2011

Records retention

Evidence of qualification to receive incentive payments must be retained for SIX years


Two Sides To The StoryHealth IT Vendors

Design EHR technologies that meet the standards and certification criteria

Submit EHR technologies to an ONC-Authorized Testing and Certification Body (ONCATCB), which tests and certifies EHR technologies for use

Health Care Providers Demonstrate meaningful

use of certified EHR technology to qualify for the Medicare and Medicaid EHR incentive programs by using MU technology in the operation of the facility.


What Is Meaningful Use?Your facility must attest that:

Are using certified EHR technology (with technology specified so it can be checked)

Have met each of the 15 core meaningful use objectives; and 5 of the 10 “menu” objectives

Have accurately and completely reported the associated HIT functionality measures – one for each objective

Have accurately and completely reported 6 quality measures using your EHR to generate values (electronic reporting from EHR starting in 2012)

Reporting period is 90 days in first reporting year

Core SetPolicy

Priority

Stage 1 Objectives Measure

Improving quality, safety, efficiency and

reducing health disparities

Use CPOE for medication orders 30%+ ofpatients

Implement drug-drug & drug-allergy checks Functionally enabled

Generate and transmit permissible prescriptions electronically (eRx)

40%+ of eligible

prescriptions

Record selected demographics (preferred language, gender, race, ethnicity, date of birth)

50%+ of patients

Maintain an up-to-date problem list of current and active diagnoses

80%+ of patients

Maintain active medication list 80%+ of patients

Improving quality, safety,

efficiency and

reducing health

disparities(cont.)

Maintain active medication allergy list 80%+ of patients

Record and chart changes in selected vital signs (height, weight, BP, BMI, growth charts (2-20 yrs.)

50%+ of patients

Record smoking status for patients 13 years old or older 50%+ of patients

Implement one clinical decision support rule along with the ability to track compliance that rule

1 rule

Report ambulatory quality measures to CMS or the States Aggregate numerator/

denominator

Policy Priority


Engage patients and families in their healthcare

Provide patients with an electronic copy of their health information (including diagnostic test results, problem list, medication lists, and medication allergies) upon request, within 3 days of request

50%+ of all patients who

request

Provide clinical summaries to patients for each office visit within 3 days of visit

50%+ of all office visits

Improve Care Coordination

Capability to exchange key clinical information (for example problem list, medication lists, medication allergies, diagnostic test results) among providers of care and patient authorized entities electronically

1 test of capability

Ensure adequate security and

privacy provisions for

personal health information

Protect electronic health information created or maintained by certified EHR technology through the implementation of appropriate technical capabilities.

Conduct or review a

security risk analysis

Policy Priority


Menu SetPolicy

Priority


Improving quality, safety, efficiency and

reducing health disparities

Implement drug formularychecks

Functionality enabled

Incorporate clinical lab test results into certifiedEHR technology as structured data

40%+ of all clinical lab tests ordered

Generate lists of patients by specific conditions touse for quality improvement, reduction of disparities,

research or outreach

At least 1 report of patients with

condition

Send reminders to patients 65 years or older of 5 years or younger per patient preference for preventive/ follow up care

20%+ of patients

Policy Priority


Engage patients and families in their healthcare Improve Care Coordination

Provide patients with timely electronic access to their health information (including lab results, problem list,

medication lists, medication allergies) within four business days of the information being available to the EP

10%+ of patients

Use certified EHR technology to identify patient-specificeducation resources and provide those resources to the

patient if appropriate

10%+ of patients

Improve carecoordination

Perform Medication Reconciliation when the EP or eligible hospital receives a patient from another setting of care or provider of care

50%+ of care transitions to EP

Provide summary of care record for each transition of a patient to another setting of care or provider of care or referral to another provider of care

50%+ of care transitions from

EP

Improve population health

Capability to submit electronic data to immunization registriesor Immunization Information Systems and actual submission in accordance with applicable law and practice

At least 1 test

Capability to submit electronic syndromic surveillance data topublic health agencies and actual submission in accordance with applicable law and practice

At least 1 test

Policy Priority


Some measures can be reported as inapplicable if the EP has no applicable patients or an insufficient # of actions that would allow calculation

EP’s must submit clinical data on 6 total measures – 3 Core (using alternate if necessary) …

Core Measures + Alternate Core Measures

NQF 0013 Hypertension: Blood Pressure Measurement

NQF 0028 Preventive Care and Screening Measure Pair: a. Tobacco Use Assessmentb. Tobacco Cessation Intervention

NQF 0421PQRI 128

Adult weight screening and follow up

NQF0024 Weight Assessment and Counseling for Children and Adolescents

NQF 0041PQRI 110

Preventive Care and Screening: Influenza Immunization for Patients ≥ 50 Years Old

NQF 0036 Childhood Immunization Status

- Measures are reported as numerator/denominator - EP’s can report a denominator of ZERO if there are

no applicable cases

… and 3 “additional measures” (38 available)

NQF 0059PQRI 1

Title: Diabetes: Hemoglobin A1c Poor ControlDescription: Percentage of patients 18 - 75 years of age with diabetes (type 1 or type 2) who had hemoglobin A1c > 9.0%.

NQF 0575 Title: Diabetes: Hemoglobin A1c Control (<8.0%)Description: The percentage of patients 18-75 years of age with diabetes (type 1 or type 2) who had hemoglobin A1c <8.0%

NQF 0081PQRI 5

Title: Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)Description: Percentage of patients aged 18 years and older with a diagnosis of heart failure and LVSD (LVEF< 40%) who were prescribed ACE inhibitor or ARB therapy.

A few examples:


Where Do I Sign Up?Registration begins in January 3, 2011 at the

EHR Incentive Program websitehttp://www.cms.gov/EHRIncentivePrograms/

Requirements includeName NPI Business address and phone Taxpayer ID number for incentive payments Medicare or Medicaid program selectionState selection for Medicaid providers

http://www.cms.gov/EHRIncentivePrograms/

Select your EHR partner WHO IS CERTIFIED!

Develop detailed implementation plan Set goals & detailed timelines Set expectations Gain “buy in” Plan for the unexpected

Pick your program (Medicare or Medicaid or E-Rx)

Implement!

More InformationFor 3 MEDICARE tip sheets,

go to http://www.cms.gov/EHRIncentivePrograms. Select the “Medicare Eligible Professional” tab on the left, and then scroll to “Downloads.”

Medicaid EHR Incentive Payments for Eligible Professionals Go to http://www.cms.gov/EHRIncentivePrograms.

Select the “Medicaid Eligible Professional” tab on the left, and then scroll to “Downloads.”

EHR Incentive Program TimelineFind it at http://www.cms.gov/EHRIncentivePrograms

in the “Downloads” section of the “Overview” tab. 72

http://www.cms.gov/EHRIncentivePrograms



Multiple Layers of Audits – Federal Medicare

Incorrectly Billed Claims

Processing Errors

Medical Necessi

ty

Incorrect

Payment Amounts

Non-covered Services

Incorrectly

Coded Services

Duplicate

Services

RAC X X X X X X XMAC X X X X X X X

PSC/ZPIC X X X X XCERT X X X X X

MAC Billing Audits

X X X X X X

Office of Audit Services Audits

X X X X

Annual Work Plan Projects X X X X X X

Large $ Items X X X

74

Don’t Be Caught

Unaware……...

Be Prepared!


CPT: 96445 To 96446Intra-peritoneal Chemo

96445 has been deleted96446, Chemotherapy into the peritoneal cavity

through an indwelling catheter or portNo peritoneocentesis necessaryReflects current practice…


New HCPCS Codes 2011


Changed and Deleted HCPCS 2011

Changed

Deleted


Your To Do List Right Now Make sure you have received 2009 E-Rx and PQRI payments.

Run your 2011 numbers using the new RVUs and allowables.

Ascertain your vendor’s plan for Meaningful Use for implementation in 2011 or 2012.

Select your incentive programs for 2011.

Check to make sure you are NOT billing overfill in your facility.

Update your Superbill---for a suggested one, see http://communityoncology.info/category/library/

Think about alternative revenue streams—oral drugs, trials, etc.

Participate in the struggle—can you afford another cut or even a hold.


CAN Web SiteThe latest newsFormsRegulationsNewslettersPresentationshttp://communityoncology.info


CONTACT INFO

[email protected]@yahoo.com800-795-2633

Newsletter is free!

Send all RAC information to me at the ABOVE E-mails or FAX to 650-618-8621

Go to our website: http://www.onpointoncology.com




THANK YOU FROM ONPOINT ONCOLOGY LLC!

medicare 2011 omf march, 2011. agenda what’s going on right now medicare pfs final rule 1/1/2011...

Documents

sgr medicare

medicare program

medicare patients

medicare statute

practicesonpoint oncology

debacleonpoint oncology

yearonpoint oncology

medical oncology