Strategies for the Oncology Community

Latest Oncology News

PRESIDENT TRUMP SIGNS COVID RELIEF BILL INTO LAW

By | Latest Oncology News | No Comments

On December 21, Congress passed a comprehensive bi-partisan year-end bill that funds the federal government through FY 2021, provides additional COVID relief and economic stimulus funds, and includes important changes to the 2021 Medicare Physician Fee Schedule. The legislation was finally signed into law by President Trump late Sunday, December 27, averting a government shutdown on Tuesday.Along with the COVID-19 relief and economic stimulus funds, the bill includes provisions which will help to alleviate the 10.2% reduction in Medicare’s payment rates (due to the 10.2% decrease in the conversion factor for 2021) included in the CMS 2021 Medicare Physician Fee Schedule (PFS) final rule. The bill provides: An increase of 3.75% to the PFS conversion factor for all specialties and services in 2021. A three-year delay in payments for a new add-on evaluation and management (E/M) code G2211 for visit complexity inherent in E/M visits. An extension of the 2%…

Read More

CMS Delays Radiation Oncology Start Date

By | Latest Oncology News | No Comments

On October 21, 2020, CMS announced they received feedback from a number of stakeholders about the challenges of preparing to implement the Radiation Oncology (RO) Model by January 1, 2021 and as a result, they would delay the RO Model start date to July 1, 2021. The RO Model tests whether bundled, prospective, site neutral, modality agnostic, episode-based payments to physician group practices (PGPs), hospital outpatient departments (HOPD), and freestanding radiation therapy centers for radiotherapy (RT) episodes of care reduces Medicare expenditures while preserving or enhancing the quality of care for Medicare beneficiaries. The design of the RO Model includes several key programmatic elements: Alternative Payment: Episode Payments:CMS makes prospective, episode-based (i.e., bundled) payments, based on a patient’s cancer diagnosis, that cover RT services furnished in a 90-day episode for the 16 cancer types meeting the included cancer type criteria described in the final rule; Site-neutrality:The Model uses site-neutral payment…

Read More

Medicare 2021 Proposed Physician Fee Schedule and OPPS Rules

By | Latest Oncology News | No Comments

CMS RELEASES CY 2021 PROPOSED RULES On August 4, 2020, the Centers for Medicare and Medicaid Services (CMS) released the proposed 2021 Medicare Physician Fee Schedule (PFS), and Hospital Outpatient Prospective Payment System (OPPS) rules. Below are some of the highlights of the rules. PHYSICIAN FEE SCHEDULE PROPOSED RULE (PFS) CY 2021 Under the PFS proposed rule, physicians would see a reduced conversion factor (CF) from $36.09 in 2020, to $32.26, effective Jan. 1, 2021. Table 90 of the proposed PFS rule shows the estimated impact on total allowed charges by specialty. If the rule is finalized as proposed, CMS estimates the following payment rate changes: Hematology/Oncology +14% Radiation Oncology and Radiation Therapy -6%, Rheumatology +16% Physician Assistants +8% Nurse Practitioners +8% The PFS proposed 2021 rule includes changes to previously finalized billing and coding requirements for office and outpatient visits by incorporating revisions recommended by the American Medical Association (AMA). Among the…

Read More

Audit Activity

By | Latest Oncology News | No Comments

Audits In response to the recent increase in providers reaching out to us regarding audits, we want to remind you of a few basics. First, the Centers for Medicare and Medicaid Services (CMS) healthcare audit programs include the Unified Program Integrity Contractors (UPICs) audit program, the Recovery Audit Contractor (RAC) program, and the Comprehensive Error Rate Testing (CERT) program. It is important to identify the entity that is auditing you. E/M Services Billed with Modifier 25 There has been an increase in audits on evaluation and management (E/M) services billed on the same day as chemotherapy. We know that the American Medical Association (AMA) CPT and Medicare guidelines state that medically necessary, significant and separately identifiable E/M services are payable when billed on the same day as drug administration services.  What is less clear is the criteria payers use to determine that the E/M service is significant and separately identifiable….

Read More

January 8, 2020 News

By | Latest Oncology News | No Comments

NEW RAC AUDIT – ESA On December 10, 2019, CMS approved a new RAC audit – Issue Number 0171 Erythropoiesis Stimulating Agents for Cancer Patients: Medical Necessity and Documentation Requirements, this RAC audit will apply to all A/B MACs for physicians/non-physician practitioners and hospital outpatient claims. This RAC audit is a complex review, which almost always involves a request for medical records from the contractor. Under the audit issue description, CMS states, “Medical records will be reviewed to determine if the use of ESA in cancer and related neoplastic conditions meets Medicare coverage criteria. Affected Codes J0881 and J0885 that were billed with modifiers EA and EB.” Dates of service to be audited are claims having a “claim paid date” which is less than 3 years prior to the Demand Letter date. The National Coverage Determination (NCD) for ESAs can be accessed here: National Coverage Determination Manual, Chapter 1, Section 110.21: Erythropoiesis…

Read More

CMS RELEASES 2020 FINAL RULES

By | Latest Oncology News | No Comments

On Friday, November 1, 2019 the Centers for Medicare and Medicaid Services (CMS) released the 2020 Medicare Physician Fee Schedule (PFS) final rule, which includes updates to the Quality Payment Program (QPP), and the 2020 Medicare Hospital Outpatient Prospective Payment System final rule. The final rules are effective on January 1, 2020. Medicare Physician Fee Schedule 2020 Final Rule  The finalized Calendar Year (CY) 2020 PFS conversion factor is $36.09, up slightly from the CY 2019 PFS conversion factor of $36.04. Below are some of the key changes for CY 2020 and CY 2021. CMS Reported Estimates of Payment Impact on PFS Services: Hematology/Oncology 0% Nurse Practitioner 0% Physician Assistant 0% Radiation Oncology 0% Rheumatology 0% Documentation – Evaluation and Management (E/M) Services for CY 2020 Physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse-midwives can review and verify (sign and date), rather than re-document, notes made in…

Read More

View all Oncology News