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CMS Issues New CPT Code for Billing Prolonged Drug and Biological Infusions Using an External Ambulatory Infusion Pump

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MLN Matters® Number MM9749 CMS Issues New CPT Code for Billing Prolonged Drug and Biological Infusions Using an External Ambulatory Infusion Pump On August 19, 2016 CMS published MLN Matters® Number MM9749 which states that CMS has established a new code G0498 for billing the ambulatory infusion pumps used in extended IV infusions. CMS is directing all Medicare MACs to load the new code. Code: G0498 Long Descriptor: Chemotherapy administration, intravenous infusion technique; initiation of infusion in the office/other outpatient setting using office/other outpatient setting pump/supplies, with continuation of the infusion in the community setting (e.g., home, domiciliary, rest home or assisted living) using a portable pump provided by the office/other outpatient setting, includes follow up office/other outpatient visit at the conclusion of the infusion. MLN MM9749 states that G0498 is effective for dates of service on or after January 1, 2016. G0498 has a procedure status of “C”; codes…

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CMS Releases Clarification on Billing for Prolonged Infusion Services

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MLN Matters® Number: SE1609 Medicare Policy Clarified for Prolonged Drug and Biological Infusions Started Incident to a Physician’s Service Using an External Pump   On Friday, April 29, CMS released MLN Matters® Number SE1609, which they describe as a clarification. In fact, the clarification outlined in this MLN Matters Special Edition article fundamentally changes our understanding for billing external infusion pumps that are initiated in the HOPD or physician office and sent home with the patient for the remainder of the CIV infusion of the drug or biological. In the past, the rules for billing for these services and the drugs provided via the ambulatory infusion pump have been a bit confusing as the direction provided from the DME MAC and the Part B MAC were often at odds. The CMS MLN Matters article was published in response to the confusion between the DME and Part B MACs and their…

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CMS Proposes New Part B Drug Payment Model

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On February 5th, the Centers for Medicare & Medicaid Services (CMS) posted and then removed a transmittal to Medicare contractors that outlined a new payment model to be tested for Part B drugs. Transmittal 137, Change Request 9501 was to have an effective date of July 1, 2016 and an implementation date of July 5, 2016. This transmittal instructed Medicare Administrative Contractors (MACs) and other Medicare shared system maintainers, to put in place the necessary system changes to implement the Part B Drug Payment Model which would consist of the testing of different Average Sales Price (ASP) payment limit values in certain defined geographic areas based on ZIP code. Details of what the changes to ASP would be or exactly how they will be applied were not provided in the transmittal. However, CMS did state that they would also test the impact of targeted pricing changes to payments for individual Part B drugs beyond…

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Congress Passes Permanent SGR Fix

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Late last night, the Senate passed H.R. 2, the “Medicare Access and Chip Reauthorization Act,” (MACRA), by a vote of 92-8. This bill is the same bill that was passed by the House on March 26 by a vote of 392-37.The bill now goes to President Obama for his signature. President Obama has previously indicated he would sign the bill. Medicare payments will remain at the rate that was effective prior to the April 1 deadline until July 1, 2015 at which time the fee schedule conversion factor will be increased by 0.5%. Among the bill’s significant provisions: Replaces the SGR with an increase of 0.5% in Medicare physician reimbursement starting in July 2015 through December 2015, and then annual 0.5% increases lasting through 2019 Consolidates reporting programs, such as the Meaningful Use program for electronic health records and several quality reporting programs, into a new, merit-based incentive payment system,…

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ICD-10 Update & Payment Reform Proposal

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5/5/2014 CMS PUBLISHES STATEMENT ON ICD-10 IMPLEMENTATION & TESTING On Friday, May 2, the Centers for Medicare and Medicaid Services (CMS) issued a MLN Connects™ Provider eNews Special Edition with information on the new ICD-10 implementation date and the previously scheduled ICD-10 end-to-end testing. The Protecting Access to Medicare Act of 2014 implemented on April 1, 2014, includes a provision that the U.S. Department of Health and Human Services Secretary may not adopt ICD-10 prior to October 1, 2015. Friday, CMS published the Special Edition MLN eNews article stating that they would release an interim final rule in the near future that will include a new compliance date of October 1, 2015 for the use of ICD-10. CMS also states that the rule will require HIPAA covered entities to continue to use ICD-9-CM through September 30, 2015. The MLN Connects™ Special Edition eNews also announced the cancelation of the previously…

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CMS PUBLISHES PROVIDER CHARGE & PAYMENT DATA

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4/9/2014 On Wednesday, April 8, the Centers for Medicare and Medicaid Services (CMS), published files detailing 2012 Medicare Part B payments to individual providers and physician practices. The files include what the provider charged as well as Medicare payments by procedure code. The files, which are on the CMS website, provide charge and payment data which CMS states they released in response to demands for transparency. Of concern, is the fact that the data was released without explanation of the Medicare payment system or what the data really shows. This is particularly troublesome for oncology as high cost chemotherapy drugs are shown as having a high revenue rate without mention of the cost of the drugs. In addition, the data is misleading as some revenue that is reported for one provider may be dispersed to other group providers or practices. Since publication of the data, news articles in national publications…

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