Oncology News Archives

CMS Releases Proposed 2019 Medicare Physician Fee Schedule Rule

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CMS RELEASES 2019 PROPOSED PHYSICIAN FEE SCHEDULE RULE On Thursday, July 12, CMS released the 2019 Proposed Physician Fee Schedule Rule. Below are a few of the proposed changes of interest to oncologists. https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-14985.pdf Streamlining Evaluation and Management (E/M) Payment and Reducing Clinician Burden In the Proposed Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2019 Fact Sheet, CMS states they are proposing to streamline E/M payment through their proposals: • To allow practitioners to choose to document office/outpatient E/M visits using medical decision-making or time instead of applying the current 1995 or 1997 E/M documentation guidelines, or alternatively practitioners could continue using the current framework; • To expand current options by allowing practitioners to use time as the governing factor in selecting visit level and documenting the E/M visit, regardless of whether counseling or care coordination dominate the visit; • To expand…

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SNF SERVICES DENIED IN ERROR TO BE REPROSSED AUTOMATICALLY BY THE MACs

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On March 1, 2018 CMS notified MACs of a Common Working File (CWF) issue causing certain allowable services with dates of service January 1, 2018 through February 27, 2018 to deny incorrectly indicating the service is part of Skilled Nursing Facility (SNF) Consolidated Billing (CB). In some cases overpayment demand letters were issued for claims that were previously paid. The CWF issue was corrected on February 27, 2018. CMS says no provider action is necessary at this time. Affected claims will be reprocessed and recoupment of any money demanded for previously paid claims due to this issue will be halted and/or returned to providers.

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MEDICALLY UNLIKELY EDIT DENIALS REPORTED

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On March 6, Bristol-Myers Squibb announced that the U.S. Food and Drug Administration (FDA) approved a supplemental biologics license application updating the nivolumab (Opdivo®) dosing schedule to include 480 mg infused every four weeks (Q4W). If you are using the new Q4W dosing schedule be aware that HCPCS J9299 nivolumab, 1 mg has a current Medically Unlikely Edit (MUE) value of 440 units. An MUE for a HCPCS/CPT code is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service. MUEs are designed to prevent billing errors by denying items billed above the established number of units. In this case, J9299 would deny for units billed over the established MUE value of 440 (based on previous prescribing information). The MUE files are updated quarterly, in the meantime, MUE denials for J9299 claims of more than 440mgs should…

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Medicare’s 2018 Final Rules

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The first two days of November saw a flurry of activity from the Centers for Medicare & Medicaid Services (CMS) as they released three final rules. On November 1, 2017, CMS issued the 2018 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System final rule with comment period (CMS-1678-FC). The CY 2018 Medicare Physician Fee Schedule Final Rule was placed on display at the Federal Register on November 2, 2017. This final rule updates payment policies, payment rates, and other provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after Jan. 1, 2018. For details of the PFS and OPPS final rules access the Q4 2017 Oplinc Best Practices Newsletter under the Publications tab on this website or go to: http://www.oplinc.com/publications/newsletter-archives/

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CMS Quality Payment Program Updates

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CMS QUALITY PAYMENT PROGRAM The Medicare Access and CHIP Reauthorization Act (MACRA) repealed the Sustainable Growth Rate (SGR) formula for physician payments and introduced a new Medicare value-based reimbursement system. The new system, the Medicare Quality Payment Program (QPP), has two tracks that providers will choose from, the Advanced Alternative Payment Models (APMs) or the Merit-based Incentive Payment System (MIPS). Providers who are subject to the QPP include physicians, physician assistants (PAs), nurse practitioners (NPs), clinical nurse specialists (CNSs), and certified registered nurse anesthetists (CRNAs). Providers that are new to Medicare, and those that meet a low-volume threshold are exempt from MIPS this year as are certain providers participating in an APM. Earlier this month, the Centers for Medicare & Medicaid Services (CMS) released an online lookup tool through which providers can determine their participation status in the Merit-based Incentive Payment System (MIPS) by entering their 10-digit National Provider Identifier…

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Fraud and Abuse Initiatives

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In the current political environment, the future of the Affordable Care Act and other health care initiatives is likely to look very different than they do now. However, two initiatives are expected to continue, the movement toward value-based payments, and audits to prevent and recover improper payments. The Q1 2017 Oplinc Best Practices Review Newsletter looks at some of the current health care fraud and abuse programs and discuss what you can do to prepare your practice. Access this newsletter by clicking on Oplinc’s Best Practices Review Newsletter Archive.

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Medicare Updates

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OBAMA ADMINISTRATION HALTS PART B DRUG MODEL On Thursday, December 15, the Obama administration announced that the proposed Medicare Part B Drug Model would not move forward at this time. The decision to halt the program came after much criticism, for the scope and design of the program, from public comments on the proposed rule to a letter signed by more than 170 members of the House to CMS and the Centers for Medicare & Medicaid Innovation (CMMI). In their letter, the congressional members state that CMMI models should be implemented in a voluntary, limited-scale basis, and that the CMMI has exceeded its authority with the development of the mandatory Part B Drug Payment Model. In a statement explaining the decision to halt the proposed program, a CMS spokesperson said, “While CMS was working to address these concerns, the complexity of the issues and the limited time available led to…

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CMS Releases 2017 Physician Fee Schedule Final Rule

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On Wednesday, November 2, 2016, CMS released the 2017 Physicians Fee Schedule Final Rule. This final rule updates payment policies, payment rates and other provisions for services furnished under the Medicare Physician Fee Schedule. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) calls for a conversion factor (CF) increase of 0.5% from 2016 – 2019. However, the 2017 CF is also impacted by the Achieving a Better Life Experience (ABLE) Act of 2014. The ABLE Act sets a target for adjustments to misvalued codes in the fee schedule of 1.0% for 2016, and 0.5% for 2017 and 2018. In the 2017 final rule, CMS finalized misvalued code changes achieving a 0.32% net expenditure reduction. This does not meet the misvalued code target of 0.5% for 2017. Therefore, as required under the ABLE Act, CMS must apply a reduction of equal to the percentage difference between the target 0.5%…

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CMS Releases Final Rule on MACRA, MIPS & APMs

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On October 14, 2016, CMS issued the Final Rule that implements the Medicare Access and CHIP Reauthorization Act (MACRA). The final rule, Medicare Program; Merit-based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models, provides details on the first year implementation of the new Quality Payment Program (QPP) and the two paths eligible clinicians will choose from: Advanced Alternative Payment Models (Advanced APMs) and the Merit-based Incentive Payment System (MIPS). In response to commenters concerns and suggestions, the final rule, released on October 14, includes some significant changes from the proposed rule. The first payment year for MIPS is 2019 and will be based on the 2017 MIPS performance. Acknowledging commenters concerns that eligible clinicians will not be ready by January 1, 2017 to report under MIPS, CMS has developed 3 options for participation in the MIPS path…

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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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