Oncology News Archives

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CMS QUALITY PAYMENT PROGRAM The Medicare Access and CHIP Reauthorization Act (MACRA) repealed the Sustainable Growth Rate (SGR) formula for physician payments and introduced a new Medicare value-based reimbursement system.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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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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