The Centers for Medicare & Medicaid Services (CMS) launched the Physician Voluntary Reporting Program (PVRP) in 2006 to better analyze the quality of care provided to Medicare beneficiaries by using a set of codes established by Medicare. PVRP-specific G-codes and CPT® Category IIs were reported voluntarily by participating providers. In return, the providers received confidential feedback reports regarding their practice’s performance in 2006. For more information on this program read The PVRP Payment Maze in Oplinc’s Best Practices Review Volume 2 Issue.

The 2006 PVRP ended December 31, 2006. The PVRP will be replaced by the 2007 Physician Quality Reporting Initiative (PQRI), as mandated by the Tax Relief and Health Care Act of 2006.

Under the 2007 PQRI, participating providers (who meet reporting guidelines) may be paid a 1.5% bonus, subject to a CAP, on certain services reported during the reporting period of July 01, 2007 through December 31, 2007.

As of the date of this printing, details have yet to be released but at a January 26, 2007 meeting in Arlington, Virginia, Herb Kuhn, Deputy Administrator of CMS stated that drugs and labs will be excluded from the 1.5% bonus. Mr. Kuhn also stated that CMS had not yet determined if participation will be physician oriented or group oriented.

QualityNet, established by CMS, maintains a web site providing healthcare quality improvement news and resources for healthcare providers. QualityNet provides the confidential feedback reports to PVRP participating providers. According to the QualityNet website providers do not need to enroll to participate in the PQRI. Details about this program are to be published on the CMS website by February 15, 2007.

Watch this publication for more information on the 2007 PQRI as details become available.

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Find The Latest Medicare Coding Edits on the CMS Website

The Centers for Medicare and Medicaid Services (CMS) developed and maintains the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to prevent improper coding that leads to inappropriate payment in Part B claims.

The Correct Coding Initiative (CCI) edits are updated and published quarterly. The new versions are effective each January 1, April 1, July 1 and October 1. The latest update is Version 13.0 effective January 01, 2007. In accordance with most payment policies, the effective date of the edits is based on the date of service. For more information on the CCI read The National Correct Coding Initiative in Oplinc’s Best Practices Review Volume 2 Issue 1.

In addition to the Column 1/Column 2 and Mutually Exclusive edit tables CMS publishes and posts the NCCI Policy Manual for Part B Medicare Carriers on their website. This manual provides policy narratives that help explain the edits. The NCCI Policy Manual is not updated as often as the edit tables, the most recent Policy Manual is Version 12.3 published in October 2006.

The current NCCI Policy Manual includes the following policy narrative of interest to oncologists on modifiers, drug administration, and lab services:

Chapter 1:
General Correct Coding Policies for National Correct Coding Initiative Policy Manual for Medicare Services

Chapter one includes a discussion of the correct use of modifiers -25 and -59. This is a timely reminder as the use of modifiers to bypass CCI edits is discussed in the Office of Inspector General (OIG) Spring 2006 Semiannual Report to Congress. For more information on this report read The OIG Report To Congress in Oplinc’s Best Practices Review Volume 2 Issue 4.

Modifier -59: Modifier -59 is an important NCCI-associated modifier that is often used incorrectly. For the NCCI its primary purpose is to indicate that two or more procedures are performed at different anatomic sites or different patient encounters. It should only be used if no other modifier more appropriately describes the relationships of the two or more procedure codes. The CPT Manual defines modifier -59 as follows:

Modifier -59: "Distinct Procedural Service: Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier 59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician. However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used."

Example: The column one/column two code edit with column one CPT code 38221 (bone marrow biopsy) and column two CPT code 38220 (bone marrow, aspiration only) includes two distinct procedures when performed at separate anatomic sites or separate patient encounters. In these circumstances, it would be acceptable to use modifier –59. However, if both 38221 and 38220 are performed through the same skin incision at the same patient encounter which is the usual practice, modifier –59 should NOT be used. Although 38221 and 38220 are different procedures, they are bundled when performed through the same skin incision at a single patient encounter. In this scenario bill 38221 for the biopsy and G0364 for the aspiration performed through the same incision.

Modifier -25: Modifier –25 is identified in the CPT Manual as a “significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service”. This modifier may be appended to an evaluation and management (E&M) code reported with another procedure on the same day of service. The NCCI includes edits bundling E&M codes into various procedures not covered by global surgery rules. If in addition to the procedure the physician performs a significant and separately identifiable E&M service beyond the usual pre-procedure, intra-procedure, and post-procedure physician work, the E&M may be reported with modifier –25 appended. The E&M and procedure(s) may be related to the same or different diagnoses.

Chapter 5:
Surgery: Respiratory, Cardiovascular, Hemic and Lymphatic Systems

Chapter 5 clarifies:

• CPT codes 90760-90761 should not be reported for infusions to maintain patency of a vascular access site.
• In most cases separate payment will not be made for anesthesia for a medical or surgical service when provided by the physician performing the service. Drug administration codes 90760-90775 should not be reported when these services are related to the delivery of an anesthetic agent. If the drug administration service is for a purpose unrelated to anesthesia, intra-operative care, or post-procedure pain management, the drug administration service may be reported with the appropriate modifier.

Chapter 10:
Pathology & Laboratory Services

The issue of additional and repeat tests is addressed in this chapter. If, a test is ordered and performed, and additional related procedures are necessary to provide or verify the result, these would be considered part of the ordered test:

• If a patient with leukemia has a thrombocytopenia, and a manual platelet count (CPT code 85032) is performed in addition to the performance of an automated hemogram with automated platelet count (CPT code 85027), it would be inappropriate to report CPT codes 85032 and 85027 because the former provides verification for the automated hemogram and platelet count (CPT code 85027).
• If a patient has an abnormal test result and repeat performance of the test is done to verify the result, the test is reported as one unit of service rather than two.

If a treating physician orders an automated complete blood count with automated differential WBC count (CPT code 85025) or without automated differential WBC count (CPT code 85027), the laboratory sometimes examines a blood smear in order to complete the ordered test based on laboratory selected criteria flagging the results for additional verification. The laboratory should NOT report CPT code 85007 (microscopic blood smear examination with manual WBC differential count) or CPT code 85008 (microscopic blood smear examination without manual WBC differential count) for the examination of a blood smear to complete the ordered automated hemogram test (CPT codes 85025 or 85027). The same principle applies if the treating physician orders any type of blood count and the laboratory’s practice is to perform an automated complete blood count with or without automated differential WBC count.

If a treating physician orders an automated hemogram (CPT code 85027) and a manual differential WBC count (CPT code 85007), both codes may be reported. However, a provider may not report an automated hemogram with automated differential WBC count (CPT code 85025) with a manual differential WBC count (CPT code 85007) because this combination of codes results in duplicate payment for the differential WBC count. CMS does not pay twice for the same laboratory test result even if performed by two different methods unless the two methods are medically reasonable and necessary.

An example of additional separately payable laboratory tests includes tests that when positive require additional separate follow-up testing which is implicit in the physician’s order. For example, if a urine culture is positive, the laboratory then tests to identify the organism which is separately reportable. In this case the initial positive result has limited clinical value without the additional testing. The additional testing is separately reportable because it is not performed to complete the ordered test. Furthermore, the ordered test if positive requires the additional testing in order to have clinical value.

Chapter 11:
Therapeutic or Diagnostic Infusions/Injections and Immunizations

Many of the coding rules for drug administration services including chemotherapy are listed in this chapter. The following clarifications are included:

CPT codes 90760, 90765, 90774, 96409, & 96413 represent “initial” service codes. Only 1 “initial” service code may be reported unless it is medically reasonable and necessary that the drug or substance administrations occur at separate vascular access sites. To report two different “initial” service codes use NCCI-associated modifiers.

When performing IV and/or intra-arterial infusions and injections the following are routinely necessary and therefore not separately reportable:

• Placement of peripheral vascular access devices
• Insertion of an intravenous catheter

However, insertion of central venous access and selective arterial catheterizations are not routinely necessary to perform infusions/injections, therefore these services may be reported separately.

If the sole purpose of fluid administration (e.g., saline, D5W, etc.) is to maintain patency of an access device, the infusion is neither diagnostic nor therapeutic and should not be reported separately. Similarly, the fluid utilized to administer drug(s)/substance(s) is incidental hydration and should not be reported separately.

Transfusion of blood or blood products includes the insertion of a peripheral intravenous line (e.g., CPT codes 36000, 36410) which is not separately reportable. Administration of fluid during a transfusion or between units of blood products to maintain intravenous line patency is incidental hydration and is not separately reportable.

If therapeutic fluid administration is medically necessary (e.g., correction of dehydration, prevention of nephrotoxicity) before or after transfusion or chemotherapy, it may be reported separately.

CPT code 96522 describes the refilling and maintenance of an implantable pump or reservoir for systemic drug delivery. The pump or reservoir must be capable of programmed release of a drug at a prescribed rate. Do not report this code for:

• Accessing a non-programmable implantable intravenous device for the provision of infusions
• Accessing or flushing an indwelling peripherally-placed IV catheter port (external to skin), subcutaneous port, or non-programmable subcutaneous pump.

CPT code 96522 and CPT code 96521 (refilling and maintenance of portable pump) should not be reported with CPT code 96416 (initiation of prolonged intra-venous chemotherapy infusion (more than eight hours, requiring use of a portable or implantable pump) or CPT code 96425 (chemotherapy administration, intra-arterial; infusion technique, initiation of prolonged infusion (more than eight hours requiring the use of a portable or implantable pump). CPT codes 96416 and 96425 include the initial filling and maintenance of a portable or implantable pump. CPT codes 96521 and 96522 are used to report subsequent refilling and maintenance of the pump.

A concurrent intravenous infusion of an antiemetic or other non-chemotherapeutic drug with intravenous infusion of chemotherapeutic agents may be reported separately as CPT code 90768 (concurrent intravenous infusion). CPT code 90768 may be reported with a maximum of one unit of service per patient encounter regardless of the number of concurrently infused drugs or the length of time for the concurrent infusion(s). 

Prior to January 1, 2005, the NCCI edits with column one CPT codes 96408 (Intravenous chemotherapy administration by push technique) and 96410 (Intravenous chemotherapy administration by infusion technique, up to one hour) each with column two CPT code 90780 (Therapeutic or diagnostic intravenous infusion up to one hour) were often bypassed by utilizing modifier -59. Use of modifier -59 with the column two CPT code 90780 of these NCCI edits was only appropriate if the 90780 procedure was for hydration, antiemetic, or other non-chemotherapy drug administered before, after, or at different patient encounters than the chemotherapy. Modifier -59 should not have been used for “keep open” infusion for the chemotherapy.

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Medicare Premiums Tied to Income

Each year CMS updates the Medicare premiums, deductibles and co-payments using a formula set by statute. The law requires that the standard monthly premium, paid by Medicare beneficiaries, for Medicare Part B must cover 25% of Medicare’s costs, including the costs of maintaining a reserve against unexpected spending increases. The federal government pays the remaining 75%.

The standard Medicare Part B monthly premium is $93.50 in 2007. This is an increase of 5.6% or $5.00 over the 2006 rate.

The Medicare Modernization Act of 2003 (MMA) requires that beginning in 2007 higher income beneficiaries (single beneficiaries with annual incomes over $80,000 and married couples with incomes over $160,000) be responsible for a higher percentage of the coverage cost of Medicare Part B, reducing the cost to the federal government. The increase in coverage costs to the higher income beneficiaries will be transitioned in over a three-year period.

By the end of the transitional period higher income beneficiaries will pay a monthly premium equal to 35, 50, 65 or 80 percent of the total cost depending on their income level. The Congressional Budget Office has estimated that this surcharge will raise $15 billion from 2007 to 2013.

2007 Medicare Part B Premium Rates

The 2007 Part B monthly premium rates to be paid by beneficiaries who file an individual tax return (including those who are single, head of household, qualifying widow(er) with dependent child, or married filing separately who lived apart from their spouse for the entire taxable year), or joint tax return are:

*Standard Medicare Part B monthly premium

In addition, the monthly premium rates to be paid by beneficiaries who are married, but file a separate return from their spouse and lived with their spouse at some time during the taxable year are:

(CMS, 2007) www.cms.hhs.gov/apps/media/press/release.asp

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CONTRACTING WITH AN INDEPENDENT NURSE FOR FLUCTUATING STAFFING NEEDS

By Sheila Schluterbusch, RN and Stephanie Hartung, RN

Everyone knows that there is a nursing shortage, and that finding a nurse with specialized skills to hire for your practice can be a difficult task. For example, one oncology practice we’ve worked with hasn’t had an experienced chemotherapy nurse apply for an open position in response to their ads in the past two years. Nursing agencies can help with staffing needs, but another resource shouldn’t be overlooked: independent contract nurses. Their numbers are increasing, and they offer some distinct advantages.

These nurses often cost less to hire, since the medical practice works directly with the nurse, eliminating agency fees. Utilizing a contract nurse will enable you to establish a rapport with one nurse, and then build a relationship, so that consistency is established, as opposed to having to accept whomever an agency sends.

Contract length can be more flexible, and the contract can include language that states the nurse will work on an as-needed basis agreeable to both parties, or fix the length to a specific number of weeks; whereas a traveling nurse agency may require a minimum time commitment in order to cover their expense of moving the nurse from another, distant location. This flexibility would enable your business to cover intermittent busy periods, vacations, maternity leave and other unexpected nurse shortages.

Some practices bring in an independent contractor to orient a new nurse to the infusion area, providing hands-on training in mixing and administering chemotherapy. By doing so, the regular staff will not be overburdened with providing patient care as well as training the new nurse. The reverse of this scenario could apply as well – utilize an independent contract nurse to work for a week or two so that the preceptor on staff can devote 100 percent of their time getting the new nurse well trained.    

Once you’ve found the contractor, what should the contract look like? It needn’t be a 14-page single-spaced document that many agencies require of their registrants. While we are not attorneys and don’t pretend to know all about contract law, we use a very short, simple format that suits ours and our clients’ needs well.

First, the parties are named, with addresses and phone numbers listed, and the phrases “heretofore known as ‘nurse’” and “heretofore known as ‘facility’” added after the appropriate name. The purpose of the contract should be stated, for example:

“ For the purpose of Ms. X providing the above-named facility with temporary nursing staffing on an individual basis, as requested by the facility, and as agreed upon regarding date, shift times, and nursing role.”

Next come terms and conditions, with each item listed such as:

“Each party voluntarily binds themselves to the following terms and conditions:”

1. Site of employment: This is the address where the nurse will be working, usually your business address, or you may want to add the addresses of any satellite clinics the nurse will float to.
2. Duration of Contract: The Start Date and Scheduled End Date are listed here, as well as a clause for continuation: This contract may be extended as the parties agree.
3. Nurse’s position: The nurse will perform duties as per job description provided by the facility as long as the work requested is within the nurse’s scope of practice and meets standards and definitions as currently stated in the Nurse Practice Act in the state in which the nurse will be working.  This paragraph is fairly open-ended and allows you to define the work expected of the nurse.
4. Hours of work: Variable, as agreed upon by nurse and facility. This wording provides for scheduling flexibility.
5. Monetary compensation and benefits: Contract dollar amount is to be $ X per hour, with the nurse to be paid a minimum of 40 hours per week. Or you can leave out the minimum hours, depending on what you’ve agreed with the contractor. Do address who’s going to take care of payroll taxes: All payroll taxes, both federal and state, will be solely the responsibility of the nurse. (Or “the facility” pays the taxes). The facility will pay the nurse biweekly on the dates that regular employees are paid. (Or weekly, or whenever you’ve agreed to pay them. Often the contract nurse will simply submit an invoice which can be paid as with any other accounts payable.) The facility will provide no fringe benefits to the nurse in terms of vacation or sick time accrual, health or any other insurance benefits, food allowance or other typical “employee” benefits. You might want to be more specific here, and list the benefits your regular employees receive, and specify if these will or will not be provided.
6. Nurse’s other responsibilities: The nurse agrees to interact with regular staff in a cordial, pleasant, and professional manner. We all just want to get along!

Some other agreements that help ensure quality care of your patients by the contractor:

The nurse agrees to become familiar with the facility’s policies and procedures related to infection control, safety, quality assurance, patient care and ancillary department procedures in order to safely and prudently carry out the duties she has agreed to perform.

The nurse agrees to abide by the rules and policies of the facility while performing duties there.

The nurse agrees to consult with regular staff and supervisors as needed to assure a high standard in delivery of care to patients and to assure continuity of care between providers.

The next two have to do with malpractice insurance, credentials, and licensures:

The nurse will carry her own malpractice insurance above and beyond whatever insurance the facility carries for those performing services in the facility.

The nurse will maintain and keep current the credentials and licensures required to practice nursing in the state in which working, and will be prepared to produce evidence of her or his Registered Nurse License for the state of practice, Oncology Nursing Certification, and / or Cancer Chemotherapy Provider Certification when reporting to the facility for work. If your facility requires Basic Life Support, ACLS, TB testing documentation, etc., you can add those here.

Lastly, provision must be made for ending the contract, or renewing it if necessary:

Termination of Agreement: Either party, facility or nurse, may terminate this agreement at any time without cause or prejudice by a simple verbal notification to the other party. The contract may be reinstated should the facility find an ongoing need for coverage and the nurse agrees to continue her services. A simple notation of cancellation date and /or renewal date will be noted on the contract as necessary. Then add spaces for date and signatures.

Some additional tasks you may want to use a contract nurse for in an Oncology practice are:

• To train billing staff in the general flow and timing of chemotherapy administration so that they have a better understanding of why, for instance, a first treatment utilizing a certain drug may require several more hours than each subsequent treatment with the same drug.
• Give regular staff occasional, much needed time off without placing an extra burden on the rest of the nurses to work additional hours.
• Provide specific training to staff members in need of development of venipuncture, lab draw, port accessing and IV skills.

In working as traveling independent contract nurses for quite a few years, one of the things we expected to encounter was potential resentment from the regular staff that the contractor was making more in terms of hourly wages than the staffed nurses. The staff can usually be apprised that extra wages may be paid to a contractor in lieu of any benefits. It has been our experience that the staff is very receptive to the idea that they will directly benefit by having the extra set of hands, for whatever term the contractor will be there. The staff in each facility has generally been very thankful for the help and we have not had a negative response from any nursing colleague that we have worked with. 

In summary, using a temporary independent contract nurse can benefit everyone – the facility gets expert help in a cost effective manner, tailored to specific needs; the staff is assured of having time off as needed without creating a burden to others the contractor gains additional insight and knowledge about practices, and most of all, the patient undergoing treatment benefits by having adequate nursing coverage, and care provided to them by nurses that are skilled, trained, professional and happy.

In today’s complex health care environment, it may be time for your facility to look at a contract nurse to meet current needs and with which to build a relationship for the future.

Contact the authors:

Stephanie Hartung, RN
Certified ONS Cancer Chemotherapy Provider
541.593.8886
shartung@cmc.net

Sheila Schluterbusch, RN, OCN
Certified ONS Cancer Chemotherapy Provider
720.984.3505
lesnsheila@hotmail.com

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Before You Contract With a Travel Nurse

First and foremost, have your healthcare attorney review any contract prior to signing it. At a minimum your attorney should verify:

• That the contractor meets all state, local and/or regulatory requirements necessary to perform the tasks assigned in your facility;
• That the contract meets all state, local and/or regulatory requirements;
• That the contractor’s status and lack of benefits (if benefits are not provided) are clear. In the recent court case Barfield v. New York City Health and Hospitals Corp., 2006 WL 1462269 (S.D.N.Y. 2006) the court ruled that the hospital was a joint-employer with the staffing agencies and that the nurse could collect overtime payments from the hospital.

Prior to contracting with an individual thoroughly prescreen the individual through interviews, reference checks, verifying education, certifications and licenses.

Most states have a free online State Board of Nursing License Verification page with a searchable database through which you can verify state licensing status. The National Council of State Boards of Nursing (NCSBN) has contact information for most State Boards of Nursing on their website as well as an online national database that you can access for a fee.

Prior to contracting with an agency or individual verify that they have not been excluded from Federal programs by searching the online OIG List of Excluded Individuals. Providers and entities that hire or contract with excluded individuals/entities to provide items or services to Federal program beneficiaries may be subject to a civil monetary penalty (CMP) of up to $10,000 for each service or item furnished by the excluded entity and an additional penalty of up to three times the amount claimed as well as possible exclusion themselves. For more information on the Federal Exclusion Program read the article Compliance Programs: Preventative Medicine for Practices in Oplinc’s Best Practices Review Volume 2 Issue 4.