2008 will not bring with it extensive changes in coding and billing rules and regulations as has been the case in recent years. However, it is still imperative that your business office staff has the most up to date coding and billing resources.

For Medicare patients we must follow all Medicare coding rules and regulations. Resources readily available on the CMS Website include:

• Medicare Carriers Manual (MCM)
• Day-to-day operating instructions, policies, and procedures based on statutes and regulations, guidelines, models, and directives 
• Program Transmittals
• Communicate new or changed policies/procedures
• National Coverage Determinations (NCDs)
• NCD sets forth the extent to which Medicare will cover specific services, procedures, or technologies on a national basis
• National Correct Coding Initiative (NCCI)
• Edits implemented to ensure that only appropriate codes are grouped and priced
• Local Coverage Determination (LCDs)
• A decision by a fiscal intermediary or carrier whether to cover a particular service on an intermediary-wide or carrier-wide basis i.e., a determination as to whether the service is reasonable and necessary

Identifying Official Coding & Billing Resources

The Administrative Simplification Section of the Health Insurance Portability and Accountability Act (HIPAA) of 1996 required the Department of Health and Human Services to name national standards for electronic transaction of health care information.

The HIPAA Final Rule names the Healthcare Common Procedure Coding System (HCPCS) as a national standard code set.  HCPCS is divided into two principal subsystems, HCPCS Level I CPT® code set and the HCPCS Level II code set.

The CPT (Current Procedural Terminology) code set is developed and maintained by the American Medical Association (AMA). The CPT consists of descriptive terms and identifying numeric codes used for reporting medical services and procedures furnished by physicians and other health care professionals. The CPT codes are published and updated annually by the AMA with an effective date of January 1st of each year.

The AMA CPT codebook includes the CPT Level I and Level II (HCPCS) Modifiers, Place of Service (POS) codes and detailed clinical examples for Evaluation and Management services.

Prior to the beginning of each year review your electronic or paper charge sheets to verify that the codes and their descriptions accurately describe the services you are providing. Have staff members from the business office and clinical office compare the codes and descriptions in the 2008 CPT with those on your forms.

You can order CPT codebooks that are published by alternative publishers but in doing so you may lose some valuable information. The AMA CPT Professional codebook includes narrative developed by the CPT Editorial Panel and features references that indicate when additional instruction is available in the AMA’s CPT Changes: An Insider’s View or the AMA CPT Assistant monthly newsletter. All AMA coding resources are available on the AMA Website.

HCPCS Level II codes are alpha-numeric codes consisting of one alphabetical letter followed by four numeric digits. These codes are used primarily to identify those products, supplies, and services that are not included in the CPT codes, such as ambulance services, drugs, and Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS).

Under HIPAA the Centers for Medicare and Medicaid Services (CMS) has the authority to maintain and distribute HCPCS Level II Codes.  HCPCS Level II codes are released on January 1st and July 1st of each year and are effective six months after the date of the release.

The HCPCS Level II Codes are available on the CMS Web site on the HCPCS Quarterly Update page.  Monitor the HCPCS for deleted, revised and new HCPCS and update your practice management systems and charge forms to reflect the changes.

Other HIPAA designated standards include ICD-9-CM volume 1 and 2 for diagnosis codes, ICD-9-CM volume 3 for inpatient hospital services, CDT for dental services, and NDC codes for drugs. The National Center for Health Statistics (NCHS) and CMS are responsible for overseeing all changes and modifications to the ICD-9-CM.

The AMA CPT Changes: An Insider’s View is published annually by the AMA and includes the logic and rationale of CPT changes as well as clinical examples of the new or revised codes and coding guidelines. This publication is a reference guide to be used along with the most current CPT codebook.

The 2006 edition is particularly helpful when looking for detailed information and guidance on drug administration services. If you don’t already have this edition it is highly recommend that you order it. Be careful, when looking for coding guidance start with the most recent editions first and work your way backwards so that you aren’t following outdated information.

The CPT Assistant published monthly by the AMA provides clarification to confusing coding issues, coding commentaries, rationale behind the coding rules, clinical vignettes and coding FAQs.

On March 5, 2007 the AMA announced the establishment of a newly formed Editorial Advisory Board (EAB) for the CPT Assistant. The EAB members are:

Chair: William Thorwarth, MD
Vice Chair, CPT Editorial Panel

Secretary: Dan Reyes
Managing Editor, CPT Assistant
American Medical Association

J. Martin Tucker, MD
CPT Editorial Panel

Peter A. Hollmann, MD
CPT Editorial Panel

Albert Bothe, Jr., MD
CPT Advisory Committee

Richard A. Molteni, MD
CPT Advisory Committee/
Former CPT Editorial Panel

Helene M. Fearon, PT
Health Care Professionals Advisory Committee

Charles F. Koopman, Jr., MD
AMA/Specialty RVS Update Committee

Kenneth B. Simon, MD, MBA
Centers for Medicare and Medicaid Services

Richard W. Whitten, MD, MBA
Contractor Medical Director

Gerald E. Silverstein, MD
America's Health Insurance Plans

Claudia J. Bonnell, RN, MLS
Blue Cross Blue Shield Association

Nelly Leon-Chisen
American Hospital Association

Lianne Stancik
American Medical Association

Danielle Pavloski
American Medical Association

What does this mean to you?  The AMA acknowledges that the development of the new CPT Assistant Editorial Advisory Board (EAB) is an effort to increase its standing with public and private payers. The inclusion of public and private payers in the CPT Assistant EAB will lead to a greater acceptance of CPT coding guidelines.

In conversation on October 27, 2007 Dr. Richard Whitten, Contractor Medical Director, Medicare Part B for Alaska, Hawaii and Washington and CPT Assistant EAB member,  stated that there will be substantial support for coding guidance found in the CPT Assistant subsequent to the establishment of the EAB.

With the formation of the EAB and their process of consensus agreement the AMA says that the focus of the newsletter will subtly shift to responding to “real world” coding issues.

The AMA states that formal input from key stakeholders will:

• Give the publication even greater standing among public and private payers
• Make for a much more dynamic publication by being alerted to problem coding issues and responding quickly with articles or clarifications
• Provide an educational vehicle for attempting to reduce conflict between physicians and third-party payers and resolve differences of opinion among various CPT stakeholders

With the formation of the new EAB and the AMA’s stated goals for the publication every practice will need to have a subscription to the CPT Assistant if they want to be up to date on coding guidance. This publication is well worth the subscription price and is available in both print and electronic format.

Practical Tips for the Oncology Practice (previously titled Practical Tips for the Practicing Oncologist), is a comprehensive reference guide containing frequently asked questions about coding, reimbursement, coverage, and regulatory policies specific to the oncology practice. Practical Tips for the Oncology Practice also contains an extensive appendix of important resource information including sample forms, contact information for CMS local and regional offices, and supporting documentation from Medicare manuals and the Federal Register specific to oncology. 

In addition to the information available in Practical Tips ASCO staff will also answer your coding and reimbursement questions by email at practice@asco.org.

Summary of New/Deleted 2008 CPT Codes

Deleted Effective 12/31/2007:

• 36540 Collection of blood specimen from a completely implantable venous access device
• 36550 Declotting by thrombolytic agent of implanted vascular access device or catheter 
• 99361 Medical conference by a physician with interdisciplinary team of health professionals or representatives of community agencies to coordinate activities of patient care (patient not present); approximately 30 minutes  & 99362  approximately 60 minutes
• Telephone calls 99371 simple or brief 99372 intermediate & 99373 complex or lengthy

New Effective 1/1/2008

• 36591  Collection of blood specimen from a completely implantable venous access device
• 36592  Collection of blood specimen using established central or peripheral catheter, venous, not otherwise specified
• 36593  Declotting by thrombolytic agent of implanted vascular access device or catheter
• 90776 Therapeutic, prophylactic or diagnostic injection (specify substance or drug); each additional sequential intravenous push of the same substance/drug provided in a facility (List separately in addition to code for primary procedure)
• 98966-98968 Telephone assessment & management services provided by a qualified nonphysician healthcare professional
• 98969 Online assessment and management service provided by a qualified nonphysician health care professional
• 99366-99368 Medical team conference with interdisciplinary team of health care professionals
• 99406 Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes; 99407 intensive,  greater than 10 minutes
• 99441-99443  Telephone evaluation and management services provided by a physician to an established patient, parent, or guardian
• 99444 Online evaluation and management service provided by a physician to an established patient, guardian, or health care provider
• 99605-99607 Medication therapy management service(s) provided by a pharmacist, individual, face-to-face with patient

New Modifiers Effective 1/1/2008 

• EA Erythropoietic stimulating agent (ESA) administered to treat anemia due to anti-cancer chemotherapy.
• EB ESA administered to treat anemia due to anti-cancer radiotherapy.
• EC ESA administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy.
• ED* Hematocrit level has exceeded 39% (or hemoglobin level has exceeded 13.0 g/dl) for 3 or more consecutive billing cycles immediately prior to and including the current cycle.
• EE* Hematocrit level has not exceeded 39% (or hemoglobin level has not exceeded 13.0 g/dl) for 3 or more consecutive billing cycles immediately prior to and including the current cycle

*Modifiers ED & EE apply only to ESRD patients receiving dialysis in renal dialysis facilities

References: CR 5700 www.cms.hhs.gov/Transmittals/downloads/R1307CP.pdf

The codes and descriptions listed above are provided as a summary only. For a complete listing of coding changes & descriptions refer to the AMA CPT® 2008.  www.ama-assn.org

Important Note: Not all codes will be accepted by Medicare, verify all coding changes & rules with your Medicare Contractor and other payers!

CPT® is a Trademark of the American Medical Association Current Procedural Terminology (CPT) is copyright 2007 American Medical Association. All Rights Reserved No fee schedules, basic units, relative values, or related listings are included in CPT.   The AMA assumes no liability for the data contained herein The AMA CPT is available on the AMA website at: www.ama-assn.org

Medicare Premiums Increase in 2008

The Medicare Modernization Act of 2003 (MMA) requires that beginning in 2007 higher income beneficiaries be responsible for a higher percentage of the coverage cost of Medicare Part B, reducing the cost to the federal government.

The Part B Premiums are based on annual income and by the end of the 3-year transition period in 2010 higher income beneficiaries will pay a monthly premium equal to 35%, 50%, 65%, or 80% of the total cost, depending on their income level.  

In the second year of the transition, the 2008 Part B monthly premium rates for all Medicare beneficiaries have increased again.

The table below shows the 2008 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.  

Source: CMS Fact Sheet

The table below shows the 2008 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:

Source: CMS Fact Sheet

CMS Delays Required Use of Tamper-Resistant Prescription Pads

On May 25, 2007 Section 7002(b) of the U.S. Troop Readiness, Veterans’ Care, Katrina Recovery, and Iraq Accountability Appropriations Act of 2007 was signed into law. This section mandates the use of tamper-resistant prescription pads for all written, non-electronic Medicaid prescriptions.

On August 17, 2007, CMS issued a letter to State Medicaid Directors with guidance on implementing the new requirement. CMS outlined three baseline characteristics of tamper-resistant prescription pads stating:

To be considered tamper resistant on April 1, 2008, a prescription pad must have at least one of the following three characteristics:

• One or more industry-recognized features designed to prevent unauthorized copying of a completed or blank prescription form;
• One or more industry-recognized features designed to prevent the erasure or modification of information written on the prescription by the prescriber;
• One or more industry-recognized features designed to prevent the use of counterfeit prescription forms.

No later than October 1, 2008, to be considered tamper resistant, States will require that the prescription pad have all three characteristics.

CMS says they will leave it to each State to define the specific features it will require to meet those characteristics in order to be considered tamper resistant.

The new tamper-resistant requirement does not apply in the following situations:

• When the prescription is electronic, faxed, or verbal; (CMS encourages the use of e-prescribing as an effective means of communicating prescriptions to pharmacists.)
• When a managed care entity pays for the prescription;
• To refills of written prescriptions presented to a pharmacy before April 1, 2008; or
• In most situations when drugs are provided in nursing facilities, intermediate care facilities for the mentally retarded, institutions for mental disease, and certain other institutional and clinical facilities.

CMS has published a resource document for State Policymakers and a list of Top FAQs on the Tamper Resistant Prescription Pad Law on their Web site. 

On September 29, 2007, President Bush signed the “Extenders Law”, which delays the implementation date of this requirement to April 1, 2008.

CMS Releases 2008 Medicare Physician Fee Schedule Final Rule

On Thursday November 1, 2007 CMS issued the 2008 Medicare Physician Fee Schedule Final Rule, Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, and Other Part B Payment Policies for CY 2008; Revisions to the Payment Policies of Ambulance Services Under the Ambulance Fee Schedule for CY 2008; and the Amendment of the E-Prescribing Exemption for Computer-Generated Facsimile Transmissions.

A copy of the Final Rule is available now. However, the Final Rule is not expected to be published in the Federal Register until November 27, 2007. The document published in the Federal Register will be the official CMS approved document and may vary slightly from this published copy. Once published in the Federal Register a 60 day comment period will commence.

The Final Rule at 1481 pages will take some time to read and study the details; an in-depth analysis of the Final Rule will follow in the next Oplinc Best Practices Review Newsletter. Below is a summary of some of the provisions:

• Based on the Sustainable Growth Rate (SGR) formula the estimated 2008 physician fee schedule update is negative 10.1% and the conversion factor (CF) for CY 2008 is $34.0682 down from $37.8975 in 2007.
• The 1.00 floor to the Work GPCI expires January 1, 2008 (this will negatively impact rural providers).
• 2007 was the first year in the four year transition process for the Practice Expense RVU changes. In 2007 PE was calculated using 25% of the new methodology and 75% of the old.  In 2008 this changes to 50% new methodology and 50% old methodology resulting in an additional small decrease to some services.
• The Budget Neutrality Adjuster (BNA) that is 0.8994 in 2007 will be decreased to 0.8806 in 2008. In 2007 the BNA results in a 10.1% decrease to the Work RVUs for all services paid under the Medicare Physician Fee Schedule (MPFS) in 2008 the new BNA will decrease these RVUs by approximately 12%. Note: drugs and labs are not affected as they are not paid under the MPFS.
• CMS will continue to pay for G0322 Pre-admission-related services for intravenous infusion of immunoglobulin (IVIG). This payment is in addition to the payment for the IVIG and the administration code.
• CMS declined to use The Physician Assistance and Quality Initiative (PAQI) Fund to buy down the SGR and stop the 10.1% cut to physician payments. Instead they will use $1.35 billion from the PAQI Fund for bonus payments in the PQRI program.
•  The proposal to eliminate the computer-generated fax exemption from e-prescribing effective January 1, 2008 has been extended to January 1, 2009 to allow all prescribers and dispensers adequate time to obtain or upgrade existing software.
• Effective January 1, 2008 all claims for ESAs in the treatment of anemia must include the most recent hemoglobin (hgb) or hematocrit (hct). In the Final Rule CMS states that they are not directing physicians as to how often or when to draw the hgb or hct the requirement is to report “the most recent” hgb or hct preceding the ESA administration. CMS did not provide details on how the hgb or hct should be reported; instead they plan to use the Change Request process to issue implementation instructions to the Medicare Contractors including requirements for provider education.
• CMS declined to finalize any of the proposed self-referral provisions in the Proposed Rule with the exception of the anti-markup provisions for diagnostic tests due to the number and significance of the self-referral proposals, and the volume of public comments received. However, CMS says they have sufficient information to finalize revisions to the physician self-referral regulations without the need for new proposals and additional public comment and will publish a future final rule addressing these provisions.
• CMS did not finalize the reporting regulations for the treatment of bundled price concessions. Stating that the ASP calculation has implications for the integrity of the ASP payment methodology, CMS said they will continue to monitor the issue and they may provide more specific guidance in the future through rulemaking or through program instruction or other guidance.

The table below illustrates the changes in the drug administration services due to the PE revisions transitioned in at 50% in 2008 and the negative 10.1% update bringing the Conversion Factor (CF) to $34.0682. Figures below are based on information provided in the 2008 Final Rule and are subject to change if Congress acts to stop the negative 10.1% update.