AMA Rejects Request For New Hem/Onc CPT Codes

Neltner Billing and Consulting recently submitted documents to the AMA suggesting that the infusion coding oncology and hematology rely on for appropriate payment of professional physician work and practice expense is failing in its purpose. Along with those documents we made requests for revised CPT coding to better reflect the work physicians are truly performing.

Unfortunately, the CPT Panel rejected our requests for the following reasons – with which we disagree:
1) They feel the existing E/M codes adequately describe physician services.
2) They feel our proposal lacked specialty society support.

1) We disagree and maintain that the existing E/M codes do not represent the professional work value associated with oncology/hematology treatment planning. They do not include specific bullet points or measures which can be scored to attribute to the level of service indicated. We have evidence that auditors continually fail to recognize the physician work associated with oncology/hematology planning in that levels of service are down-coded because credit is not properly attributed to the medical decision making. Auditors use medical necessity as the overarching criteria for down-coding the level of service, relying on the incorrect premise that a new problem, diagnosis or complication must be present in order to bill a level five service.

Auditors fail to recognize that a comprehensive review and exam combined with the high medical decision-making elements associated with administering drugs that cause extensive toxicity qualify as a level five service – even in a stable, chronically ill patient. The misunderstanding associated with what truly constitutes a level five service provides additional evidence that there is a need for separately reportable codes to identify the treatment planning elements of oncology and hematology encounters. The AMA coding in the infusion coding preamble discusses the highly complex nature of oncology care. Therefore, one code cannot come close to offering evidence of the different levels of care required to identify the correct treatment planning code for different levels of care.

2) With respect to a lack of support from specialty societies, we did receive and review the comments provided by the American Society of Clinical Oncology and the American Society of Hematology. While these societies ultimately don’t support the specific code requests, both expressed agreement with our contention that the physician work is not adequately captured with the existing E/M codes, nor is it included in the drug infusion codes. (Both societies indicated that a single code to represent oncology treatment planning would be more favorable rather than the proposed tiered set of codes.) With due respect, we do not believe that either ASCO or ASH understand what is happening in the community. After all if 95% of their members are under-coding – and hence, devaluing their service – who is going to complain? What we are experiencing is that auditors are looking at level five notes and calling them level three services.

Physicians across the US continue to down-code for fear of audits, and the work to defend their choice of high complex coding is under attack by carriers who use tactics of three formal reviews that will result in a lot work to defend an additional $40 payment per code. Also, these auditors and their processes do not allow a change in policy if you do actually win at the highest appeal. We have specific documentation to support this concern.

That is why we believe new coding with better definitions will resolve the concern.

Where do we go from here?
What we have done is ask the AMA to synchronize our coding request with the coding request proposed in 2004 by the Drug Administration work group (as suggested by ASCO and ASH). We would be pleased to have the Panel consider the proposed codes in a condensed format, represented by some variation of codes, rather than the series of codes originally requested. This would also be more consistent with the perspectives of ASCO and ASH.

We are hoping to hear back from the AMA and request reconsideration for this coding effort to be placed on the February 2010 agenda of the CPT Panel Executive Committee.

Stay tuned.

“Red Flags” Rules Deadline Postponed

The deadline for the “Red Flags” Rule has been postponed to November 1, 2009. The FTC decided to delay the deadline in order to give businesses additional time to educate themselves, review their procedures, and develop their implementation plans.

If you need help in understanding how to protect the identities of both your employees and patients, please contact us for assistance. We’ve already reviewed and implemented our procedures and we can help put you in touch with some of the experts to help you do the same.

Are Your Medical Practices Compliant With the “Rules”?

We are reaching out to all our readers in the medical field to alert them about the August 1st, 2009 deadline (recently extended from May 1st) associated with the “Red Flags” Rule enforced by the Federal Trade Commission (FTC), as well as compliance with the Fair and Accurate Credit Transactions Act (FACTA).

You may know that in order to fight identity theft (the fastest-growing crime in the U.S.), Congress added new sections to the federal Fair Credit Reporting Act (FCRA) when it passed FACTA in 2003 — in which privacy, limits on information sharing, new consumer rights to disclosure and accuracy are all addressed.

While the American Medical Association (AMA) has sought exemption from compliance for physicians and medical organizations, the FTC recently made it very clear that industry-based exclusions are not allowed.

These provisions have created serious new responsibilities for our physician clients as well as potential liabilities (both financial and legal).

What does this mean for our industry? By August 1st, you need to have formal, written procedures in place outlining how you plan to protect the identity of both your own employees and your patients.

If you need more information or have not met compliance for these procedures, contact us for assistance.

We can also put you in touch with some of the experts we have been working with to address identity theft protection for our own employees at Neltner Billing.

Are Your Medical Practices Compliant With the “Rules”?

We are reaching out to all our readers in the medical field to alert them about the impending May 1st, 2009 deadline associated with the “Red Flags” Rule enforced by the Federal Trade Commission (FTC), as well as compliance with the Fair and Accurate Credit Transactions Act (FACTA). You may know that in order to fight identity theft (the fastest-growing crime in the U.S.), Congress added new sections to the federal Fair Credit Reporting Act (FCRA) when it passed FACTA in 2003 – in which privacy, limits on information sharing, new consumer rights to disclosure and accuracy are all addressed.

While the American Medical Association (AMA) has sought exemption from compliance for physicians and medical organizations, the FTC recently made it very clear that industry-based exclusions are not allowed. These new provisions have created serious new responsibilities for our physician clients as well as potential liabilities (financial and legal).

What does this mean for our industry? By May 1st, you need to have formal, written procedures in place outlining how you plan to protect the identity of both your own employees and those of your patients.

If you need more information about meeting compliance with these procedures contact us, and we’ll help you out. We can also put you in contact with some of the experts we have been working with to address identity theft protection for own employees.

The V Coding Trap

We believe there are many flaws in the coding arena and want to discuss one in particular we believe is a trap. Don’t fall into it.

Be aware when using the chemotherapy V Codes (V58.11 or V58.12) or you may not get reimbursed properly for what you are really owed.

Cancer patients have lots of problems, and their treatment if often complex. We firmly believe that “there is no such thing as a routine chemotherapy”. Therefore, oncologists/ hematologists need to assess patients when they arrive for their chemotherapy – to be sure they are stable enough to have their treatment that day. Typically, this assessment would constitute a Level IV or Level V visit. We find this to be true with 90% of the patients in the practices we work with across the country.

Unfortunately, by reporting the V code as a primary diagnosis as required by some local coverage determinations, you are essentially saying the only reason for the encounter was to administer chemotherapy, thereby indicating the evaluation and management service was not necessary and should not be paid. In essence, you’re telling them “Don’t’ pay me” when you do this.

So, how do you get paid for your physician assessment and the chemotherapy? We bill cancer diagnosis as the primary code plus the V code as the secondary, and our clients are getting paid. We’ve not had denials doing it this way. If you use the V code as the primary code, you risk not getting reimbursed for your assessment.

Are You Paying Attention to Your Fee Schedules?

Have you reviewed your fee schedules lately to determine if you’re getting proper reimbursement for all your services? Now is a great time to take a look at what you are doing and make appropriate changes for 2009.

We have found on a regular basis that physicians are miscalculating their non-Medicare fees, which means revenue they are due is slipping through their fingertips. Here are some steps to take to help you determine if the private payers are reimbursing you at a fair rate.

1. Measure and Document What You Can Control
< Determine your total overhead expenses. Separate physician work (including physician salaries and benefits as well as any bonuses) and practice expense (including staff salaries/benefits, space expenses, office supplies and medical supplies).
< Calculate your cost per RVU. Calculate cost for visit services; calculate cost for treatments and procedures; calculate total cost per treatment.
< Compare your practice revenue with your costs (be sure to include Medicare and non-Medicare).
Preforming this exercise once per year will help you set practice benchmarks and sound measures for decision-making.

2. Review What’s Going On Outside Your Practice
Now, you’re ready to review your current private pay fee schedules to determine whether they measure up to your current costs.
Here are some tips:
< What should you expect as payment from non-Medicare payers? We believe at least 30% above Medicare.
< Should you utilize the “loaded” Medicare fee schedule as your basis for negotiating a contract with non-Medicare payers? We think not. Rather, use the unadjusted RVU data, because the geographic adjustment factor could potentially lower your payment.
< Should you accept the non-Medicare payer contracts as is? No! Rather, “calculate and negotiate”. If you document what your reimbursement should truly be, you have more leverage to negotiate with payers. You should include the following: data for expenses – need to be sure yours are covered; data that illustrates you need to be reimbursed at least “X” amount of money and why; tell them at what rate other payer contracts are reimbursing – then compare.

For an example of how to calculate Fee Schedules, visit neltnerbilling.com.