Medical Oncologists and Meaningful Data

This blog post is Part I in a series on the topic of “meaningful data”.

Any of us working in Medical Oncology know that the Evaluation and Management (E&M) guidelines are not specialty specific, and that the treatment planning of infusion therapy is considered part of a visit. We know that this “suggests” that the majority of visits in a medical oncology physician office should be a level V service.

However, if we use the Physician Quality Reporting Initiative (PQRI) as the starting point for determining meaningful value, we see we have no less than 10 meaningful data points to begin adding to the note to help confirm the value. For example, if staging and line of therapy are added to every note, each has points that add value to the complexity of the note. If this is done in less than six months, medical oncology will have the perfect level V note as well as the demand for the level VI thru IX note.

Let’s take a quick look at the current state of the oncology business.

GPOs and Sales Margins
Mergers and takeovers are everywhere, from US Oncology becoming McKesson, to P4 Healthcare being purchased by Cardinal Health. And Oncology Supply has so many layers of overhead within their GPO structure, it’s no wonder medical oncologist can’t buy drugs at ASP. Contrary to what everyone says about the market, the system was designed so that every medical oncologist should be making at least a 6% margin on its drug purchases.

Don’t be confused on drug sales margins – the sales margin actually needs to be 18% when considering the low reimbursements on the services. Do medical oncologists continue to under code? The answer in my opinion is an obvious “yes” when you look at the national bell curve.

The national bell curve is 5% at level II, 38% at level III, 48% at level IV and 9% at level V. Our audits at Neltner Billing and Consulting (based on reviewing oncology notes) show that the oncology bell curve should be 70% at level V, 20% at level IV, 10% at level III and no level II visits.

Stay tuned in my next blog post for more information on this topic. Check out our in depth Billing Brief article How the Business of Oncology Drugs Relates to Meaningful Data For the Medical Oncology Practice (Part I of III) posted on our website, www.neltnerbilling.com. Let us know your comments.

Flaws In Medicare Coding Interpretations

We work with medical oncologists/hematologists across the country in both the private practice and hospital settings. Based on our experience, I'd like to point out a couple of key flaws in the current Medicare code interpretations.

First, several of our oncology physician clients in various states have recently experienced what I consider to be unfair treatment and flat out harassment by local carriers over the topic of “medical necessity”. Local Medicare carriers have taken it upon themselves to “down code” many of these physicians’ visits without foundation (mainly those billed at level V) and send them accompanying letters that are threatening in nature.

We have conducted our own audits on these charges in question and feel that thorough documentation has been provided in every case to warrant appropriate billing. Within a specialty like oncology, we should expect to see high-level coding on a regular basis. The local carriers do not believe these visits met the criteria of “medical necessity”, thus their decision was to “down code”. Their interpretation of the national Medicare regulation is that a level V visit requires a “new medical problem”. We disagree.

We firmly believe these physicians have billed for legitimate services within the published guidelines, and their notes reflect as such. We feel these local carriers are acting wrongly and unfairly. There is no documentation published at either the local or national level stating that a “new medical problem” is required to bill higher level codes.

Over the past few years, we requested numerous ALJ hearings in response to these down-coding situations and have won several of them – one as recent as this month for an oncology practice in Paducah, Kentucky.

That leads me to the second problem needing to be addressed. While we keep winning local ALJ hearings, our physicians continue to get down-coded for the same reasons over and over again. There appears to be no process (or the current process is flawed) for taking these ALJ Hearing victories up the food chain and communicating them to the proper people – so that local carriers can become informed in order to keep these same errors from happening to other physicians. A related issue is that the ALJ victories apply to only the specific charts that the carriers have audited. They then go after more charts for these same physicians, and the process starts all over again. It’s a waste of the physicians’ time and a waste of tax payer’s money.

What should we do to fix this situation?

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.