Reimbursement E-News
ISSUE: 17
May 2014
MISSION STATEMENT
NJSOM is committed to keeping our
members informed through quarterly
educational conferences, networking, and
continuous updates to our website. As part of
our responsibility we strive to create an
environment of constant learning and
improvement in the Oncology/Hematology
arena. NJSOM works hard to foster a network
of growth, support and collaboration among
our members.
NJSOM is committed to the highest standards
of ethics and integrity and strongly believes
that we are responsible to our members,
stakeholders, and to the community we serve.
We believe that through education and
commitment, NJSOM can improve the
practice of Oncology in the State of New
Jersey and subsequently improve the lives of
cancer patients and their families.
ADVERTISING OPPORTUNITIES!!
We are looking for supporters of the
NJSOM Reimbursement E-News.
Interested parties contact one of our
Board Members…CLICK HERE
New Jersey Society of Oncology Managers
PO Box 95
Florham Park, New Jersey 07932
Phone:
Fax:
E-mail:
800.658.5011
973.453.8133
info@njsom.org
Front Page
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Novitas
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Welcome to this Publication of the Monthly Newsletter!!
The New Jersey Society of Oncology Managers Reimbursement E-News is a monthly publication focused on
the latest reimbursement news for your Oncology Practice. You can scroll through the document a page at a
time or you can use the links along the bottom to assist in quick navigation.
Please feel free to submit any comments, suggestions, stories and/or questions to Michelle Weiss, editor, at
njsombilling@gmail.com
Community
Oncologists and
Administrators
on Capitol Hill Talking
Sequestration and Payment
Reform
May 2, 2014 – COA President Dr. Mark Thompson
led a team meeting with members of Congress and
staff in previewing the Virtual Hill Days May 7-8 to
stop the sequester cut to cancer drugs.
Kathleen Sebelius
Resigns as
HHS Secretary
By JOANNE KENEN | 4/10/14 6:53 PM
EDT Updated: 4/10/14
Health and Human Services Secretary Kathleen Sebelius
is resigning six months after a disastrous rollout of
President Barack Obama’s signature health law,
according to administration sources. On Friday, Obama
will nominate Sylvia Mathews Burwell, the director of
the Office of Management and Budget, to replace her.
READ MORE
CMS
Medicare
Other Payer
Updates
READ MORE
Other News
Patient
Assistance
Frequently
Asked
Questions
N JS O M
R ei m b u rs em en t
E - N ews
May 2014
I s s u e 17 Pag e 2
Front Page News
CMS Releases Trove of Medicare Physician Billing Data
Apr 09, 2014 - The Centers for Medicare & Medicaid Services is making this information available for the first time in 35 years. Meanwhile,
in their first run at the data, news outlets report that a small number of doctors account for a large share of Medicare costs. READ MORE
Sliver of Medicare Doctors Get Big Share of Payouts
By REED ABELSON and SARAH COHENAPRIL 9, 2014 - A tiny fraction of the 880,000 doctors and other health care providers who take Medicare
accounted for nearly a quarter of the roughly $77 billion paid out to them under the federal program, receiving millions of dollars each in some cases in a
single year, according to the most detailed data ever released in Medicare’s nearly 50-year history. READ MORE
CMS Releases Tool to Search the Medicare Database by Provider
Following CMS’ release of physician-specific raw Medicare data last week, the agency posted a tool to allow searches of the Medicare database by
provider. This new look-up tool makes it easier to use the large data set about physician information that CMS released on April 9, 2014 to look up
specific providers. CLICK HERE to access the tool.
Are You Taking a Peek at Your Neighbor?
ASCO Calls on CMS to Resolve
Medicare Payment Data Issues
(ASCO in Action) Apr 17, 2014 - The American
Society of Clinical Oncology (ASCO) is urging the
Centers for Medicare & Medicaid Services (CMS)
to immediately correct inaccuracies in Medicare
physician payment data released last week.
READ ARTICLE
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Novitas
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Written by Nancy J. Beckley, MB, MBA, CHC
Do you know how much your healthcare “neighbors” charge? Can you believe the kind of fraud that
is going on?
The recent release by the Centers for Medicare & Medicaid Services (CMS) of the 2012 Medicare
Physician Payment Data has generated a lot of buzz in the popular media as well as the trade
media. The professional statisticians (think RACmonitor contributing columnist and mathematician
Frank Cohen) have downloaded the massive data file, converted it into a robust database, and are
busy running algorithms. The rest of us amateurs are left to peek at the data through one of the
portals, such as the Wall Street Journal’s Medicare Payment to Providers 2012.
Have you been there yet? Who did you look up? A colleague, a competitor, your primary care
physician? Or perhaps your physical therapist or favorite ambulance company? Physicians and
ancillary providers alike, if they billed Medicare in 2012, likely are all there. READ MORE
CMS
Medicare
Other Payer
Updates
Other News
Patient
Assistance
Frequently
Asked
Questions
N JS O M
R ei m b u rs em en t
E - N ews
May 2014
I s s u e 17 Pag e 3
Front Page News
ASCO Proposes Innovative
Patient-Centered Payment System
for Cancer Care
May 4, 2014 - The American Society of Clinical Oncology
(ASCO) today released a detailed proposal for a new
approach to physician payment for cancer care services under
Medicare. ASCO’s model would fundamentally restructure
the way oncologists are reimbursed for cancer care in the
United States by focusing payment on the full range of
patient services that oncologists provide, while incentivizing
high-quality, patient-centered care.
READ MORE
Avoiding EHR Note
'Cloning' While Maintaining Efficiency
Copying-and-pasting in your electronic health record system can boost productivity,
but use judgment
In the wake of a recent government report that said the Centers for Medicare and
Medicaid Services (CMS) is not doing enough to prevent electronic health record (EHR)enabled billing fraud, some physicians say they’re concerned that CMS might outlaw
copying and pasting of previous visit notes into current notes in EHRs. Such a move,
they say, would make practices less efficient and impede patient care.
Calendar of Events
"There comes a point where you can’t hamper the workflow of a doctor in the office if
you want them to take good care of patients,” says Edward J. Gold, MD, an internist in
Emerson, New Jersey.
FULL ARTICLE
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Novitas
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CMS
Medicare
Other Payer
Updates
Other News
Patient
Assistance
Frequently
Asked
Questions
N JS O M
R ei m b u rs em en t
E - N ews
May 2014
I s s u e 17 Pag e 4
Novitas Solutions Inc.
JL Top Claim Submission Errors
The Top Claim Submission Errors and their resolution for March
2014 are now available. Please take some time to review these
errors and avoid them on future claim submissions.
2014 Medicare Symposium "Understand the Basics of
the Medicare Program" Session Handout Updated
The 2014 Medicare Symposium session handout for "Understand the Basics of the
Medicare Program" has been updated! If you have registered for this event, please take
the time to review and print the updated handout.
READ MORE
READ MORE
Informational Alert
Common Working File (CWF) Hosts will be Conducting History Purges
On Saturday, May 10, 2014, the CWF Southeast, South, and Pacific Hosts will be
conducting a history purge.
On Saturday, May 17, 2014, the CWF Northeast, Great Lakes, and Keystone Hosts will be
conducting a history purge.
Due to the anticipated duration of this activity and to ensure the completion of weekly processing and
scheduled data center maintenance, there will be a CWF Dark Day at those Hosts only on the Saturday
specified for the purge.
This means there will be no access to the Health Insurance Master Record (HIMR)
query, which is usually available until noon on Saturdays. All files received from satellites for each Fridays’
cycle will be completed prior to bringing CWF production down for those three weeks. If, for any reason,
satellite files are received late Saturday morning, they will be processed by CWF after the history purge has
been completed.
The oldest claim history maintained at all nine of the CWF Hosts, after the purge process
will be as follows:
Oldest Inpatient claim Thru Date to be kept on file is January 1, 1966
Oldest Outpatient claim Thru Date to be kept on file is February 1, 2012 (27 months)
Oldest Part B claim Thru Date to be kept on file is May 1, 2012 (24 months)
Front Page
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Novitas
Solutions Inc.
CMS
Medicare
Other Payer
Updates
Novitas Solutions
e-News
Electronic Billing
Quarterly Newsletter
MAY 2014
(Next edition to be released in May)
Articles of note:
 Novitasphere Update
 Correct Usage of the EDI Fax Cover
Sheet
 New Process for EDI Enrollment Forms
And More…Available
CLICK HERE
Other News
Patient
Assistance
Frequently
Asked
Questions
N JS O M
R ei m b u rs em en t
E - N ews
May 2014
I s s u e 17 Pag e 5
Novitas Solutions Inc.
JL Part B Top Inquiries
(January 2014 - March 2014)
The monthly Part B FAQs have been updated. Please take some
time to review these FAQs for answers to your questions.
Local Contractor Pricing
Information is now Available!
A new information page specific to Local Contractor Pricing has been added to the Fee
Schedule section of our web site. This new page includes an overview of the local
pricing process, information on drug pricing, a section of frequently asked questions,
pricing references, and pricing resources.
READ MORE
READ MORE
New homepage for Clinical Trial and Device Information!
Other Part B
Frequently Asked
Questions (FAQs)
(January - March
2014)
The Other Frequently Asked
Questions (FAQs) have been
updated. Please visit our
FAQs for the answers to your
questions.
We are pleased to announce a new look and location for our Clinical Trial and Device information. Simply move your
cursor to LCDs/Medical Policy located on the left menu and then click on Clinical Trials/Devices. You can find the
most up-to-date information on Clinical Trials, Investigational Device Exceptions (IDEs), Humanitarian Device
Exemptions (HDEs), Humanitarian Use Devices (HUDs), Pre-Market Approvals (PMAs), PMA Post-Approval
Extension Studies, and Pre-Market Notification (PMN) (510(k)).
READ MORE
Medicare Part B- H O T L I N K S !
2014 Medicare JL Part B Fee Schedule
April 2014 Average Sales Price (ASP) Files
2014 Physician Fee Schedule Final Rule
Current Active Part B LCD Policies
Quarterly Update to CCI Edits Effective 4/1/2014
2014 CMS Physician Fee Schedule Final Rule Fact Sheet
READ MORE
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Novitas
Solutions Inc.
CMS
Medicare
Other Payer
Updates
Other News
Patient
Assistance
Frequently
Asked
Questions
N JS O M
R ei m b u rs em en t
E - N ews
May 2014
I s s u e 17 Pag e 6
Novitas Solutions Inc.
Self-Service Tools
Did you know Novitas has many interactive apps to help answer your
questions? We created these helpful tools to give you access to information you
need, when you need it, without having to pick up the phone. Here are some of
the great tools we offer to our providers:
Appeals Status Tool
Check to see if your appeal had a favorable outcome!
This app shows details on the appeals you’ve submitted to Medicare.
Enrollment Status Tool
Have you filed an enrollment application or
revalidation recently? Check to see where it’s at.
Fee Schedule lookup App
This app provides quick access to fee rates for
CY 2012, 2013, and 2014!
Secondary liability calculator
Having trouble understanding the payment
on Medicare Secondary claims? This tool helps you calculate what
Medicare’s liability would be when there is another primary insurer.
Also make sure to check out the Patient Responsibility
Calculator afterwards to determine if there is a balance due from the
patient
Interactive Voice Response Unit (IVR)
If you can’t find the information you’re looking for with these tools, make sure
to review our IVR user guide. The IVR will give you comprehensive
information on Claim Status and Patient Eligibility. You can also get check
status, order a duplicate remittance, or get that patient account number you
were looking for!
IVR User Guide
IVR Alphanumeric Conversion Tool
IVR Name to Number Conversion Tool
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Novitas
Solutions Inc.
CMS
Medicare
Enroll for Novitasphere Portal today!
Novitas Solutions is pleased to announce open enrollment of its
Novitasphere Portal!
Novitasphere is a free, web-based portal that will allow you access to
Eligibility, Claim Information and Remittance Advice, Claim Submission
with File Status, Electronic Remittance Advice (ERA), Claim Correction,
and a MailBox. Eliminate the need to call Novitas for this information,
resulting in time savings for your office! Novitasphere is also a great
alternative to using dial-up or Secure File Transfer Protocol (SFTP) for
your EDI transactions.
If you are a Medicare JL Part B Provider in the states of Pennsylvania,
New Jersey, Maryland, Delaware and the District of
Columbia/Metropolitan area, please visit our dedicated Novitasphere
Portal center for information related to Novitasphere. This page will be
your go-to resource for information on Novitasphere, technical
requirements, the enrollment process, and contact information for Novitas
as it relates to the portal. Please carefully review the information on this
center before completing your Enrollment Form.
It is important to note, customers must be running Internet Explorer
Version 8 (or newer), Google Chrome, Apple Safari, or Mozilla Firefox in
order to access Novitasphere.
You can find the Novitasphere Portal center on the left side of the JL Part
B center CLICK HERE or by visiting CLICK HERE.
Other Payer
Updates
Other News
Patient
Assistance
Frequently
Asked
Questions
N JS O M
R ei m b u rs em en t
E - N ews
May 2014
I s s u e 17 Pag e 7
Novitas Solutions Inc.
Here are Upcoming Training Events
You Won’t Want to Miss
On-Demand Education
DATE
TIME
EVENT
LOCATION
05/13/14
10:00am-1100am
Part B Incident To and Shared Split Billing
05/15/14
10:00am-11:00am
Ask-the-Contractor Teleconference
05/16/14
10:00am-11:30am
05/20/14
11:00am-12:00pm
Part B Understand the LCD and NCD
Process
New Patient Guidelines and Coding
05/20/14
2:00pm-3:30pm
05/23/14
10:00am-11:30am
05/27/14
10:00am-11:30pm
06/03/14
10:00am-1100am
Via Webinar
Via
Teleconference
Via Webinar
Via Webinar
Walking Through the CMS Regulations-A
Journey of Compliance
Part B Medicare Secondary Payer Basics
Via Webinar
Part B Established Patient Billing and
Coding Office Visits
Evaluation and Management Score Sheet:
Part 1- Understanding the Key Components
of Evaluation and Management Services
Update-New Novitas Website
Via Webinar
Via Webinar
Via Webinar
06/04/14
1:00pm-2:30pm
Via Webinar
06/04/14
10:00am-1100am
Using Place of Service Codes Correctly
Via Webinar
06/05/14
10:00am-1100am
Evaluation and Management Score Sheet:
Part 2- Introduction to the Score Sheet
Via Webinar
NJSOM
Members
don’t miss
this
meeting!
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Novitas
Solutions Inc.
CMS
Medicare
Other Payer
Updates
Other News
Weekly Audio Podcasts
Training Modules
Medicare Reference Manual
Specialty Guides
Acronyms & Abbreviations
Frequently Asked Questions
Quick Ref. Guides & Claims Errors/Issues
Evaluation & Management (E/M) Center
Comprehensive Error Rate Testing
(CERT) Center
CMS Education
Open Payments (Physician Payments
Sunshine Act) *
Medicare Learning Network *
National Provider Training Program *
Internet-Only Manual *
Provider Specialty Links
Reducing Medicare and Medicaid Fraud
and Abuse: Protecting Practices and
Patients *
How CMS Is Fighting Fraud: Major
Program Integrity Initiatives *
Safeguarding Your Medical Identity *
Are You Ready for the National Physician
Payment Transparency Program? *
Patient
Assistance
Frequently
Asked
Questions
N JS O M
R ei m b u rs em en t
E - N ews
May 2014
I s s u e 17 Pag e 8
CMS Medicare
Performant Recovery can only audit issues approved by CMS and posted on their website. Be sure to monitor the Performant Recovery
website frequently to stay up to date on audit issues. We will keep an eye on the Performant Recovery website and provide updates in
future Reimbursement E-News. Visit https://www.dcsrac.com/PROVIDERPORTAL.aspx and click on the issues link to view
approved issues.
Important Provider Notice:
May 01, 2014 - The following information is intended to notify providers of current
Recovery Auditors' activities after June 1, 2014.
As noted in previous updates, the last day that Recovery Auditors may send adjustment files to the Medicare Administrative
Contractors (MAC) is June 1, 2014. As of June 2, 2014, only claim closure files may be sent to the MACs by the Recovery Auditor.
Because no additional reviews will occur under the current contracts, current Recovery Auditors will not be required to update the "New Issue"
(Approved Issue) portion of their websites as of June 2, 2014. However, Recovery Auditors shall continue to update the "Claim Status" portion of their
provider portal, in a timely manner, until further notice.
Recovery Auditors shall complete all Discussion Periods that are underway as of June 1, 2014. Recovery Auditors shall continue to accept new
Discussion Period requests until June 30, 2014. All Discussion Periods initiated during June shall be completed. Recovery Auditors shall not accept
new Discussion Period requests after July 1, 2014.
Recovery Auditors shall continue to maintain their customer service areas (telephone lines and appropriately training staff) and process for escalating
concerns, until further notice.
Recovery Auditors shall continue to support the appeal process.
Note: Medicare Administrative Contractor (MAC) processes will continue. Therefore, claims sent for adjustment, by a Recovery Auditor, on or before
June 1, 2014 may complete the adjustment process on, or after, June 2, 2014. The Medicare Appeals process will also continue. Therefore,
recoupments can occur, if a provider does not file a timely appeal (to the 1st or 2nd level of appeal), or receives an "unfavorable" decision at the 2nd
level (QIC) of the appeals process.
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CMS
Medicare
Other Payer
Updates
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Assistance
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Asked
Questions
N JS O M
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E - N ews
May 2014
I s s u e 17 Pag e 9
CMS Medicare
Holistic
Collaborative Documentation
Written by Sharon Easterling, MHA, RHIA, CCS, CDIP, CPHM
Isn’t it great to imagine a health system in which the documentation
shares a common thread and consistency across all payer types? One in
which a patient with chronic systolic congestive heart failure has that
diagnosis in their hospital medical record for Part A payment and within
the physician record for Part B payment? Is it possible to have “Holistic”
Documentation? This very well may be, as CMS continues to place
providers on a path to meeting Meaningful Use, ICD-10, and ValueBased Purchasing/Pay for Performance/Accountable Care initiatives.
Documentation has emerged into the need to document for payment and,
ultimately, for survival.
READ MORE
Crowdsourcing
Compliance:
The Wrong Way to Do Things
Written by Frank Cohen, MPA Created on Thursday, 01 May 2014
On April 9, the Centers for Medicare & Medicaid Services (CMS) made
public a database that for years has been both highly coveted and highly
protected. Prior attempts to get it released were stridently challenged in court,
as it was believed that releasing the data, with all of its flaws and limitations
would do more harm than good. Well, not much has changed, except now the
data is freely available on the CMS website. The database contains
utilization, billing, and payment data on pretty much every person and
organization that billed Medicare in 2012.
READ MORE
New Data Spotlight Tracks
Rising Enrollment in Medicare Advantage Plans
A new brief from the Kaiser Family Foundation documents the continuing climb in Medicare Advantage plan
enrollment, even at a time when payments to such plans are being reduced under the Affordable Care Act. Despite
spending reductions enacted in the ACA to reduce historical overpayments to Medicare Advantage plans, from
March 2013 to March 2014 enrollment in Medicare Advantage plans grew by 9 percent, or 1.4 million people, to
reach a total of 15.7 million Medicare beneficiaries.
READ MORE
Front Page
News
Novitas
Solutions Inc.
CMS
Medicare
Other Payer
Updates
Other News
Patient
Assistance
Frequently
Asked
Questions
N JS O M
R ei m b u rs em en t
E - N ews
May 2014
I s s u e 17 Pag e 10
CMS Medicare
“HIPAA EDI Standards”
Web-Based Training Course — Revised
The “HIPAA EDI Standards” Web-Based Training (WBT) course was revised
and is now available. This WBT is designed to provide education on electronic
billing, transaction standards, and code sets. It includes an overview of the
steps involved in the Medicare electronic data interchange process. Continuing
education credits are available to learners who successfully complete this
course. See course description for more information.
New MLN Provider Compliance Fast Fact
A new fast fact is now available on the MLN Provider Compliance
web page. This web page provides the latest MLN
Educational Products and MLN Matters® Articles designed to help
Medicare health care professionals understand common billing errors
and avoid improper payments. Please bookmark this page and check
back often as a new fast fact is added each month.
To access the WBT, go to MLN Products and click on “Web-Based Training
Courses” under “Related Links” at the bottom of the web page.
CMS Tipsheet for Multiple Locations
Recent LearnResource
& MedLearn Matters Articles
CMS has created the new Multiple Locations Tipsheet for eligible
professionals practicing at multiple locations. The Tipsheet provides
information on how to successfully demonstrate meaningful use in the
Medicare and Medicaid EHR Incentive Programs. The Tipsheet
includes guidance on determining if a location is equipped with
certified EHR technology, calculating patient encounters, and what to
do when different menu objectives and clinical quality measures are
chosen across locations. Visit the CMS EHR Incentive Programs
website for more resources to help you successfully participate.
Front Page
News
Novitas
Solutions Inc.
CMS
Medicare
Other Payer
Updates
Individualized Quality Control Plan for CLIA Laboratory
Non-Waived Testing — Register Now
Stage 2 Meaningful Use Requirements, Reporting Options,
and Data Submission Processes for Eligible Professionals —
Registration Now Open
Notices of Intent to Apply for the Medicare Shared Savings
Program 2015 Program Start Date Due by May 30
CMS is Accepting Suggestions for PQRS Measures
Other News
Patient
Assistance
Frequently
Asked
Questions
N JS O M
R ei m b u rs em en t
E - N ews
May 2014
I s s u e 17 Pag e 11
CMS Medicare
New Fact Sheet Available on How to Avoid the 2016 PQRS Payment Adjustment
Are you an eligible professional or part of a group practice participating in Physician Quality Reporting System (PQRS) this year?
If so, you must satisfactorily report data on quality measures during 2014 to avoid the 2016 payment adjustment. Review the new
fact sheet for guidance on how to avoid the 2016 PQRS Payment Adjustment.
Avoid the 2016 Payment Adjustment
You can avoid the 2016 payment adjustment by meeting one of the following criteria during the one-year 2014 reporting period
(January 1–December 31):
If Participating as an Individual Eligible Professional: Meet the criteria for satisfactory reporting adopted for the 2014
PQRS incentive. Or, participate in PQRS via qualified clinical data registry, qualified registry, or claims reporting and
report at least three measures covering one National Quality Strategy (NQS) domain for at least 50 percent of your Medicare
Part B Fee-For-Service (FFS) patients.
If Participating as a Group Practice: Meet the Group Practice Reporting Option (GPRO) requirements for satisfactory
reporting. Or, participate in PQRS via qualified registry reporting and report at least three measures covering one NQS
domain for at least 50 percent of your group practice’s Medicare Part B FFS patients.
Want more information about PQRS? Visit the PQRS website
PQRS Participants: New Email Address for QualityNet Help Desk
Do you have questions about participating in the Physician Quality Reporting System (PQRS)? The QualityNet Help Desk
is available to assist you with your PQRS inquiries. The QualityNet Help Desk can provide guidance on:
General PQRS program information
Portal password issues
Feedback report availability and access
PQRS-IACS registration questions
PQRS-IACS login issues
Contact the Help Desk - Hours: 7am through 7pt CT; Monday-Friday - Phone: 866-288-8912; TTY: 1-877-715-6222 – Email: Qnetsupport@hcqis.org
Other PQRS Resources - Additional resources are available on the Educational Resources web page to help you satisfactorily report your 2014 PQRS
data.
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CMS
Medicare
Other Payer
Updates
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Questions
N JS O M
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May 2014
I s s u e 17 Pag e 12
CMS Medicare
CMS NEWS
FOR IMMEDIATE RELEASE - May 2, 2014
Administration announces proposal to clarify availability of Health
Insurance Marketplace coverage to workers eligible for COBRA
WASHINGTON – The Obama administration today announced updates to
model notices informing workers of their eligibility to continue health-care
coverage through the Consolidated Omnibus Budget Reconciliation Act.
The updates make it clear to workers that if they are eligible for COBRA
continuation coverage when leaving a job, they may choose to instead
purchase coverage through the Health Insurance Marketplace.
READ MORE
New MLN Educational
Web Guides Fast Fact
A new fast fact is now available on the MLN Educational Web Guides
web page. This web page provides information on Evaluation and
Management services; Guided Pathways that contain resources and
topics of interest; lists of health care management products; and easy-tounderstand billing and coding educational products. It is designed to
provide educational and informational resources related to certain
Medicare Fee-For-Service initiatives. Please bookmark this page and
check back often as a new fast fact is added each month.
http://www.dol.gov/opa/media/press/ebsa/ebsa20140750.htm
"Part C & Part D: Organization Determinations, Appeals & Grievances”
Web-Based Training Course — Released
PART C
The “Part C Appeals: Organization Determinations, Appeals & Grievances” Web-Based Training Course (WBT) was released and is now available. This
WBT is designed to provide designed to provide education on Medicare Part C Appeals for health care and plan professionals. It includes information on
basic definitions of terms related to Part C organization determinations, appeals & grievances; requirements for organization determinations; and common
problems encountered by plans. Continuing education credits are available to learners who successfully complete this course. See course description for
more information.
PART D
The “Part D Organization Determinations, Appeals & Grievances” Web-Based Training Course (WBT) was released and is now available. This WBT is
designed to provide designed to provide education on Medicare Part D Appeals for health care and plan professionals. It includes information on basic
definitions of terms related to Part D coverage determinations, appeals & grievances as well as, requirements for appeals, effectuation and grievances.
Continuing education credits are available to learners who successfully complete this course. See course description for more information.
To access the WBTs, go to MLN Products and click on “Web-Based Training Courses” under “Related Links” at the bottom of the web page.
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CMS
Medicare
Other Payer
Updates
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Frequently
Asked
Questions
N JS O M
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E - N ews
May 2014
I s s u e 17 Pag e 13
CMS Medicare
EHR Incentive Program: Hardship Exception
Applications due July 1 for Eligible Professionals
Are you a Medicare provider who was unable to successfully demonstrate
meaningful use for 2013 due to circumstances beyond your control? CMS is
accepting applications for hardship exceptions to avoid the upcoming
Medicare payment adjustment for the 2013 reporting year. Payment
adjustments for the Medicare Electronic Health Record (EHR) Incentive
Program will begin on January 1, 2015 for eligible professionals.
However, you can avoid the adjustment by completing a hardship exception
application and providing supporting documentation that proves
demonstrating meaningful use would be a significant hardship for you. CMS
will review applications to determine whether or not you are granted a
hardship exception. CMS has posted hardship exception applications on the
EHR website for:
Eligible professionals
Eligible professionals submitting multiple National Provider
Identifiers (NPIs)
Applications for the 2015 payment adjustments are due July 1, 2014 for
eligible professionals. If approved, the exception is valid for one year.
New Hardship Exception Tipsheets
You can also avoid payment adjustments by successfully demonstrating
meaningful use prior to the payment adjustment. Tipsheets are available on
the CMS website that outline when eligible professionals must demonstrate
meaningful use in order to avoid the payment adjustments.
Want more information about the EHR Incentive Programs?
Make sure to visit the Medicare and Medicaid EHR Incentive Programs
website for the latest news and updates on the EHR Incentive Programs.
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Novitas
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CMS
Medicare
Learn About the Special EHR Reporting
Periods for Eligible Professionals in 2014
If you are an eligible professional, make sure you are aware of the special
Electronic Health Record (EHR) reporting periods for submitting
meaningful use measures in 2014.
Meaningful Use Reporting for Medicare and Medicaid Eligible
Professionals
You only need to demonstrate meaningful use for a three-month, or 90-day,
reporting period, regardless if you are demonstrating Stage 1 or
Stage 2 of meaningful use. Choose your reporting period based on your
program and participation year:
Medicare beyond first year of meaningful use: Select a three-month
reporting period fixed to the quarter of the calendar year.
Medicare in first year of meaningful use: Select any 90-day reporting
period. To avoid the 2015 payment adjustment, begin your reporting
period by July 1 and attest by October 1.
Medicaid: Select any 90-day reporting period that falls within the
2014 calendar year.
For More Information
Make sure to visit the
EHR Incentive Programs
website for the latest news and
updates on the EHR Incentive
Programs.
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CMS Medicare
EHR Incentive Programs: Eligible Professionals Should
Review Changes in Stage 1 Meaningful Use Criteria
Are you a Medicare eligible professional who is participating or planning to participate in Stage 1 of the Medicare or
Medicaid Electronic Health Record (EHR) Incentive Program this year? The Stage 2 rule for meaningful use included
changes to Stage 1 requirements that took effect on January 1, 2014. These changes include:
Record and Chart Changes in Vital Signs
Change: The age limit increased for recording blood pressure in patients from age 2 to age 3; there is no age
limit for height and weight.
2014 Measure: For more than 50 percent of all unique patients seen by the eligible professional during the
EHR reporting period, blood pressure (for patients age 3 and over only) and height and weight (for all ages)
should be recorded as structured data.
Patient Electronic Access
Change: Menu objective “Timely electronic access to health information” and core objective “Electronic copy
of health information” are combined to become the new “View online, download, and transmit” core
objective.
2014 Measure: More than 50 percent of all unique patients seen by the eligible professional during the EHR
reporting period are provided timely (available to the patient within 4 business days after the information is
available to the eligible professional) online access to their health information.
Clinical Quality Measure (CQM) Reporting
Change: Reporting CQMs is still required, but it has been removed as a separate objective.
Stage 1 Resources: Resources to help you understand changes to Stage 1 of meaningful use are available on the EHR
Incentive Programs website, including:
Stage 1 Changes Tipsheet
2014 Stage 1 Changes Tipsheet
New MLN
Connects™ National
Provider Call
Transcripts and
Audio Recordings
Call materials for MLN
Connects™ Calls are located on
the Calls and Events web page.
Audio recordings and written
transcripts are now available for
the following calls:
April 8 —Medicare Shared
Savings Program ACO:
Preparing to Apply for
2015, audio, and
transcript
April 10 —How to Register
for the PQRS Group
Practice Reporting Option
in 2014, audio and
transcript
Visit the Medicare and Medicaid EHR Incentive Programs website for the latest news and updates on the EHR
Incentive Programs.
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IMPORTANT!!
Apr 30, 2014
May 2, 2014
A.I. duPont Hospital
out of network as of May 1, 2014
Claim Editing Update:
E&M Services and Modifier 25
Beginning August 1, our claim system will deny certain
services when performed by the same provider on the same day
as another service/procedure even if one of the codes in
question is appended with Modifier 25.
Horizon BCBSNJ's participation agreement with A.I. duPont Hospital is
terminated as of May 1, 2014.
LEARN MORE
LEARN MORE
Apr 29, 2014
Update:
Conversion of Small Employer
Group Coverage
May 1, 2014
Claim Adjustment Notification: Medicare
Advantage Institutional Claims
Beginning June 1, 2014, certain claims will be adjusted to correct
reimbursement that was calculated at the incorrect allowance.
We continue to address challenges in the conversion of small employer group
health insurance plans to 2014 ACA-compliant plans.
LEARN MORE
LEARN MORE
Apr 25, 2014
NaviNet End User
Agreement Update
Apr 25, 2014
Modifier SU
Reimbursement Policy
NaviNet will be deploying an updated End User Agreement to help maintain the
highest levels of patient privacy and security.
Services appended with modifier SU are not eligible for
reimbursement.
LEARN MORE
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Office Manager Seminars
Join us for an Office Manager Seminar. We make doing business with us easier. Topics include: 2014 Products, Polices & Procedures, Healthcare
Effectiveness Data Information Set (HEDIS®) and Medicare Star, ICD-10 Readiness, Patient-Centered Programs, Risk Adjustment, Stage 2 Meaningful
Use.
If you have questions about the seminar, please call 1-973-466-5573 or e-mail Physician_seminars@HorizonBlue.com.
To register, email Physician_Seminars@HorizonBlue.com with your name, practice name, Tax ID number and preferred date and location. You can also
fax the registration form to 1-973-274-4049.
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Apr 15, 2014
Horizon Advance EPO:
Participation and Reimbursement
Our new Horizon Advance EPO plan includes unique benefit designs regarding physician and
facility participation and reimbursement.
QUICKLINK
Horizon
Medical Policy Manual
LEARN MORE
For details….CLICK HERE
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A Few Articles
You Won’t Want to Miss:
A Few Articles You Won’t Want to Miss:
 Optum Cloud Features…pg 20






 UnitedHealthcare Medical Policy, Drug Policy, Coverage
Determination Guideline and Utilization Review Guideline
Updates…pg 25
 Changes in Advance Notification and Prior Authorization
Requirements…pg 57
Changes to July 1, 2014 National Precert List (Includes Gazyda)…pg 1
Questions about Health Insurance Exchanges?…pg 1
Submit preauthorizatons for certain services…pg 3
Aetna 2014 HEDIS data collection is underway…pg 6
Coverage determinations and utilization management…pg 7
Check out our new and improved Education Site…pg 8
 Reminder: PPACA Medicaid PCP Enhancement Payments…pg 58
 United for Reform Resource Center – Helping Providers Stay
And Much More….
MARCH 2014 Qtly Issue
Available HERE
Abreast on the Latest Reform Updates…pg 61
 Learn About Advance Notification and Prior Authorization on
UnitedHealthcareOnline.com…pg 63
 Change in HCPCS Code J3489 Pricing…pg 80
Information for Providers:
Contracts, Legal Notices
 Oxford® & River Valley Medical and Administrative Policy
Updates…pg 82 to pg 95
NEW!
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Provider Resources
Medicaid Managed Care Contract
Dual Eligible Special Needs Plan Contract
Accountable Care Organizations
Public Notices
New Jersey Medicaid State Plan
And Much More…
MAY 2014 Bi-Monthly
Issue Available HERE
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DRUG SHORTAGES –
If you are looking for a complete list of Drug Shortages from the FDA CLICK HERE. Another good
resource which provides detailed information about the various drug shortages can be found HERE.
Facing Dire Shortage of IV Saline, FDA Again
Turns to Enforcement Discretion Approach
Latest News | Posted: 30 April 2014 - by Alexander Gaffney, RAC
In the face of mounting concerns about a shortage of intravenous saline solutions, the US Food and Drug Administration (FDA)
announced it is once again utilizing an uncommon regulatory mechanism to ease the shortage—a mechanism no longer on the
strongest of legal footings.
READ MORE
RECENT FDA APPROVALS/CHANGES
FDA Approves Zykadia for Late-Stage Lung Cancer
04/29/2014 03:08 PM EDT
The U.S. Food and Drug Administration today granted accelerated approval to Zykadia (ceritinib) for patients with a
certain type of late-stage (metastatic) non-small cell lung cancer (NSCLC). READ MORE
****************
FDA Approved Ofatumumab
FDA approved ofatumumab (Arzerra Injection, for intravenous infusion; GlaxoSmithKline) in combination with chlorambucil, for the treatment of
previously untreated patients with chronic lymphocytic leukemia (CLL), for whom fludarabine-based therapy is considered inappropriate. Diplomat has
access to dispense Arzerra. April 17, 2014 – MORE INFORMATION.
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****************
FDA Approves Cyramza for Stomach Cancer
04/21/2014 04:09 PM EDT
The U.S. Food and Drug Administration today approved Cyramza (ramucirumab) to treat patients with advanced stomach cancer or gastroesophageal
junction adenocarcinoma, a form of cancer located in the region where the esophagus joins the stomach. READ MORE
JOP Articles on 340B and Payment Reform
On April 15, 2014, ASCO's Journal of Oncology Practice (JOP) published two articles for early release: An ASCO policy statement on the 340B program
(which included program recommendations) and an article regarding physician payment reform. You can visit the early release webpage on
the JOP website to read these articles or click on the links provided below.
Policy Statement on the 340B Drug Pricing Program by the American Society of Clinical Oncology
Potential Approaches to Sustainable, Long-Lasting Payment Reform in Oncology
Pfizer Has Brought Its Patient Assistance Programs Together
To better address changing patient needs, Pfizer has consolidated its U.S.-based patient assistance
programs. For more than 25 years, Pfizer has offered an array of programs to help eligible patients
in the U.S. get access to its medicines. From 2009 to 2013, the company helped more than 3 million uninsured and underinsured patients get access to more
than 37 million prescriptions, equaling more than $7.3 billion.
On April 1, 2014, in response to changing needs, Pfizer has brought its patient assistance programs together under one program called Pfizer RxPathways.
The new name is intended to better reflect the purpose of the program – to provide patients with “pathways” to get access to their Pfizer medicine – and
will replace most Pfizer patient assistance programs; including FirstResource.
Pfizer RxPathways offers a range of support services, including insurance counseling, co-pay help, and medicines provided free or at a savings. Eligibility
requirements are the same as for the previous programs and vary by type of assistance. Patients who are currently receiving their medicines through Pfizer
Helpful Answers and FirstResource will be automatically enrolled in Pfizer RxPathways and do not have to take any action to continue receiving their
medicines. Also, to learn more, visit www.PfizerRxPathways.com.
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Cancer Doctors Plan
to Compare Value of
Expensive Drugs
Cancer Drugs: Too Expensive to Compare?
(Modern Healthcare) Apr 17, 2014
The prices of some cancer drugs are so high that they
preclude trials comparing their effectiveness, according
to two National Cancer Institute researchers. A task
force of clinical oncologists, meanwhile, is working on
an algorithm for making such comparisons.
(Bloomberg) Apr 17, 2014 - The
world’s largest organization of
cancer doctors plans to rate the cost
effectiveness of expensive oncology
drugs, and will urge physicians to
use the ratings to discuss the costs
with their patients.
READ MORE
READ MORE
Recent News Regarding
HIPAA Violations
Chris Christie's NJ Budget Proposal Slashes
Funding for Cancer Research
(NJ.com The Star-Ledger [Newark, NJ])
Apr 19, 2014 - New Jersey’s leading cancer research organization
faces the loss of about a third of its funding in Gov. Chris Christie’s
proposed budget, provoking criticism from those concerned by the cut
of $10 million in state subsidies.
READ ARTICLE
On April 22, the United States Department of Health and Human Services
Office for Civil Rights (OCR) reported that two entities paid $1,975,220
collectively to resolve potential violations of the Health Insurance Portability
and Accountability Act (HIPAA) Privacy and Security Rules. This was a
result of two compliance reviews and investigations of reported security
breaches. The full article can be found HERE.
HIPAA Compliance is extremely important. OCR has six educational
programs for health care providers on compliance with various aspects of the
HIPAA Privacy and Security Rules. Each of these programs is available with
free Continuing Medical Education credits for physicians and Continuing
Education credits for health care professionals. One module focuses
specifically on mobile device security. The programs are available … \
CLICK HERE
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JUST RELEASED!
ASCO Research Program Quality Assessment Tool:
Basics for a Quality Community-Based Research Site
WEBCAST: The
Evolving Use of White
Bagging in Oncology
Kantar Health examines the current
trend of increased use of "white
bagging" in community oncology
practices, and the dual drivers of
payer encouragement and physician
choice. Specialty distributors and
GPOs support "buy and bill" as the
primary method of distribution of
oncology drugs. However, a diverse
array of competing specialty
pharmacies (SPs) already
commanding the majority of the oral
market, continue to make headway
into physician buy and bill via white
bagging with the support of payers.
ASCO's Community Research Forum recently released the ASCO Research Program Quality Assessment Tool.
The Tool is designed to help community-based research sites exceed the minimum standards of conducting clinical
research and provides an overview of ASCO's recommendations for the important components of an internal
quality assessment program. A checklist tool is also provided to help sites conduct an assessment of whether their
program includes these important components. The Tool is available for free. For access, CLICK HERE.
VIEW WEBCAST
OF INTEREST:
Aetna, MOASC Contracting Network,
Cardinal Health Specialty Solutions
Aim To Improve Quality, Costs of Cancer Care in California
Key Points:
This program identifies clinical best practices that improve cancer treatment and make it more affordable.
A steering committee of California oncologists has been formed to support the program. They will
continue to update evidence-based treatment plans and supportive care plans for certain types of cancer.
“By helping our members to develop and implement cancer care pathways, we can help ensure oncologists
are fairly reimbursed for the quality care they provide to patients while removing unnecessary costs from
the health care system. At the same time, oncologists have a clear voice in the future of patient care,” said
Dr. Vu Phan, president, MOASC Contracting Network.
READ MORE
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NJSOM Featured Corporate Sponsor Assistance Program
NJSOM will profile a different Corporate Sponsor Assistance Program each Reimbursement E-News
ACCC's 2014
Patient Assistance
and Reimbursement
Guide
Help your patients and your
cancer program!
Accordingly, cancer programs
are spending increased time
helping patients identify and
access resources to help with
costs related to their treatment,
medications, missed work hours,
transportation, and more.
ACCC's 2014 PAP Guide is
designed to help busy clinicians
with these responsibilities, and
much more. View PAP Guide
Online
Health Care Professionals
Incyte is committed to providing timely and accurate product information to health care professionals
upon request. If you have a question, please contact our Medical Information team toll free at 1-855-4MEDINFO (855-463-3463).
E-mail: medinfo@incyte.com. Normal business hours: 8 a.m. to 8 p.m. ET, Mon-Fri.
Patient Assistance
Patients living with myelofibrosis face many challenges. IncyteCARES (Connecting to Access,
Reimbursement, Education and Support), is a comprehensive program created by Incyte to connect
eligible patients to access and reimbursement services, plus ongoing education and resources, during
their treatment with Jakafi. Patients can access information about Jakafi and the IncyteCARES
program by calling toll-free at 1-855-4-Jakafi (855-452-5234) or visiting www.jakafi.com.
Indication
Jakafi is a prescription medicine used to treat people with intermediate or high-risk myelofibrosis (MF),
including primary MF, post–polycythemia vera MF and post–essential thrombocythemia MF.
To access their website CLICK HERE
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Frequently Asked Questions
Reimbursement Questions & Answers
If you have reimbursement questions you need answers to, please submit them to
njsombilling@gmail.com.
QUESTION: How can a group or facility that loses a physician use locum tenens while recruiting a new
physician?
ANSWER: The group will contract with locum tenens physicians and pay them on a fixed amount per diem.
This payment to the contracted physicians is considered paid by the regular physician (the group pays the
locum tenens physician on behalf of the regular physician). The group may bill for the contracted physician for
up to 60 days. The claim contains HCPCS modifier Q6. The claim must include both the group NPI and the regular physician’s NPI. The group must
keep on file a record of each service provided by the substitute physician, associated with the substitute physician’s NPI when required, and make this
record available to Medicare upon request.
%%%%%%%%%%%%%
QUESTION: Does a locum tenens physician need to complete a Medicare provider enrollment application prior to be a locum tenens physician?
ANSWER: No, currently locum tenens physicians are not required to be enrolled in the Medicare program.
%%%%%%%%%%%%%
QUESTION: Do resident physicians fall under the guidelines for locum tenens?
ANSWER: Currently, locum tenens physicians are not required to be enrolled in the Medicare program. A locum tenens physician is one who has an
unrestricted license to practice in the state in which the services will be provided, has no practice of his/ her own, moves from area to area as needed, and
Continued on next page…
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Frequently Asked Questions
receives payment from the regular physician on a fixed amount per diem. The locum tenens physician has the status of an independent contractor rather than
of an employee. The locum tenens physician must have a NPI number also. A resident would need to meet these guidelines to qualify.
%%%%%%%%%%%%%
QUESTION: Where do we find the guidelines for locum tenens?
ANSWER: The guidelines are found in the CMS Medicare Claims Processing Manual (Pub. 100-04), chapter 1, section 30.2.11
(http://www.cms.gov/Regulations-and-Guidance/Guidance/ Manuals/downloads/clm104c01.pdf).
%%%%%%%%%%%%%
QUESTION: Can a Nurse Practitioner, wiring within their scope of care, bill an office visit for counseling based on time when face to face with the patient
reviewing chemotherapy protocol ordered by the MD including potential side effects, etc., writes prescriptions for all oral medications within the protocol,
advises patient of optional programs for physical and mental support during and after chemo and listens to patients questions and needs), as incident to (if
the MD is in the suite and readily available) or as single provider? This is a follow up visit and not the same day as the visit with the MD.
ANSWER: A non-physician practitioner (NPP) can bill services based on time when the counseling & coordination of care guidelines are met. These are
discussed in the 1995 and the 1997 Documentation Guidelines (DG). The documentation should show the total face-to-face time with the patient in an
office setting, or the total face-to-face time or time spent on the floor or unit in a facility setting. The documentation should also show the time and nature
spent in counseling and/or coordinating care. The total time spent cannot be rounded. The time used must meet or exceed that noted in the procedure code
chosen. In addition, the time used to determine the procedure code is only time spent with the practitioner providing the service. Time spent with other
members of the office staff does not contribute to the time spent with the practitioner. When the NPP is providing a service as incident to the physician,
time can also be used when the service meets both the incident to guidelines and the counseling & coordination of care guidelines. For the incident to
requirement, the services have to have been provided under the physician's plan of care for the individual patient. If the NPP
goes outside of the established plan of care, the services no longer meet the incident to requirements and therefore, must be
billed under the NPP's provider number.
%%%%%%%%%%%%%
QUESTION: When sending additional information to Medicare – responding to an audit, is it ok to highlight the items we
want to be sure they see?
Continued on next page…
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Thank You
New Jersey Society of Oncology
Managers
Board of Trustees
ANSWER: Medicare encourages providers to take the initiative and review medical records prior to submission.
Items like the physician order, drug waste, signatures, etc. are sometimes difficult for the auditor to see.
However, highlighting to draw attention to a specific part of the medical record may render the information
unreadable. A better practice is to circle or mark the information with an asterisk or, establish a checklist and
number the items required and then mark the items with the various numbers within the record. The auditor will
be sure to catch all necessary information quickly and your result is likely to be positive.
President:
Linda DeAngelis
Mercer Bucks Hematology Oncology
Email: lmdeangelis@verizon.net
%%%%%%%%%%%%%
Vice President:
QUESTION: We were wondering if we hired a pharmacist will we be able to bill for the mixing of the
chemotherapy? Currently our nurses mix.
Jeanne McCarty
Burlington County Hematology
Oncology
Email: bchemonc@verizon.net
ANSWER: You cannot separately bill for the mixing fee. The mixing of the drug is in the “Relative Value
Units” for the administration code. When you are paid for the administration, the payer is also reimbursing for
mixing the drug.
Secretary:
Karen Deaner
Adult Medical Oncology Hematology
Group
Email: kdeaner990@gmail.com
Treasurer:
Denise Johnstone
Essex Oncology of North Jersey, PA
Email: dj@essexoncology.com
Editor
Michelle Weiss
Weiss Oncology Consulting
Email: njsombilling@gmail.com
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NJSOM Newsletter Disclaimer
This newsletter is intended for informational purposes only. NJSOM makes no warranties or representations,
express or implied, as to the accuracy or completeness, timeliness or usefulness of any opinions, advice, services or
other information contained or referenced in this newsletter. Information is provided for reference only and is not
intended to provide reimbursement or legal advice. Laws, regulations, and policies concerning reimbursement are
complex and are updated frequently and should be verified by the user. Please consult your legal counsel or
reimbursement specialist for any reimbursement or billing questions.
CPT codes are owned and trademarked by the American Medical Association. All Rights Reserved.
No portion of this publication may be copied without the express written permission of NJSOM. In no event may
any portion of this publication be reprinted and used for commercial purposes by any party other than NJSOM.
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