SAVE THE
DATE
April 7-8, 2016
DECEMBER ISSUE OF THE POHMS NEWSLETTER – ISSUE 23
POHMS Spring
Conference
Sheraton
Valley Forge;
King of
Prussia, PA
POHMS – Premier Oncology Hematology Management Society
1802 Route 31 North #312 Clinton, NJ 08809
Phone: (908) 537-6880| Fax: (866) 631-3299
Editor: Michelle Weiss, Weiss Oncology Consulting - Michelle@WeissConsulting.org
This newsletter is intended for informational purposes only. 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 POHMS. In no event may any portion of this publication be copied or reprinted and used for commercial purposes by
any party other than POHMS.
INSIDE THIS ISSUE….TABLE OF CONTENTS
NATIONAL
NEWS
To View
This
Newsletter
Simply select a
link from the
topics listed on
the right or just
scroll through the
entire issue.
CMS
MEDICARE
OTHER PAYER
UPDATES
FAQ’S
NOTIVAS
SOLUTIONS
INC
OTHER NEWS
POHMS
PAGES
THE POHMS NEWSLETTER - DEC 2015 - Issue 23 Page 2
CORPORATE
ALLIES
ATTENTION
CORPORATE
SPONSORS
Advertising
Opportunity!!
We are looking for
supporters of the POHMS
Newsletter.
Interested parties contact
one of our Board
Members…
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HOME
NATIONAL
NEWS
Aetna
expert explores new cancer
payment methodology
November 29, 2015 by Tracey Walker
New payment models that were initially developed for primary
care or common surgical procedures are now being developed
and used for patients with blood diseases. Michael A.
Kolodziej, MD, national medical director, oncology solutions,
office of the chief medical officer, Aetna, will address some of the challenges of
creating payment models for hematologic conditions, review data on hematologic
services utilization, and evaluate how insurers are implementing these models, at
the American Society of Hematology (ASH) meeting in Orlando, Florida. READ
MORE
Budget deal cuts pay to
hospital-owned practices
December 1, 2015 by Bob Gatty
Washington—There was generally positive news for Medicare
providers in the new 2-year budget agreement signed into law by
President Obama Nov. 2 as well as the 2016 physician fee
schedule just released by the Centers for Medicare & Medicaid
Services (CMS). READ MORE
OIG Releases 2016 Work Plan
The Office of the Inspector General (OIG) has released its 2016 work plan, detailing more than 40 new investigations it plans to undertake in the coming
year. According to the report, the new inquiries cover CMS's management of the ICD-10 implementation, Medicare Part D beneficiaries' exposure to
inappropriate drug pairs, CMS's ability to oversee Part D pharmacies, and increases in brand-name drug prices under Part D. In addition, OIG plans to
review specialty drug pricing and reimbursement in Medicaid, tobacco establishment compliance with the Family Smoking Prevention and Tobacco
Control Act, among other topics. View the Work Plan Here
OIG Releases Study on Growth and Profitability of 340B Program
Wednesday, November 25, 2015
The HHS Office of the Inspector General finds that the 340B drug discount program produced profit margins of 58% on covered drugs. READ MORE
New OIG Report Shows Hospitals’ Huge 340B Profits from Medicare-Paid Cancer Drugs
The Office of Inspector General (OIG) has just released another eye-opening report on the 340B drug discount program: Part B Payments For 340BPurchased Drugs. (Free download) READ MORE
THE POHMS NEWSLETTER - DEC 2015 - Issue 23 Page 3
The following JL ICD-10
Oncology Related Local Coverage
Determinations have been revised:
NOVITAS
SOLUTIONS
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HOME
Important reminder
on how to correctly submit
documentation for ADRs
(Additional Documentation Requests)
Biomarkers for Oncology (L35396)
Implantable Infusion Pump (L35112)
Services That Are Not Reasonable and Necessary (L35094)
Thrombolytic Agents (L35428)
Providers Not Required to Revise Physician Orders
Written Before October 1, 2015
Novitas Solutions’ Medical Review Department
continues to experience improper submission of
documentation in response to an ADR. Please take a
moment to review the information provided in How
to Correctly Submit Documentation for Additional
Documentation Requests (ADRs).
CMS (Centers for Medicare & Medicaid Services) posted a new FAQ about physician orders
written before the October 1 ICD-10 compliance date. FAQ 12625 explains that CMS is not
requiring the ordering provider to translate ICD-9 diagnosis codes to ICD-10 on orders written
before October 1 for lab, radiology, or any other services.
For more guidance on claims processing and billing, please visit the CMS ICD-10 FAQ
webpage.
New CERT A/B MAC Outreach & Education
Task Force Publication on Lab Documentation
The CERT A/B MAC Outreach & Education Task Force posted a new publication titled
Complying with Documentation Requirements for Laboratory Services. If you order lab
services for Medicare patients, please read this important publication. Learn about how you can
properly document orders and reduce the CERT error rate.
THE POHMS NEWSLETTER - DEC 2015 - Issue 23 Page 4
Correction to Telephone
Number in 2016 Participation
Post Card Mailing
An incorrect telephone number was printed in a
recent post card mailing you may have received
on the 2016 Medicare Participation Process. The
correct phone number to call if you do not have
internet access and require a hardcopy of the
2016 Participation Enrollment and Information
Package is 1-877-235-8073. We apologize for
any inconvenience.
HOME
NOVITAS
SOLUTIONS
The Holiday Season
is Here!
Listed are Novitas training events an oncology
practice should consider!
The holiday season is upon us and
while we are happy to work with
you, your written and/or verbal
feedback is the only gift that we
need! Please note that Novitas
employees are prohibited from
accepting any gifts from providers
at any time and not just during the
holiday season.
CLICK HERE
to access the educational area
of the Novitas website!
DATE
TIME
EVENT
LOCATION
12/8/15
10:00a-11:00a
Via Webinar
12/8/15
2:00p-3:00p
12/9/15
10:00a-11:00a
Understanding the Enrollment of Clinics/Group
Practices and Certain Other Suppliers (CMS855B and CMS-855R)
Novitasphere Provider Portal Enrollment
Overview
Subsequent Hospital Care Rules and Coding
12/10/15
2:00p-3:00p
Via Webinar
12/11/15
10:00a-11:00a
Save Time and Money with Electronic
Remittance Advice
Novitasphere Claim Correction Overview
12/15/15
11:00a-12:00p
New Patient Guidelines and Coding
Via Webinar
12/18/15
11:00a-12:00p
Via Webinar
12/12/15
11:00a-12:00p
The Established Patient: Billing and Coding
Office Visits
Novitasphere Claim Submission Overview
THE POHMS NEWSLETTER - DEC 2015 - Issue 23 Page 5
Via Webinar
Via Webinar
Via Webinar
Via Webinar
Thank you!
NOVITAS
SOLUTIONS
2016 Medicare Part A and B
Deductibles and Coinsurances are
Now Available
The 2016 Medicare Part A and B Deductibles and Coinsurances are now
available. Please take a moment to review.
READ MORE
CMS Education
Novitas Solutions e-News
Electronic Billing Quarterly
Newsletter
Articles of note:
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HOME
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
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 *
 Frustrated When a Medicare Secondary Payer
(MSP) Claim Rejects?
 How to Review Pending End User Requests for
Novitasphere in CMS Enterprise Portal (EIDM)
And More…
NOVEMBER Issue Available
CLICK HERE
On-Demand
Education
Medicare Part B - H O T L I N K S !
2016 Medicare JL Part B Fee Schedule
Current Active Part B LCD Policies
Current Average Sales Price (ASP) Files
Quarterly Update to CCI Edits
2016 Physician Fee Schedule Final Rule
2016 CMS Physician Fee Schedule Final Rule Fact Sheet
THE POHMS NEWSLETTER - DEC 2015 - Issue 23 Page 6
HOME
CMS
MEDICARE
What's New!
Performant Recovery Providers: The discussion period offers the opportunity
for the provider to submit additional information to the RAC to indicate why
recoupment should not be initiated. Discussions may be processed entirely in
writing or may require a teleconference with the provider. To request a
discussion, please download the Discussion Request Form that can be found
HERE. This form, along with any additional documentation should be
submitted.
To get to the
Performant
Recovery
website
CLICK HERE
OIG Work Plan: Fair Warning
By Chuck Buck
The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) 2016 Work Plan comes with a warning: the OIG
continues to be relentless in detecting and pursuing waste, fraud, and abuse.
In the 75-page plan, posted to the OIG's website on Monday, the agency reported that in the most recent fiscal year it had recoveries of more than $3
billion. The OIG indicated that it also had excluded 4,112 individuals and entities from participating in HHS programs during that time. Moreover, the
OIG noted that it had brought 925 criminal actions against individuals or entities that engaged in crimes against HHS programs, as well as 682 civil
actions, which the OIG includes as false claims and "unjust-enrichment lawsuits filed in federal district court, CMP settlements, and administrative
recoveries related to provider self-disclosure matters." READ MORE
New Claim Filing Requirements for Hospital-Based Off Campus Clinics
By Duane Abbey, PhD, CFP
Starting Jan. 1, 2016, hospitals will need to alter the way in which they bill for both professional and facility component claims for off-campus,
hospital-based (or, more accurately, provider-based) clinics. The Centers for Medicare & Medicaid Services (CMS) has decided to start collecting data
relative to these clinics, and presumably, other off-campus provider-based operations as well. READ MORE
THE POHMS NEWSLETTER - DEC 2015 - Issue 23 Page 7
RAC Monitor continued on next page…
The Corporate Integrity Agreement:
Avoiding Audits
CMS
MEDICARE
HOME
By Edward Roche, MA, M. Phil, PhD. JD November 18, 2015
Some audits end badly. The provider must pay back all that was received for improper claims, for example. But it might not end
there. There remains the possibility of civil money penalties under 42 U.S. Code § 1320a–7a, and complete exclusion from any
healthcare program that gets even part of its funding from the federal government. READ MORE
Pushed and Pulled RA Contracts Emerge from Scuffling
By Emily Evans November 18, 2015
On Friday evening the Centers for Medicare & Medicaid Services (CMS) released its long-awaited request for proposals for the Medicare Recovery
Auditors (RAs). As this program has been the subject of much political, regulatory, and judicial meddling, there are no surprises. The basic contours of
the program are the following:

There will be five RAC regions instead of the current four. Four of the five regions will be dedicated to audits of inpatient stays (except shortstay inpatient services, which will be subject to a different process), outpatient stays, physicians, inpatient rehabilitation facilities (IRFs), longterm care hospitals (LTCHs), and skilled nursing facilities (SNFs). The fifth RAC will be dedicated to audits of home health, hospice, and
durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claims. This structure is bad news for home health, hospice, and
DMEPOS, which have been given little attention to date, their improper payment rates notwithstanding. READ MORE
Smoking Cessation Claims
Editing Incorrectly
A system error caused claims for smoking cessation with dates
of service on or after October 1, 2015, to edit incorrectly. Your
Medicare Administrative Contractor (MAC) will correct all
affected claims. No provider action is required.
THE POHMS NEWSLETTER - DEC 2015 - Issue 23 Page 8
Predicting the Future of
Meaningful Use 3
To get a sense of where the Meaningful Use program
may be headed, and why so few physicians have
participated beyond Stage 1, Medical Economics
conducted a Q&A with John Halamka, MD, MS. Find
out what you need to know
HOME
CMS
MEDICARE
New Educational
Web Guides
Fast Fact
A new fast fact is available on
the Educational Web Guides
webpage. Visit the webpage
for resources on CMS
initiatives, including:
 Evaluation and
Management services
 Guided Pathways
resource booklets
 Health care
management, billing,
and coding products
ICD-10
Transition:
Clarifications
about NCDs
and LCDs
All Medicare national
and local coverage
policies are translated
for ICD-10, and to
receive payment,
providers must bill
using ICD-10 codes
for services rendered
on or after October 1,
2015. Check the
National Coverage
Determination (NCD)
and Local Coverage
Determination (LCD)
policies in the
Medicare Coverage
Database to find out
which ICD-10 codes
support medical
necessity.
See the
announcement for
more information.
THE POHMS NEWSLETTER - DEC 2015 - Issue 23 Page 9
New FAQs on Participation in EHR Incentive Programs
HOME
On October 6, CMS released the final rule with comment for the Medicare and Medicaid Electronic Health Record (EHR)
Incentive Programs. CMS also released three new FAQs, providing clarification on how to attest to certain measures for
health information exchange, patient electronic access, and other objectives that require patient action.
CMS
MEDICARE
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For the Health Information Exchange objective for meaningful use in 2015 through 2017, may an Eligible Professional (EP),
eligible hospital, or critical access hospital count a transition of care or referral in its numerator for the measure if they
electronically create and send a summary of care document using their Certified EHR Technology (CEHRT) to a third party
organization that plays a role in determining the next provider of care and ultimately delivers the summary of care
document? See FAQ 12817.
If multiple EPs or eligible hospitals contribute information to a shared portal or to a patient's online Personal Health Record (PHR), how is it
counted for meaningful use when the patient accesses the information on the portal or PHR? See FAQ 12821.
In calculating the meaningful use objectives requiring patient action, if a patient sends a message or accesses his/her health information made
available by their EP, can the other EPs in the practice get credit for the patient’s action in meeting the objectives? See FAQ 12825.
Medicare Quality Reporting
Programs: 2016 Physician Fee
Schedule Call — Register Now
Tuesday, December 8 from 1:30-3pm ET
To Register: Visit MLN Connects Event Registration.
Space may be limited, register early.
During this call, find out how the 2016 Medicare
Physician Fee Schedule final rule impacts Medicare
Quality Reporting Programs. A question and answer
session will follow the presentation. READ MORE
EHR Incentive Programs:
Recording from Final Rule Webinar Available
The presentation and webinar recording from the Electronic Health Record (EHR)
Incentive Programs webinar on the final rule are available on the 2015 Program
Requirements web page. The October 8 webinar covered:
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THE POHMS NEWSLETTER - DEC 2015 - Issue 23 Page 10
Overview of the final rule
Requirements for 2015 through 2017 (Modified Stage 2)
Stage 3 requirements for 2018 and beyond
What you need to know to participate in 2015
New CMS resources
HOME
CMS
MEDICARE
Recent LearnResource
& MedLearn Matters Articles
Notice POHMS Members…
If there is a specific Payer you would like included
in this newsletter, please email the editor, Michelle
Weiss at Michelle@weissconsulting.org
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OPEN ENROLLMENT REMINDER

Medicare Advantage Plan - October 15 – December 7
o Changes from Medicare to MR Advantage


o From Advantage to a different Advantage

o Join a Medicare Prescription Drug Plan
o Switch or cancel Prescription Drug Plans

Medicare Advantage Disenrollment Period - January 1 – February 14
o Leave MA plan and switch to original Medicare
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Health Insurance Marketplace - November 1 – January 31, 2016
o Join or switch plans
THE POHMS NEWSLETTER - DEC 2015 - Issue 23 Page 11
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2016 Value Modifier Informal Review Deadline Extended to
December 16
2016 PQRS Payment Adjustment: Informal Review Deadline
Extended to December 16
Medicare Coverage of Screening for Lung Cancer with Low Dose
Computed Tomography (LDCT)
Update to the List of Compendia as Authoritative Sources for Use
in the Determination of a "Medically-Accepted Indication" of
Drugs and Biologicals Used Off-label in an Anti-Cancer
Chemotherapeutic Regimen
Claim Status Category and Claim Status Code Update
Implement Operating Rules - Phase III ERA EFT: CORE 360 Uniform
Use of Claim Adjustment Reason Codes (CARC) and Remittance
Advice Remark Codes (RARC) Rule - Update from CAQH CORE
New Influenza Virus Vaccine Code
Quarterly Update in the Medicare Physician Fee Schedule
Database (MPFSDB) - October CY 2015 Update
Changes to the Laboratory National Coverage Determination
(NCD) Edit Software for January 2016
Medicare Remit Easy Print (MREP) Upgrade
Internet Only Manual Updates to Pub. 100-01, 100-02 and 10004 to Correct Errors and Omissions (2015)
Reporting Principal and Interest Amounts When Refunding
Previously Recouped Money on the Remittance Advice (RA)
HOME
OTHER
PAYER
UPDATES
Independence medical record requests and ePASS®
submissions now using EFT for payments
PARTNERS IN HEALTH UPDATE December 2015
Posted December 1, 2015 - Payments issued on or after November 1, 2015, for medical record requests and SOAP Progress
Note submissions through ePASS, will be processed and distributed through electronic funds transfer (EFT). We will continue to
send paper checks for those providers who are not EFT-enabled; however, we encourage all providers to sign up for EFT. If you
are interested in receiving payment via EFT, please follow the instructions in our EFT Attestation and Registration Guide, which
is available in the NaviNet® Resources section of the Provider News Center. If you have any questions on the EFT registration
process, contact the eBusiness hotline at 215-640-7410.
Reminder: Upcoming
changes to drug
precertification
requirements for 2016
Posted October 30, 2015
Effective January 1, 2016, new
precertification requirements will apply to
our commercial and Medicare Advantage
HMO and PPO members for the seven
medical benefit drugs listed below:
READ MORE
Notification - IV Bortezomib
(Velcade) Updated policy
effective 1/5/2016
This policy was updated to be consistent
with US Food and Drug Administration
(FDA) Labeling and Drug Compendia.
New/Updated Policies that may affect oncology
practices....
08.00.83e, Pralatrexate (Folotyn®) for Injection
Effective: 11/04/2015 | Posted: 11/04/2015
08.00.99b, Belimumab (Benlysta®)
Effective: 11/04/2015 | Posted: 11/04/2015
Type of policy change: Medical Necessity Criteria; Medical Coding; General
Description, Guidelines, or Informational Update
Current Issue
Available HERE
06.02.10n, Genetic Testing for Inherited Susceptibility to Colon Cancer and
Microsatellite Instability Testing (Familial Adenomatous Polyposis and Lynch
Syndrome)
Effective: | Posted: 11/06/2015
Type of policy change: General Description, Guidelines, or Informational Update
08.00.88c, Ofatumumab (Arzerra™)
Notification: 10/30/2015 | Effective: 11/30/2015 | Posted: 11/30/2015
Type of policy change: Medical Necessity Criteria; Medical Coding; General
Description, Guidelines, or Informational Update
READ MORE
THE POHMS NEWSLETTER - DEC 2015 - Issue 23 Page 12
READ MORE
Current Issue
Available HERE
HOME
FOUR CODES TO BE ADDED TO LIST OF
PROCEDURES REQUIRING AUTHORIZATION, EFFECTIVE 1/1/16
OTHER
PAYER
UPDATES
Effective with dates of service of Jan. 1, 2016, and beyond, we will revise our list of outpatient procedures/services requiring
authorization to add four procedure codes. The procedure codes are listed in the chart below. (Please note: The codes will not require
authorization and will not appear on the all-inclusive authorization list on the Provider Resource Center until the effect. date, 1-1-2016
CODE
DESCRIPTION
J0894
J9025
63005
J7327
INJECTION, DECITABINE, 1 MG
INJECTION, AZACITIDINE, 1 MG
LAMINECTOMY WITH EXPLORATION AND/OR DECOMPRESSION OF SPINAL CORD AND/OR CAUDA EQUINA, WITHOUT
FACETECTOMY, FORAMINOTOMY OR DISCECTOMY, (E.G., SPINAL STENOSIS), ONE OR TWO VERTEBRAL SEGMENTS;
LUMBAR, EXCEPT FOR SPONDYLOLISTHESIS
HYALURONAN OR DERIVATIVE, MONOVISC, FOR INTRA-ARTICULAR INJECTION, PER DOSE
UPMC, Highmark divorce
ends with key ruling
November 30, 2015 11:33 PM By Kris Mamula /
Pittsburgh Post-Gazette
Seniors with Highmark’s Medicare Advantage plan
coverage will continue to have in-network access to
UPMC hospitals and doctors, the state Supreme Court
ruled Monday, marking the final break in relations
between the two health care giants.
READ MORE
Arbitrators side with UPMC;
Highmark must pay $188 million for
cancer care
By Wes Venteicher
Tuesday, Nov. 10, 2015, 3:54 p.m.
An arbitration panel sided with UPMC over rival Highmark
Inc. in a $188 million contract dispute related to cancer care
payments, according to documents UPMC filed Tuesday with a
municipal regulator.
READ MORE
CLICK HERE
CLICK HERE
THE POHMS NEWSLETTER - DEC 2015 - Issue 23 Page 13
CLICK HERE
HOME
Provider Resource Center Update
Highmark continues to bring innovative products to the marketplace, with a
strong brand and strong networks. We've created this page to give you, our
network providers, convenient access to summary information on our product
lines for 2016, for both Commercial and Medicare Advantage. See links below,
and please share this information with your administrative, billing and clinical
staff. Thank you, as always, for your ongoing support and commitment to
serving our members.
OTHER
PAYER
UPDATES
Most Recent Issue …CLICK HERE

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2016 Commercial Products Summary- Coming Soon!
2016 Medicare Advantage Products Summary
NEW!
NEW!
A Few Articles
You Won’t Want to Miss:
A Few Articles You Won’t Want to Miss:

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UnitedHealthcareOnline.com Claim Reconsideration to be Retired
Reminder: Genetic Counseling Requirement Effective Jan. 1, 2016
Revision to Place of Service 22 and New POS 19
UnitedHealthcare Oxford Medical and Administrative Policy Updates
o Drug Coverage Guidelines
o Injectable Chemotherapy Drugs: Application Of NCCN
Clinical Practice Guidelines
o And more……
 Reminder: Chemotherapy Prior Authorization Requirement Effective
for UnitedHealthcare Oxford
And Much More…
DECEMBER Monthly Issue
Available HERE
THE POHMS NEWSLETTER - DEC 2015 - Issue 23 Page 14
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Updates to our National Precertification List…pg 1
o Effective 1/1/2016 - Includes: Temodar, Xeloda,
Cyramza, and Granulocyte
Precertification required for Medicare Part B immunologic
drugs…pg 2
Get precert forms on our website…pg 3
2015 Centers for Medicare & Medicaid Services compliance
requirements… pg 6
And Much More….
DECEMBER Northeast Region
Qtly Issue Available HERE
DRUG SHORTAGES –
HOME
If you are looking for a complete list of Drug Shortages from the FDA CLICK HERE.
OTHER
NEWS
RECENT FDA ONCOLOGY RELATED
APPROVALS/CHANGES

FDA approved elotuzumab (EMPLICITI, Bristol-Myers Squibb Company) in combination with lenalidomide and dexamethasone for the treatment of
patients with multiple myeloma who have received one to three prior therapies. More Information. November 30, 2015

FDA granted approval to necitumumab (PORTRAZZA, Eli Lilly and Company) in combination with gemcitabine and cisplatin for first-line treatment of
patients with metastatic squamous non-small cell lung cancer (NSCLC). Necitumumab is not indicated for treatment of non-squamous NSCLC. More
Information. November 24, 2015

FDA approved nivolumab (Opdivo Injection, Bristol-Myers Squibb Company) for the treatment of advanced renal cell carcinoma in patients who have
received prior anti-angiogenic therapy. More Information. November 23, 2015

FDA approved ixazomib (NINLARO, Millennium Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company Limited) in
combination with lenalidomide and dexamethasone for the treatment of patients with multiple myeloma who have received at least one prior
therapy. Ixazomib is the first approved oral proteasome inibitor. More Information. November 20, 2015

FDA granted accelerated approval to daratumumab injection (DARZALEX, Janssen Biotech, Inc.), administered as a single agent for the treatment of
patients with multiple myeloma who have received at least three prior lines of therapy, including a proteasome inhibitor (PI) and an immunomodulatory
agent, or who are double-refractory to a PI and an immunomodulatory agent. More Information. November 16, 2015

FDA granted accelerated approval to osimertinib (TAGRISSO) once daily tablets, AstraZeneca Pharmaceuticals LP, for the treatment of patients with
metastatic epidermal growth factor receptor (EGFR) T790M mutation-positive non-small cell lung cancer (NSCLC), as detected by an FDA-approved
test, who have progressed on or after EGFR tyrosine kinase inhibitor (TKI) therapy. More Information. November 13, 2015
Continued on next page…
THE POHMS NEWSLETTER - DEC 2015 - Issue 23 Page 15
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FDA approved cobimetinib (COTELLIC Tablets, Genentech, Inc.) for the treatment of patients with unresectable
or metastatic melanoma with BRAF V600E or V600K mutation, in combination with vemurafenib. Cobimetinib
is not indicated for treatment of patients with wild-type BRAF melanoma. More Information. November 10, 2015
OTHER
NEWS
HOME
Express Scripts to Calculate 'Blended' Drug Prices
(BioCentury) Nov 20, 2015 - Express Scripts Holding Co. CMO Steve Miller said the company will create a "blended price" for
drugs as part of its new indication-based pricing scheme. READ ARTICLE »
Helping Patients
Battle the
Financial Toxicity
of Cancer
Treatments
(Medscape Oncology) Nov 20,
2015 - In recent years, the
financial toxicity associated
with cancer treatments has
stepped out of the shadows
and into the spotlight.
READ ARTICLE (free
registration required) »
Ready for 2016 Medicare
Reimbursement Changes?
Changes under the 2016 Outpatient Prospective Payment
System (OPPS) and the 2016 Physician Fee Schedule (PFS)
final rules go into effect Jan. 1, 2016—just six weeks away. Is
your program or practice ready?
ACCC has tools to help. Read in-depth analyses of both rules
and listen to a recording of the Nov. 19 ACCC conference call
with legal experts Beth Roberts, Partner, and Beth Halpern,
Partner, Hogan Lovells, US LLP. CLICK HERE (login
required).
Payer and Policy Maker Steps
to Support Value-Based
Pricing for Drugs FREE
Peter B. Bach, MD1; Steven D. Pearson, MD
JAMA. Published online November 30, 2015
Prescription drugs is the only major category of
health care services for which the producer is
able to exercise relatively unrestrained pricing
power. By law, drug manufacturers can set the
price that Medicare and Medicaid programs pay
for new drugs….READ MORE
Read the Oncology Issues' detailed 2016 Oncology Coding &
Reimbursement Update from Cindy Parman, CPC, CPC-H,
RCC — available here online ahead of print.
ASCO in Action Brief: MACRA
How to decipher confusing ICD-10 codes
CLICK HERE TO READ ARTICLE
(ASCO in Action) Nov 13, 2015 - The Medicare Access and CHIP
Reauthorization Act of 2015 (MACRA) passed earlier this year, effectively
repealing the sustainable growth rate (SGR) and introducing comprehensive
changes in how Medicare pays physicians for services.
THE POHMS NEWSLETTER - DEC 2015 - Issue 23 Page 16
READ PRESS RELEASE
Reimbursement Questions & Answers
HOME
If you have reimbursement questions you need answers to, please submit them to
pohmsbilling@gmail.com
FAQ’S
QUESTION: We are a private practice that was purchased by the hospital. I am not sure if we need to use the new place of service
codes for our claims. How do I know?
ANSWER: This is challenging to answer without knowing more about your practice. You will also need to check with your legal counsel. Generally, if
you are currently billing ALL your services on the CMS1500 form, including drugs and administration codes, then you are most likely a true private
practice. If you are billing the E & M services on the CMS1500 form and your administration codes and drugs on the UB04 claim form, they you are
most likely a “Provider Office Department” of the outpatient hospital and therefore would need to begin billing your CMS1500 E & M claims as a
position “19”, Off-Campus Outpatient Hospital. You do not use this place of service code on the non-E & M services, but you will need to append a PO
modifier on each and every line of service billed on the UB04 claim form. CLICK HERE for a reference to the Place of Service codes, CLICK HERE
for a reference to the PO Modifier.
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QUESTION: We’ve certainly heard the buzz about the off campus payments from Medicare going down. When is this going to happen? Does it begin
in 2016? How do we know if this affects us? Where can I find more information?
ANSWER: This change will be effective for Medicare payments beginning January 1, 2017. It will apply to hospital-owned physician practices
acquired or opened since the signing of the Bipartisan Budget Act of 2015 on November 2, 2015 AND farther than 250 yards from a hospital’s main
campus. If your hospital/practice arrangement was prior to the enactment of this law, then you will be grandfathered and this change will not affect you.
CLICK HERE for a good reference article on this subject.
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QUESTION: How do I go about getting a regimen added to NCCN Guidelines or Compendia so we can be reimbursed by Medicare for the service? I
can’t remember the process. Thanks so much.
ANSWER: Below you will find information on how to submit a request to have consideration of something added to NCCN;
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Reimbursement Questions & Answers
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Submission Requests
External parties are invited to submit requests for specific issues or topics to be discussed by the NCCN Guidelines
Panel. Examples of such parties include industry, clinicians outside the Member Institutions, patient advocates, and/or
payers. Requests must be submitted at least 3 weeks prior to the scheduled Panel meeting for the specific NCCN
Guidelines to allow for the Panel Chair to review the content of the requests and for the submission materials to be distributed to the
Panel Members, as needed. Information on the Submission Requests process for external parties is available on the NCCN
website.
As part of the NCCN practices to ensure transparency, the changes to recommendations for use of drugs and biologics requested in
the Submission Request are listed in the transparency document along with the actions taken by the Guidelines Panel. Additionally,
the original Submission Request materials are posted to the NCCN website at the time of posting of the transparency document.
CLICK HERE to link to that page of NCCN and the explanation about the panel, etc.
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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
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QUESTION: We are VERY nervous billing for any visit on the same day as chemotherapy because of the modifier 25 abuse issue. What is the safest
way to document the “separately identifiable” visit and be able to bill?
ANSWER: My recommendation would be to CLEARLY document the reason you would charge for a visit above what is already paid for when billing
for a chemotherapy administration. The initial infusion code includes a minimal exam to evaluate the patient to make sure they are clinically able to
receive chemotherapy, “affirmation of care”. For example the minimal exam could include; a minimal exam, review of labs, decision to proceed with
treatment, etc. Having a physician face to face with the patient vs a nurse doesn’t make it ok to bill for this service. If the patient is being evaluated for
something unrelated to the infusion, then the “chief complaint” or reason for visit should clearly reflect that and the “Medical Decision Making” portion
THE POHMS NEWSLETTER - DEC 2015 - Issue 23 Page 18
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Reimbursement Questions & Answers
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of the note should be related to that unrelated condition. Additionally, the level of service billed should ONLY be related to the
“additional” work performed.
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QUESTION: If a patient comes to the office and just talks with the doctor to decide what they are going to do next, can we bill for the visit?
ANSWER: Yes you can, you would score this visit based on the time the physician spent face to face with the patient counseling and coordination of
care. You will use the E & M codes, (99212 – 99215) and choose the code that coordinates the amount of time spent. The physician MUST document
1) total amount of time spent counseling and coordinating care face to face with the patient 2) that more than 50% of the visit was spent counseling and
coordinating the care 3) a summary of what was reviewed/discussed. If any of the 3 are missing in the documentation, the note cannot be scored based
on time. Below is a reference from a CMS Transmittal #178:
“A cancer patient has had all preliminary studies completed and a medical decision to implement chemotherapy. At an office visit the
physician discusses the treatment options and subsequent lifestyle effects of treatment the patient may encounter or is experiencing. The
physician need not complete a history and physical examination in order to select the level of service. The time spent in
counseling/coordination of care and medical decision- making will determine the level of service billed. The code selection is based on
the total time of the face-to-face encounter or floor time, not just the counseling time. The medical record must be documented in
sufficient detail to justify the selection of the specific code if time is the basis for selection of the code.”
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QUESTION: Can a midlevel provider (NP OR PA) bill Medicare using their own NPI when they supervise chemotherapy as long as they are acting
within their “scope of care”. Are they allowed to bill for the work the nurses do – “incident to” a midlevel provider?
ANSWER: Thank you for your patience while I researched this matter. I also consulted with our Policy staff before sending this response. The
licensed/enrolled midlevel provider, acting within his/her state scope of practice, may act as the supervising physician when ancillary staff is
administering chemotherapy based on the initial physician's order/plan of care. Of course, all incident to criteria would need be met and the midlevel
provider must be working with their legal scope of care. The service would be billed by the midlevel provider.
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QUESTION: We have a patient who is in hospice. The patient (and the family) now want to continue chemotherapy treatment. Will Medicare still
reimburse
us for the
chemo?
THE POHMS
NEWSLETTER
- DEC 2015 - Issue 23 Page 19
DIAMOND LEVEL
CORPORATE
ALLIES
GOLD LEVEL
SILVER LEVEL
THE POHMS NEWSLETTER - DEC 2015 - Issue 23 Page 20
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We hope you enjoyed this month’s issue!!
POHMS
PAGES
Our Mission
POHMS strives to bring best practices to oncology
hematology members through professional education,
network development and availability of accessing the
benefits of volume drug purchasing through CHOC,
POHMS GPO.
POHMS Committees
Programs Committee
CHAIR: Roxanne Alessandroni
Reimbursement & Coding Committee
CHAIR: Maryann Wingate
Legislative Committee
CHAIR: Diane Carter
Membership/Membership
Development Committee
CHAIR: Diane Minter
CO-CHAIR: Ellen Bauer
Vision Statement
The Premier Oncology Hematology Management Society
(POHMS) aspires to be the leader of educational resources
and a valued partner among oncology healthcare
professionals.
POHMS Board of
Directors
Executive Committee
Maryann Wingate
President
Mary Lois Moss
Vice President
Diane Carter
Secretary/Treasurer
Values Statement
At POHMS, we are committed to the highest standards of
ethics and integrity and strongly believe that we are
responsible to our members, stakeholders, and to the
communities we serve. As a part of our responsibility, we
strive to create an environment of continuous learning and
improvement in the oncology hematology industry.
We are passionate about the success of our members. Our
driving innovation and commitment to personal and
professional development makes an invaluable resource.
Educational programs and professional meetings help
foster a network of growth, support, and collaboration.
The sharing of ideas and trends enable POHMS to
continue to build upon our tradition of innovation.
THE POHMS NEWSLETTER - DEC 2015 - Issue 23 Page 21
Board Members
Roxanne Alessandroni
Kim DiStasio
Ellen Bauer
Lorey P. Keeney
Diane Minter
Naren Srivastava