Implementing Medicare and
Commercial Insurance Coding
Changes in 2006
Patricia Falconer, MBA
President, Health Options
650-949-2526 phone
650-745-1122 fax
Healthoptions@worldnet.att.net
Strategies For 2006
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Financial Issues
Medicare Demonstration Project
Fee Schedule Management
Operations
Financial Issues
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Plan for Reduced Cash Flow
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Medicare Revenue Loss from Elimination of 2005
Demonstration Project
Medicare Revenue Loss from 3% Reduction in
Administration CPT Codes
Delays in Medicare payments due to 1/17/06
implementation date for Demonstration codes
Fee Schedule Reductions from Commercial PPO
Insurance Plans
Medicare Demonstration
Project 2006
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Should you participate?
How to facilitate the billing process
Documentation Requirements
Demonstration Project
Philosophy
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“The project builds on the use of G-codes to gather
more specific information about patients with
particular types of cancer, including information about
the primary focus of the visit and the spectrum of
care that you provide. It will emphasize practice
guidelines as the source for standards of care,
permitting CMS to monitor and encourage quality
care to cancer patients, and to identify and promote
best cancer care practices that should lead to
improved patient outcomes”.
MediLearn Matters Number SE0589
Effective Date 1/1/06
Demonstration Project
Revenue Projection
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Calculate the total Number of 99212-99215
visits in 2005.
Estimate the percentage of Medicare patients
in the practice.
Estimate the percentage of visits representing
the 13 major diagnostic categories.
Multiply each element above and then
multiply the number by $23.00
Implement A New Superbill
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Add all Codes on Superbill.
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This will require a two page superbill.
First page: E & M codes, Procedure Codes, GCodes, and Lab
Second page: 2006 Administration CPT codes,
supplies, and J-Codes for drugs. G-Codes and
2004 CPT codes may be required for specific
contracts.
Patient insurance must be on the superbill
Update all new CPT and J-Codes
Lung Cancer
(162.2 – 162.9)
G9063
NSCLC, Stage I, Stable
G9064
NSCLC, Stage II, Stable
G9065
NSCLC, Stage IIIA, Stable
G9066
NSCLC, Stage IIIB-IV or Progression
G9067
NSCLC , Unknown, NOS
G9068
SCLC Limited
G9069
SCLC Extensive or Progression
G9070
SCLC Extent Unknown
Breast Cancer
(174.0 – 174.9)
G9071
Breast Stage I-II or T3, N1, M0, ER/PR +, Stable
G9072
Breast Stage I-II or T3, N1, M0, ER/PR -, Stable
G9073
Breast Stage III not T3, N1, M0, ER/PR +, Stable
G9074
Breast Stage III not T3, N1, M0 ER/PR -, Stable
G9075
Breast M1 or Progression
G9075
Breast Extent Unknown NOS
Prostate Cancer
(185)
G9077
Prostate T1-T2C Gleason 2-7 and PSA < 20 Stable
G9078
Prostate T2 or T3A Gleason 8-10 or PSA > 20 Stable
G9079
Prostate T3B-T4 Any N Any T N1 Stable
G9080
Prostate Rising PSA or Lack of Decline after Initial
Treatment
G9081
Prostate M1 at Diag or Metastatic, Non-Castrate
G9082
Prostate M1 at Diag or Metastatic, Castrate
G9083
Prostate, Extent Unknown NOS
Colon Cancer
(153.0 – 153.9)
G9084
Colon T1-3, N0, M0, Stable
G9085
Colon T4, N0, M0, Stable
G9086
Colon T1-4, N1-2, M0, Stable
G9087
Colon M1 or Recurrent with evidence of disease
G9088
Colon M1 or Recurrent with no evidence of disease
G9089
Colon Extent Unknown NOS
Rectal Cancer
(154.0, 154.1)
G9090
Rectal T1-2, N0, M0, Stable
G9091
Rectal T3, N0, M0, Stable
G9092
Rectal T1-3, N1-2, M0, Stable
G9093
Rectal T4 Any N M0 Stable
G9094
Rectal, M1 or Recurrent
G9095
Rectal Extent Unknown NOS
Esophageal Cancer
(150.0 – 150.9)
G9096
Esophageal T1-3, N0-1, or NX, Stable
G9097
Esophageal T4, Any N, M0, Stable
G9098
Esophageal M1 or Recurrent
G9099
Esophageal Extent Unknown NOS
Gastric Cancer
(151.0 – 151.9)
G9100
Gastric Post R0, Resectable, Stable
G9101
Gastric Post R1-2, Resectable, Stable
G9102
Gastric M0, Unresectable, Stable
G9103
Gastric M1 or Recurrent
G9104
Gastric Extent Unknown NOS
Pancreatic Cancer
(157.0 – 157.3, 157.8 – 157.9)
G9105
Pancreatic Post R0, Resectable, Stable
G9106
Pancreatic Post R1-2, Resectable, Stable
G9107
Pancreatic M1 or Recurrent
G9108
Pancreatic Extent Unknown NOS
Head & Neck Cancer
(140.0 – 140.9, 161.0 – 161.9)
G9109
Head/Neck T1-2, N0, M0, Stable
G9110
Head/Neck T3-4 and/or N1-3, M0, Stable
G9111
Head/Neck M1 or Recurrent
G9112
Head/Neck Extent Unknown NOS
Ovarian Cancer
(183.0)
G9113
Ovarian Stage IA-B Grade 1, Stable
G9114
Ovarian Stage 1A-B Grade 2-3 or Stage 1C All Grades or Stage II Stable
G9115
Ovarian Stage III-IV, Stable
G9116
Ovarian Progression, Recurrence, Plat Resistant
G9117
Ovarian Extent Unknown NOS
Non-Hodgkin’s Lymphoma
(202.00 – 202.08, 202.80 – 202.98)
G9118
NHL Stage I-II Not Relapsed Not refractory
G9119
NHL Stage III-IV Not Relapsed Not Refractory
G9120
NHL Trans to Diffuse Large B-Cell Lymphoma
G9121
NHL I-IV Relapsed/Refractory
G9122
NHL I-IV Possible Relapse or Non-response or Not listed
Chronic Myelogenous
Leukemia (205.10, 205.11)
G9123
CML Chronic Phase Not in Remission
G9124
CML Accelerated Phase Not in Remission
G9125
CML Blast Phase Not in Remission
G9126
CML in Remission
G9127
CML Extent Unknown NOS
Multiple Myeloma
(203.00, 203.01)
G9128 Multiple Myeloma Smoldering Stage 1
G9129 Multiple Myeloma Stage II or Higher
G9130 Multiple Myeloma Extent Unknown NOS
Educate Providers
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Physicians and Nurse Practitioners who
bill as “incident to”
Use Resources
Educate Billing Staff
Set up Charge Entry and
Documentation Audit System
Documentation Requirements
Primary Focus of Visit
G9050 – G9055
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Progress note section, chief complaint or
primary reason for visit, should match G-Code
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Work-Up Evaluation
Treatment Decision/Management
Surveillance for Disease
Expectant Management of Patient
Supervision Palliative
Other- Visit Unspecified
Documentation Requirements
For Guideline Adherence Codes
(G9056 – G9062)
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Must Document Source of Guideline
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ASCO
NCCN
Both
No Guideline Available or None
Clinical Trials
Documentation Guidelines
Current Disease State
G9063- G9130
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Choose the single G-Code that best
represents the disease status based on
the best available data at the time of
service
G-Code selected must match ICD-9
code
Staging should be documented in
progress note
2006 Fee Schedule- Medicare
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US House of Representatives passed a federal budget
package that stopped the 4.4% Medicare cut in
December 2005 but could not obtain final approval
before the holiday break. CMA and AMA are now
working with congress to pass the payment “freeze”.
Practices should use billed charges or the 2005
Medicare fee schedule for dates of service in 2006
except with the new administration CPT codes.
The new administration CPT codes will be paid using
the 2006 fee schedule. These codes are not part of
the “freeze”.
If Congress Freezes 2006 Medicare
Payments at 2005 Rates...
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Medicare carrier will have 2 business days to begin to
automatically reprocess claims that were paid under
the 4.5 % conversion reduction.
Payments will be issued in one lump sum by July
2006
Additional Medicare payments will increase patients
co-payments if they do not have secondary insurance
Decision to recover co-payments from patients is up
to the individual practice
Waiving co-payments due to the change in
conversion factor would not be viewed as an
“inducement”
Fee Schedule- PPO
Commercial
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Lower Contracted Reimbursement Rates for 2006
Administration CPT Codes
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Blue Shield of California PPO Default Fee Schedule
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Blue Cross Prudent Buyer PPO Default Fee Schedule
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Average of 30% Reduction
Average of 33% Reduction
Monitor PPO Plans rate changes through their
websites
Electronic Claim Clearing House Edits
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Can you submit 2004 CPT codes or 2005 G-codes if your
payer contracts require them?
Commercial Default Fee
Schedule Change Examples
CPT 2006
CPT 2005
2006
Allowable
2005
Allowable
2006 Medicare
Allowable
G0357
$117.66
$186.12
$173.95
96408
$173.95
$236.88
$173.95
Blue Cross
Prudent
Buyer PPO
96409
Blue Shield
PPO
96409
Fee Schedule - HMO
Commercial
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HMO Plans
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Take this opportunity to renegotiate your IPA HMO
contracts to include 2006 CPT codes.
Find out if your IPAs carved out the financial
responsibility for drug reimbursement for 2006
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Who pays you for drugs and procedures for each health
plan?
What rate?
Any other changes?
Managing Drug Purchasing
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Compare Quarter 1 2006 ASP with your current
practice acquisition costs
Manage your drug distributors
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Use Distributors Website for Drug Purchasing
Monitor price changes with each order
Order from multiple distributors
Review drugs within therapeutic classes to maximize
purchase power
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Growth Factors
Antiemetics
Bisphosphonates
Operations
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Implement Automated Functions wherever
possible
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Electronic Claim Submission for all payers that will
accept them. Can your software submit three digit
units?
Electronic Remittance
Electronic Patient Statements
Reduce Accounts Receivable days to match or
beat drug distributor payment terms
Resources
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www.anco-online.org
www.asco.org
www.nccn.org
www.medicarenhic.com
www.bluecrossca.com
www.mylifepath.com
www.cigna.com
www.aetna.com
www.unitedhealthcareonline.com
www.practicemanagerinsider.com
www.caring4cancer.com