Audit Forms We Do Not Like

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Here are three forms (2 pages each) that are currently being utilized in medical oncology audits – which we believe to be illegal. While these forms may be approved for use in certain specialties, they are not approved for auditors to utilize when performing oncology audits.

These forms are also being shared by certified coders in the classroom at schools and during educational coding seminars across the country – which we have discouraged.

If your practice gets audited and any of these forms are used, we suggest that you question the auditor and take immediate action. Contact ASCO as well as the AMA, and let them know. You can also contact Neltner Billing and Consulting.

Just click Here to download and view these forms.

Meaningful Data

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Medical Oncologists need to begin a process to define the value of meaningful data through the office note. Check out our latest Billing Brief newsletter that addresses the business of oncology drugs and how it relates to meaningful data. This is Part I in a series.

House and Senate Delay Physician Medicare Pay Cuts

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Both the Senate and the House of Representatives have voted to delay a 25% Medicare pay cut to physicians. Read the Reuters full article.

Oncology Practice Management Podcast Series: Value in Oncology

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Physicians and patients have one definition of value, while insurance companies have another. But, where has this disconnect come from? Oddly enough, not just oncologists, but many specialists may be under-coding for fear of audits. They therefore underutilize the level of complexity they are allowed.

While this situation is bad enough, it has even more far reaching negative implications in the use of EMR systems. It’s time to face the auditors and change the system before it’s too late.

Listen to Ron Piana with CancerNetwork.com interview Marty Neltner in the first installment of the Oncology Practice Management Podcast Series, “Value in Oncology.”

A Plea for New Coding

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Coding flaws are causing big problems for oncologists across the country. You know it, we know it. Improper and decreased reimbursements are leaving little choice but for small practices to close. Other practices are in debt to drug distributors to the tune of millions of dollars. Physicians are forced to seek other sources of revenue such as joint ventures with imaging centers. All of this inevitably increases costs to the healthcare system, the very thing we are supposed to be decreasing.

We're armed with data proving our argument that the current codes are inadequate. Read more about our "Plea for New Coding" in the current issue (May 2010) of Community Oncology.

Flaws In Medicare Coding Interpretations

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

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

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

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

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

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

What should we do to fix this situation?

AMA Rejects Request For New Hem/Onc CPT Codes

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

Unfortunately, the CPT Panel rejected our requests for the following reasons - with which we disagree:

1. They feel the existing E/M codes adequately describe physician services.
   
   
2. They feel our proposal lacked specialty society support. 

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

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

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

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

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

Where do we go from here?

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

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

Stay tuned.

Neltner Abstract Accepted by ASCO

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Neltner Billing and Consulting is honored that the American Society of Clinical Oncology accepted our abstract, "An Examination of Oncology Drug Purchasing Compared to Average Sales Price" for online posting. You can view the full abstract on the ASCO website.

Persistence Pays Off: A Success Story Worth Discussing

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On behalf of a client, we have a great success story to report. One of our oncology clients was having continued denials with a large private pay insurance company. Regarding this particular situation, the oncologist was following AMA coding guidelines, however, the insurance company did not agree. The issue at hand was relative to CPT 96413, used for initial drug infusion, along with CPT 96416, used for chemotherapy administration via IV infusion (when patients are sent home with a pump).

The physicians were doing chemo and charging the administration and chemo fee. The insurance company told them only one charge could be "initial", and that they would not be able to bill these codes together on the same day for the same patient. This started in October of 2006. They received continued denials. We exhausted the official appeals process for this physician. We then participated in a conference call with the insurance company and their legal department. The results of that call were still negative. We provided them with more information and documentation.

Fast forward a year later. They reversed their decision. We won. The oncologist won. Reimbursements will be made retro to January of 2006. This was a huge win for a solo practitioner. Persistence pays off.

If you have success stories please let us know what they are. We will share them.

Reality is in the Results, and It Is No Surprise: Your ASP Tallies

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In a recent Neltner News article, we asked for you to complete our short ASP "worksheet". We've had several responses from oncology/hematology practices, comparing what they are paying to the Medicare allowable. The results? No surprise: most physicians are paying way too much. We will continue to update this as we get more data from hematologists/oncologists across the country.

Now that you see the data, is it reality or myth that:

• Oncologists cannot purchase drugs at ASP or lower.
• Oncologists have been misled by industry representatives that oncologists are purchasing drugs at or below ASP.

The answer is reality, and you are proving it in your numbers. The table shows that most payments are red and blue. Red numbers denote payments of ASP+6% or higher; blue numbers denote payments between ASP and ASP+6%. There are few numbers in black which actually fall below ASP. Average costs are ranging from ASP + 3% to ASP + 22%.

Thank you for the responses we have received so far and please keep them coming. It is clear from what we have collected so far, that ASP is flawed. The more data we can collect, the stronger we will be in lobbying for change. The data, the reality, cannot be ignored.

See the data we've collected.

For more information contact us:
Neltner Billing and Consulting
6463 Taylor Mill Road
Independence, KY 41051
888-635-8637
info@neltnerbilling.com