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Journal of Oncology Practice, Vol 2, No 2 (March), 2006: pp. 72-a-73 © 2006 American Society of Clinical Oncology. DOI: 10.1200/JOP.2.2.72-a
Q&A From ASCO's Coding and Reimbursement HotlineThe 2006 Oncology Demonstration Project implemented by the Centers for Medicare & Medicaid Services (CMS) is substantially different from the 2005 Chemotherapy Demonstration Project. Like the 2005 Demonstration, the 2006 Project is voluntary and is open to office-based oncologists and hematologists. The 2006 Demonstration Project provides payment to physicians if certain information is collected and reported to CMS and if the patient has a diagnosis of female breast cancer, colon cancer, rectal cancer, prostate cancer, lung cancer, gastric cancer, esophageal cancer, pancreatic cancer, ovarian cancer, head and neck cancer, non-Hodgkin's lymphoma, chronic myelogenous leukemia, or multiple myeloma. The information being collected by CMS refers to the nature or focus of the patient visit, the physician's adherence to established medical guidelines, and the current disease state of the patient. CMS recognizes guidelines published by ASCO and the National Comprehensive Cancer Network (NCCN) under the 2006 Demonstration Project.ASCO has received numerous questions relating to the 2006 Project. Here are a few of the most commonly asked questions. Q: What happened to the 2005 Demonstration Project? Are the symptom codes from 2005 still valid? A: The 2005 Demonstration was applicable for services performed on or after January 1, 2005, through December 31, 2005. The symptom management codes, G9021-G9032, used for the 2005 Demonstration Project have been deleted, and therefore cannot be reported for services performed after December 31, 2005. Q: What are the new Demonstration Project codes and where can I find them? A: The new codes for the Demonstration Project fall into three categories. The categories and the corresponding codes are
Q: Does a chemotherapy treatment have to be provided in order to bill for the 2006 Demonstration Project? A: No. The focus of the 2006 Demonstration Project is on the patient's visit and current disease state along with the physician's adherence to published medical guidelines. An established patient visit (level 2, 3, 4, or 5) must be furnished in order to be eligible for the additional payment of $23. (Providers will receive 80% of the payment from the Medicare intermediary, and the patient is subject to the 20% Medicare copay.) There is no requirement that the patient encounter be related to chemotherapy. Q: Medicare identified certain cancers that are eligible under the 2006 Demonstration. Did Medicare identify specific diagnosis codes that correspond with the cancers? A: Yes. In Program Transmittal 36, Medicare lists the approved diagnosis codes for each cancer:
If a patient has a primary cancer diagnosis that is not listed, the evaluation and management services provided to that patient will not be eligible for the Demonstration Project. CMS Transmittal 36 can be found at http://www.cms.hhs.gov/transmittals/downloads/r36demo.pdf Q: I've heard conflicting information on whether or not a mid-level provider is eligible for the 2006 Demonstration Project. Can you provide some clarification? A: Instructions for the Demonstration Project, found in CMS Transmittal 36, state that mid-level practitioners who bill the Medicare program independently are not eligible to participate. However, it is ASCO's interpretation that services provided by a mid-level practitioner billing under Medicare's "incident to" guidelines are eligible for the Demonstration Project. Q: How should information on the Demonstration be documented in the medical record? A: The patient record must include documentation that includes the reporting of the appropriate G-code for (a) primary focus of visit, (b) current disease status, and (c) adherence to guidelines. Physicians must also document the source of the clinical practice guideline, though the title of the guideline is not required. CMS suggests using phrases, like the ones listed below, to document the source of the guideline.
Q: Does the 2006 Demonstration Project apply to services provided in the hospital setting? A: CMS Transmittal 36 states that service must be provided in the office setting. This would be reported using site of service code 11. Q: The 2006 Demonstration Project seems much more complicated. Has ASCO created any tools to help physicians participate? A: Yes. ASCO has created a Web site containing summaries and documentation tools for members who would like to participate in the 2006 Oncology Demonstration Project. The Web site is www.asco.org/2006demo. The site currently contains a detailed Frequently Asked Questions document and a listing of the ASCO and NCCN guidelines. Sample documentation templates for each of the specific diagnoses and synopses of guideline recommendations relevant to the Demonstration Project are also housed on the site. CMS guidance related to the Demonstration Project is on the site, as well. Figure 1 (available online at www.jopasco.org) provides a sample documentation template. NCCN has also posted some tools related to the 2006 Demonstration Project on its Web site. The information can be accessed from the NCCN home page at www.nccn.org. If you have a question relating to the Demonstration Project, call ASCO's Coding and Reimbursement Hotline at 703-299-1054.
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Copyright © 2006 by the American Society of Clinical Oncology, Online ISSN: 1935-469X. Print ISSN: 1554-7477
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