Oncology & Hematology Coding Alert

For final fee amount, consider conversion factor and geographic differences, too.

A second look at the amount of time nurses spend on chemotherapy infusion services yielded good news for your practice’s bottom line. Here’s what you can expect for IV infusion code 96413 and pump infusion code 96416 in 2013.

Start With the RVU Facts

The two codes in focus are below:

96413, Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug

96416, Chemotherapy administration, intravenous infusion technique; initiation of prolonged chemotherapy infusion (more than 8 hours), requiring use of a portable or implantable pump.

For these codes, Medicare kept the 2013 physician work relative value units (RVUs) and malpractice RVUs consistent with 2012. But the non-facility practice expense (PE) RVUs see a bit of a hike in 2013:

The increase in RVUs means in 2013 you can expect an extra $4 to $5 per service over what you would have received if RVUs stayed at 2012 levels. Although $4 may not sound like much, the per-service increase will add up over time. (Note: The dollar amounts are based on a rough calculation of the 2013 conversion factor multiplied by total RVUs. The actual formula for calculating reimbursement is discussed in more detail below.)

Learn What’s Expected for Those Increased RVUs

The PE RVU increase acknowledges the pre-service time required for these infusion services.

In deciding the 2012 PE RVUs, Medicare opted not to include 6 clinical labor minutes the AMA Relative Value Scale Update Committee (RUC) had recommended. CMS usually includes pre-service minutes for codes with global periods, and the infusion services don’t fall in that category.

The 2013 Medicare Physician Fee Schedule (MPFS, final with comment period) reveals that "commenters suggested that the recommended times for these tasks reflects the time for the oncology nurse to document the upcoming chemotherapy session based on the physician’s orders, coordinate the service under the physician’s direction, ensure that the planned infusion is consistent with physician’s direction, and confirm that there is no change in the drugs to be infused, anti-emetics to be supplied, or post-treatment instructions."

Additionally, the MPFS states that the pre-service time for pump code 96416 needs to take into account that 96413 is typically reported on the same day as 96416, so there’s some overlap in the nurse’s time on the 96413 and 96416 services.

Bottom line: CMS agreed that more nurse time should be factored into the PE RVUs for 2013. CMS included an additional 6 minutes of clinical labor pre-service time for 96413 and an additional 11 minutes in the service period for 96416.

Calculate the Impact for Your Practice

To understand the effect the PE RVU increase will have on your 2013 reimbursement, you have to remember that RVUs are only one piece of the reimbursement puzzle. Final payment is calculated by multiplying the RVUs by the conversion factor at a rate specific to your geographic area.

Conversion factor: The 2013 conversion factor (CF) is 34.0230, which isn’t too far from 2012’s 34.0376. Originally, a 25.0008 CF had been proposed, but, in what seems to have become an annual tradition, Congress voted at the last minute to prevent the cut. "This patch temporarily alleviates the problem, but Congress’ work is not complete," said AMA president Jeremy Lazarus, MD, in a statement. "It has simply delayed this massive, unsustainable cut for one year. Over the next months, it must act to eliminate this ongoing problem once and for all."

The outcome is important because the final CF makes a big difference in your income. The examples below demonstrate how to multiply the CF by the total RVUs to get a code’s national rate.

96413: If you multiply the sum of 96413’s 2012 non-facility RVUs by the 2012 CF, the equation is 4.07 x 34.0376 = $138.53. So 96413’s 2012 national rate was $138.53.

For 2013, you multiply the increased RVUs, 4.21, by the 2013 CF, 34.0230, to get $143.24. If RVUs had stayed at 2012 levels, 96413’s national rate would have been only $138.47 because of the slightly lower CF.

96416: Similar calculations for 96416 reveal a national rate of $138.19 in 2012 compared to $142.56 for 2013. If the RVUs hadn’t increased for 2013, the fee would have been $138.13.

GPCI warning: The national rate gives you a rough idea of a code’s reimbursement level. But to see what payment your practice can expect, you also need to factor in geographic practice cost indices (GPCIs). Medicare establishes a GPCI for each payment locality based on cost differences from area to area. GPCIs are divided into the same categories as RVUs: work, PE, and malpractice (MP).

A non-facility fee calculation follows this equation:

Non-Facility Pricing Amount = [(Work RVU x Work GPCI) + (Non-Facility PE RVU x PE GPCI) + (MP RVU x MP GPCI)] x CF.

MPFS online: CMS posted the 2013 Physician Fee Schedule information (final with comment period) at www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1590-FC.html.