Urology Coding Alert

Presented by Michael A. Ferragamo, MD, FACS

The following supplement to Urology Coding Alert is the transcript of a teleconference presented by The Coding Institute. To obtain the slides for the conference, please log on to our Online Subscription System at http://codinginstitute.com/login and open the PDF version of the current issue, and the slides will be contained therein. If you’re not sure how to use the Online Subscription System or need help opening the issue, please contact our customer service department at 1-800-508-2582 or service@medville.com, and one of our representatives will be able to assist you.

The speaker for the teleconference, Michael A. Ferragamo, MD, FACS, is the former chief      of Urology of Hempstead Medical Center and of Franklin Medical Center of Long Island, New York. He is currently assistant clinical professor of Urology at the State University of New York, Stony Brook School of Medicine. Ferragamo is a consultant on coding and reimbursement for the Physicians Reimbursement Systems (PRS) in Denver and is a Consulting Editor for Urology Coding Alert.

Thank you very much Erika and good morning to all our loyal subscribers and my friends.  I welcome you to this conference.  I hope that you have all received the handout with a copy of the slides that we will be using during this presentation.  Each page will contain two slides. 

Page 1, slide 1.  I would like to start off this teleconference speaking a little bit about the current coding for hormonal treatment of prostatic cancer as a lead-in to the Critical CAP (Competitive Acquisition Program) for Your Urology Practice.  Is this CAP program something that you will want to institute for your office?

Page 1, slide 2.  This slide shows us the 2005 Medicare CPT Codes and fees for drug administration.  The G codes have replaced the 96400, 90780, and 90782.  The 2004 32% transitional increase that we enjoyed last year has been discontinued but in 2005 we have received a 3% transitional increase which will again be taken away from us in 2006.  The code 96400 that we used last year for the IM or subcutaneous administration injection code for Lupron, Zoladex, Trelstar and Eligard which was paying a standard or an unadjusted Medicare fee, unadjusted for the area or state in which you practice, paying $64.07 was changed in 2005 to G0356, paying in 2005 $36.69.  A significant drop of 43%. 

The code 90780 that we used in 2004 for our IV infusions up to an hour, and this is the code that urologists use for their infusion of Zometa.  This was paying an unadjusted fee last year of $117.80, and has been replaced by G0347 paying $79.24, a significant drop of 33% from 2004.  The code 90782 which is the other code that urologists use often for the IM or subcutaneous injections for things like testosterone, the androgens, maybe B12, Epogen injections was paying an unadjusted fee last year of $24.64.  This code has been replaced by G0351 paying $19.13 this year unadjusted.  Again, a significant drop from last year. 

Page 2, slide 1.  I wanted to show you the new 2006 CPT Codes that we will be using on and after January 1, 2006 for our drug administration.  The G0356 code will be replaced in 2006 by 96402.  G0347, the infusion IV will be replaced by 90765.  The G0351, the IM or subcutaneous injection of say androgen will be replaced by 90772. 

Page 2, slide 2.  I’m not sure that these are going to be the fees but certainly the fees are going to be around this when we see them come November.  These are the 2006 proposed Medicare fees for these injection therapies.  The 3% transitional increase has been discontinued and the fees that I have down are the drug administration fees of 2003, to which we will fall back to and be fixed at that level.  As you can see, for the new code 96402, we will be paid a little bit more than last year, very interestingly; but for the infusion codes and for the IM subcutaneous, G0351 we will be paid in 2006 substantially less both for the 90765 down 46% and 90772 down about 77%.

Page 3, slide 1.  The 2005 Medicare drug payment policy is based on the Average Sales Price, ASP.  The average ASP is determined by CMS which is Medicare, based on the manufacturer’s reported average sales price, in other words what the manufacturer is selling the drugs to the physician, to the drug store, to the hospital for.  And this would also include any perks for rapid or early payment or volume purchases.  Also this average sales price would be based on the J drug code average sales prices and also (we will be talking about this) the competitive acquisition purchasing prices.  It will take into consideration the least costly alternative policy.  Remember that the average sales price now is going to be quarterly reassessed and that the average sales price may change every three months. 

Slide 2, page 3.  The 2005 Medicare drug payments then will be based on this average sales price as determined from above plus a small increase of 6%, so the fourth quarter for this year 2005, beginning October 1, 2006, we will be paid for Lupron and Zoladex by Medicare $175.04 based on an average sales price of $165.13.  Remember that drugs like Lupron, Zoladex, Trelstar and Eligard are medically equivalent drugs as determined by many studies.  These drugs all will receive the same payment this quarter at $175.04.  This medically equivalent policy is called the LCA or the Least Costly Alternative policy.  Now most of the states in the United States do follow this Least Costly Alternative policy. 

Page 4, slide 1.  You will see five states that have not chosen to adopt the LCA methodology.  From left to right these are Montana, Minnesota, Wisconsin, Illinois is below that and to the right, the state of Michigan.  The other state outlined is the state of Utah which recently decided to temporarily suspend the LCA.  I am not sure but I think they have gone back to the Least Costly Alternative. 

Page 4, slide 2.  I have outlined the drug payments by Medicare for the fourth quarter, in other words October 1 through December 31, 2005.  The 2005 fourth quarter average sales price, to which 6% has been added, is based upon the second quarter 2005 average sales price data.  I have underlined Zoladex and Lupron which we will be paid a little bit less this quarter than we were last quarter--5.4% and 2.3% respectively.  However, in the Least Costly Alternative states we will receive for Lupron and Zoladex, and as we see for Trelstar, $175.04.  When Trelstar went under the Least Costly Alternative policy in the fourth quarter, as you can see the drop of payment from last quarter was about 53%.  For Zometa at the top of the list, not much of an increase, BCG not much of an increase and Mutamycin and Thiotepa had small increases for the fourth quarter.

Page 5, slide 1.  When we look at Viadur, leuprolide acetate implant 65 mg and Vantas, histrelin 50 mg, we see that the code for Viadur J9219, Medicare payment is a little bit more than it was in the third quarter.  But Vantas code J9999 for Medicare, as it fell under the Least Costly Alternative policy, went from over $3000 to $2371.75, a significant drop of 22%. 

Page 5, slide 2.  Of course, when we look at what we are reimbursed from the carriers and especially Medicare, of importance is what we are buying the drug for, the cost or the purchase prices.  I have listed for you in the third column; these are the best purchase prices available at this time.  As you can see, Lupron, Zoladex, Eligard, and Trelstar you should not be paying more than around $150 to $151 and change.  This will bring you a profit because Medicare pays you $175.04.  This will bring you a profit per month of between $23, $24, and $25.  The percentage of these profits will range between 15% and 16%. 

When we look at Viadur and Vantas, the purchase price or the cost are the prices when you buy rather large quantities of these drugs.  As you can see, the profit per month is $47.65 and $55.98.  The last column gives you the overall 12-month profit that you will make on these drugs if you buy them in large quantities.  Viadur, there is a 31.8% profit and Vantas has a 39.5% profit.  I have included Zometa at the top of the list in which a small profit is made.  BCG and Mutamycin, you can see the profit of 16.6% and 48.9%.  This is the kind of slide you are going to have to go back and look at to see if your office is buying and purchasing these drugs at these best prices available. 

Page 6, slide 1.  I would like to go over some of these codes in a little more detail.  Code G0356 is the IM or subcutaneous hormonal antineoplastic injection code for Lupron, Eligard, Zoladex, Plenaxis, and Trelstar.  This replaces the 96400 for 2005 and hopefully you have been using this code.  In 2006, this code G0356 will be replaced by the 96402.  The G0356 is only for office use and because the work value for the E/M service 99211 has been incorporated into the G0356, you will not be paid and should not bill the 99211 on the same encounter that you do a G0356.  However, with the other E/M services, the 99212 and 99215, if you bill those services--and these should be medically necessary and significant services--along with the G0356 you will be paid for the E/M services and the G0356 but modifier-25 must be placed on the E/M service to ensure payment. 

I have included the J codes for the drugs listed above and I have indicated that most private carriers in my findings have been using the G0356 for 2005. 

Page 6, slide 2.  When would you bill a 99212 or a 99215 with modifier-25 with the G0356?  If you make an assessment or judgment by asking the patient questions as to the response that they may or may not have had to a previous injection of say Lupron--asking the patient if they have had any adverse reaction, any allergic reaction, and adverse reactions to the drug--those questionings that you make and then your medical decision and judgment that you make to give the next dose does warrant a 99212 charge.  This slide shows documentation of that assessment for a second LHRH injection specifically for a 99212.  You can see that a chief complaint has been written in and various questions have been asked, and then the various drugs administered.  Making this assessment and making a judgment to give the next dose warrants at least a 99212 with modifier -25 billed at the same time that you inject the medication using the G0356.

Page 7, slide 1.  This is a Medicare explanation of benefits.  You see we billed a 99213 because we hadn’t seen the patient in several months.  This was an office visit and we added modifier-25 and you can see the fee we were paid in New York, $72.05.  This was carried out by the urologist or a PA with the urologist in the office.  We billed the J9217 the 3-month Lupron and the new administration code G0356. 

Page 7, slide 2.  This is a Medicare individual patient.  The patient had an evaluation and injection of Lupron/Zoladex by the non-physician provider.  No physician was present in the office, the drug was supplied by the office.  The billing would be exactly the same …quot; 99212 with modifier-25 for the evaluation and assessment to give the next dose.  The injection code G0356 and then either J code as the case may be.  Notice that the ICD diagnosis, certainly for Medicare, can be exactly the same for the three charges.  However, since this was administered by a PA or NP, a non-physician provider, the billing would be in the non-physician provider’s name and numbers and the payment would be 85% of the global.

Page 8, slide 1.  This is private insurance carrier.  The patient was evaluated and an injection of Lupron/Zoladex was administered by the nurse or the medical technician.  The urologist physician was in the office suite and the drug was supplied by the HMO.  The only code that one would be able to bill for this nurse or medical technician would be the administration code.  The G0356.  The nursing visit code 99211 is not billable as it is bundled into the G0356 and cannot be unbundled.  The EOB (Explanation of Benefits) below was a private insurance carrier showing that the private insurance carrier did accept the G0356 and paid $32.20 with a $10 co-pay. 

Page 8, slide 2.  Here we have the evaluation and injection of Lupron/Zoladex by the nurse or MT and only the PA or the non-physician provider is in the office suite, the urologist is not there.  Basically the coding would be the same, again you cannot bill the 99211 but because the supervision in the office had been provided by the non-physician provider such as the PA, the billing would be made in the NPP’s name and numbers and again, the payment would be 85% of the global. 

Page 9, slide 1.  We mentioned about the HMO or the carrier or the patient supplying the LHRH.  It is very important to report that on the 1500 form to insure payment of the G0356, the administration code, when no medication appears to be billed.  Under these circumstances, this information of the drug should be mentioned on the 1500 form in box 19.  As you can see in box 19, we indicate that the patient provides his own and we named the drug Zoladex and the dosage administered. 

Page 9, slide 2.  This is a Medicare carrier.  We have an evaluation and injection of Lupron/Zoladex by the nurse or MT.  Now in this case, neither the physician, the PA nor the non-physician provider is in the office.  The nurse and the medical technician are there alone.  For Medicare no charges can be made.  Neither can you make a charge for the injection, for E/M visit, or for the drug cost itself. 

Page 10, slide 1.  What about a commercial private insurance?  Let’s say the evaluation and injection of Lupron and Zoladex is performed by the NPP, and I would like you to add the word “nurse or medical technician” but no physician is present in the office.  This is a commercial private insurance.  You can see the billing and this billing has been performed under the general supervision of the physician.  That means that the physician must be nearby, he can’t be in the Virgin Islands or in Puerto Rico when his office is in Manhattan.  He must be only one-half hour away or a telephone or a pager away.  Under these circumstances, being paid under general supervision for a commercial or private insurance, this billing is performed and billed under the M.D. or urologist, the physician’s name and numbers, and you are paid at 100% global. 

Page 10, slide 2.  This is the infusion therapy for 2005.  This is the use of the code G0347, intravenous therapy for diagnosis or therapy up to one hour.  This replaces that 90780 for 2005 and next year you will be using the code 90765.  It is for an infusion intravenous of greater than 15 minutes and this is the code that we use for the infusion of Zometa zoledronic acid.  Now the indications for the use of zoledronic acid have changed a bit.  It certainly can be used for metastatic bone disease from carcinoma of the prostate and the ICD-9 code for the primary diagnosis would be 198.5 with the secondary diagnosis of 185 carcinoma of the prostate.  Now for osteoporosis induced by hormonal treatment, you may also use Zometa with the diagnosis of 733.09 for the osteoporosis but it is mandated that you also use as the secondary diagnosis 185 carcinoma of the prostate.  Again, you cannot bill a 99211 but you can bill the 99212 through the 99215, but to get them paid you must add modifier-25 to the E/M services. 

The code for the infusion of Zometa for the drug is J3487 that is for 1 mg, the proper dosage for administration is 4 mg so one would add 4 units in box 24G of the 1500 form. 

Page 11, slide 1.  What have urologists been doing because of these financial constraints in 2005?  Well, a few patients that have drug plans have received prescriptions for the drug from their physician, they have bought the drug at the drug store using their drug plan, bringing the drug to the office for administration.  A few patients have received the drug from hospital clinics where a hospital buys the drug.  I think most urologists are contracting carefully with drug suppliers.  What does that mean? 

Page 11, slide 2.  It is explained here.  That means that you should continue to try to purchase these drugs at the lowest possible price.  The purchase prices should be equal to but no more than the average sales price and remember that you should know the average sales price and know that it is going to probably change (which it has for this year) every 3 months or every new quarter.  That means that you should negotiate your purchase price every new quarter with your vendor or supplier and if you already have a contract with a supplier, you should definitely negotiate purchase contracts every three months. 

I think the most important thing you can do in 2005 is not to purchase these drugs in large quantities, try to figure out how many drugs you need for that quarter and that is the amount you should purchase.  Do not overstock or inventory.  In this constraining environment, you certainly cannot supply free drugs or severely discount the drugs that you administer. 

Page 12, slide 1.  The second thing that urologists are doing is paying close attention to the coding and billing.  Page 12, slide 2.  This indicates that the reason for that is that profits will be very narrow, so you must pay careful attention to accurate coding with the proper administration G code.  You should bill your E/M visit with modifier-25, at least a 99212 for the clinical assessment that you make, but make sure that is documented, and you should inform the patient of his payment responsibility for the co-pay and any of the deductibles that are present.  You should carefully scrutinize the patient’s secondary medical insurance to be sure that they are going to pay the deductibles and the co-payments.  If not, those charges certainly should be made to the patient. 

Page 13, slide 1.  What is going to happen in 2006?  This is what has been proposed.  The conversion factor as of the present time is going to fall 4.3% and the convergent factor then will be $36.27.  This is less than in 2004 when it was $37.40.  Interestingly, however, urology fees are going to increase 1.8% based on the fact that practice expense relative value units are going to go up in 2006.  Again, interestingly, the practice expense relative value unit’s increase will be predominantly for procedures done in the hospital.  This increase will decrease the overall urology revenue decrease and the overall urology revenues will decrease in 2006 approximately 2.6% if the above goes through.  Drugs may be supplied by a contracting vendor or agent in the CAP program--we are going to speak about in just a moment--or you will continue to buy them being paid the average sale price plus 6% and falling under the Least Costly Alternative if you are in the majority of those states.  Using a vendor, no drug revenues will flow to your office and drug administration charges look like they are going to be fixed at 2003 level. 

Page 13, slide 2.  Practice cost expenses are going to go up a minimum of 3.1% based on the Medicare Economic Index, the MEI for 2005.  There is a proposal that the conversion factor will fall 4% to 5% per year to year 2011 and this cumulative decrease by 2011 will be 26%.  In fact, the average payment rates for 2006 will be less than the payment that we received 5 years ago in 2001. 

Page 14, slide 1.  I would like to discuss now the Competitive Acquisition Program in light of what I just mentioned.  This Competitive Acquisition Program was mandated by the Medicare Modernization Act of December 2003.  The purpose of this was to remove from the physician all drug purchasing and associated financial burdens.  He would not have to buy the drugs.  Then it would also remove from the physician the problems associated with trying to get paid for the drugs from carriers and from the patient’s deductibles and co-payments.  In other words, taking all of this financial burden away from the urologist in purchasing drugs.  He would not purchase the drugs anymore. 

Page 14, slide 2.  Physicians presently purchase injectable medications from manufacturers, contracting vendors, or via a group contract.  They administer these medications to their Medicare patients in the office.  They bill Medicare Part B for the drugs and for its administration and then they have to collect deductibles and co-payments from the patients.  The physician’s problems with this present system are several.  Number one, there is often a large dollar layout for the purchase of many of these drugs.  Many offices cannot do that large purchase.  Medicare payments based on the average sales price of 6% are often insufficient for even a minimal profit when the physician must purchase and supply the drugs.  And any problems in collecting money from the patient in the form of deductibles or co-payments--if these are not made this leads to lower drug profits and may times to losses when the physician administers a particular drug to a particular patient. 

Page 15, slide 1.  A competitive acquisition program (CAP) enrolled physicians--if he enrolls in this plan, he chooses a vendor to provide drugs included on the CAP list for use in his office.  He no longer purchases these specific and special medications for Medicare patients.  They no longer charge Medicare for the medications and they only bill Medicare Part B for the cost of the administration of the drugs and then they are burdened only with collecting the deductibles and co-pays from the patients for, let’s say, the E/M service and the drug administration service. 

Page 15, slide 2.  The CAP-enrolled physician, however, must submit a written order to the vendor for each drug that he needs and orders.  He must have a prescription order number that comes from the vendor; he has to wait for this vendor’s order number for each drug dosage that he uses.  The CAP-enrolled physician must purchase all CAP drugs listed from one vendor.  All the listed drugs on the list--and we will see that list in a moment--must be purchased from one vendor.  The enrolled physician must remain in this program for one year.  However, he also must have a buy and sell system for non-Medicare patients.  Now for Medicare patients’ drugs that are not included on the CAP list, the urologist must buy these, bill Medicare, and be reimbursed at the average sale price of 6%. 

Page 16, slide 1.  Let’s look at some of the physician problems that he may have, or your urologist may experience when they join or if they enroll or join in the CAP.  These are administrative burdens and potential restrictions on the availability of drugs. 

Page 16, slide 2.  The administrative burdens.  The urologist or physician must submit extensive written orders for each medication.  This would include the patient’s name, address, and insurance information.  It would also include date of birth, height, weight, allergies, ICD diagnosis, and much more information than is usually required in just writing out a script.  The urologist must maintain the detailed log of all drugs obtained and administered and he must submit his claim for the administration to the local carrier within 14 days because the vendor will not be paid unless that claim is in.  Medicare has mandated that those claims from the urologist for the administration must be sent in within 14 days.  The urologist must provide the vendor with all the patient’s insurance information, whether it changes or not.  He must aid the vendor in appealing any denied claims or payments and what that ‘aid’ constitutes is not well clarified.  He must appeal all rejected drug administration claims.  If he has a claim for his drug administration that is rejected, he must definitely appeal that because the vendor cannot be paid unless the drug administration claim is paid. 

Page 17, slide 1.  Let’s look at potential restrictions on drug availability.  Now a vendor may not supply the drug for a financially delinquent patient.  In other words, if the patient doesn’t pay the vendor, he is not going to supply the urologist with the drug.  The vendor also may not include a stock a specific medication that the urologist may require.  The vendor may request the physician use what is available or use a less expensive drug.  I can see confrontations arising between the physician and the vendor over this type of situation.  The physician may have to provide stock drugs, in other words, he has to keep a stock of drugs in an emergency and then seek reimbursement from the vendor.  In a moment, that problem has been solved. 

Page 17, slide 2.  Other potential restrictions on drug availability.  Remember that the competitive acquisition program, the CAP, is only for Medicare patients, it has nothing to do with other carriers.  The urologist must consult with the vendor with what to do if a drug is administered, lost, or wasted.  Again, I can see confrontation.  The physician will have to administer a specific drug, in other words, he must administer a specific drug only on the day that that drug has been assigned and is in the intended location.  In other words, he cannot take the drug to the patient’s home and administer it to the patient in his home, or he can’t take that particular drug to another office and use it on another patient.  He cannot give it on another day or location.  He must have a new prescription drug order to each location and each day that he is going to administer the drug.   

Page 18, slide 1.  Let’s look at some comments and concerns.  All physicians will be eligible in 2006 to participate in this program.  That is a change and that is good.  However, CMS Medicare is going to phase in certain drugs over periods of time.  Again, vendors are not required to furnish a drug to a patient who has a poor payment history and all problem drugs--those are drugs in which your purchase price is greater than the average sales price--will not be included and vendors may not offer all drugs in a particular class. 

Page 18, slide 2.  Urologist’s liability.  These questions are still open.  Will a vendor share liabilities for drug errors?  Will the vendor share liabilities for missed drug administration?  Will the urologist be covered for drug spoilage?  These questions have to be addressed and answered. 

Page 19, slide 1.  CAP concerns.  Who will reimburse the urologist for the administration of a stock drug in an emergency when a vendor does not provide the drug?  That has been answered and we will talk about that in a moment. 

The other interesting thing is that there will no extra dispensing payments to the urologists for all this extra paperwork that he and his staff must accomplish and do. 

Page 19, slide 2.  We do have some answers.  What about routine providing/delivery of drugs?  This will occur within two business days at least in the states, Puerto Rico, and the Virgin Islands.  Within 7 business days if you happen to practice in Guam and Samoa.  What about emergency providing/deliver of drugs?  Within one business day, but you must order the drug before 3:00 p.m. the day prior. 

Page 20, slide 1.  For the physician coding and billing, three new modifiers for CAP use have been established.  Modifier-J1 is attached to a J drug code to indicate that the drug has been a Competitive Acquisition Program (CAP) supplied drug for which no charge payment is due. 

Page 20, slide 2.  This is a 1500 form showing that we billed a 99212 with modifier-25.  We also indicated that we gave a J9202 which is a Zoladex injection, J1 indicating that this was supplied by CAP so there is zero charge.  Then we billed the injection code 96402.  Now without the J code many carriers will not pay you for the 96402 not knowing what particular drug is administered.  If you get the drug from the CAP you will put the drug that you gave in the billing, add the modifier J1 which will indicate that this was a drug supplied by the CAP program for which there is no charge as indicated on the charges which is zero. 

Page 21, slide 1.  Modifier J2 is for the re-supply of a drug for emergency use.  Page 21, slide 2.  This gives us a little more information about that.  Drugs given from the office stock, from the urologist’s stock in the office, may be resupplied by the CAP program if the true emergency existed and the criteria were present for an emergency.  Those criteria, which you should be documenting in your documentation, are that the drug was immediately required for an emergency and this was clinically determined by your physician, the urologist.  The physician could not have known or anticipated that he would need the drug, and of course, the vendor could not have timely provided the drug. 

Page 22, slide 1.  Restocking of inventory after emergency use.  If the CAP vendor is unable to supply the drug as indicated for the emergency, then the physician will provide the drug from his stock and administer the drug to the patient.  The physician then submits a specific written order to the CAP vendor using the J2 code to indicate a drug replacement order.  The vendor assigns a new prescription drug order and hopefully sends the physician the drug as a replacement. 

Page 22, slide 2.  Modifier J3 is attached to a J code to indicate a specific drug provided as “furnish as written.”  What does that mean?  Page 23, slide 1.  If the CAP vendor is unable to supply a specific formulation of a drug, that would be Lupron, the physician may then purchase, provide, and administer the drug under a “furnish as written” policy.  The physician then bills for both the drug and the administration to the particular local Medicare carrier using modifier-J3 on the drug code and he will be reimbursed on an average sales price plus 6%. 

Page 23, slide 2.  This shows a 1500 form completed for that purpose.  Notice that the drug administration J9217 which is Lupron, the J3 modifier has been added to indicate that he is furnishing a drug “furnish as written” which is not included in the CAP list of drugs. 

Page 24, slide 1.  We will now talk about drugs included in the CAP program.  There are 181 drugs out of 440 Part B eligible drugs that are included.  These 181 drugs count for 85% of all Part B Medicare spending.  These are “incident to” drugs that are only administered in the physician’s office.  Now very interestingly, drugs not included in the CAP program that you would have to buy and sell yourself include Lupron, Eligard, Vantas, testosterone, and contrast agents--these drugs are not included at this time in the CAP program. 

Page 24, slide 2.  A reference slide that you may use to see the drugs that are included in the CAP program for 2006. 

Page 24, slide 1.  Very important slide.  On August 3, 2005, the CAP program was put on hold by CMS Medicare.  They suspended any application by vendors to join the CAP program.  There was extensive public comment, many of which were poor comments concerning this program.  CMS required and wanted time to extensively review these rather negative public comments.  They hoped to improve the efficiency and most important, the attractiveness of the program.  CMS will again clarify the application process for vendors and hopefully will produce an acceptable final rule, to be published later this year.
 
Page 25, slide 2.  Vendors began to calculate their profits which appeared to be extremely low.  Some as low as 0.5%.  Because of this, two vendors that had put in applications have withdrawn their applications in September and in September of 2005, zero vendors were presently on board. 

Page 26, slide 1.  Important dates and some changes.  The physician voluntary enrollment in the CAP has been put on hold.  That was to be between October 1 to November 15, 2005.  This has been delayed to the early part of 2006.  The effective starting date has been delayed to July 1, 2006. 

Page 26, slide 2.  A recent demand by the Practicing Physicians Advisory Council (PPAC) was made to CMS.  They demanded to remove the CAP vendor drug bids from the average price calculations because this would decrease payments for drugs and penalize physicians that opted not to join the CAP program.  They also wanted the ability that in multiple person specialties, such as multiple urologists in one group, some urologists could join the program and some could remain outside of the program.  They also demanded that vendors continue to supply drugs even for financially delinquent patients who hadn’t paid their co-pays or deductibles even within the specified period which was 45 days plus 15.

Page 27, slide 1.  What should your office do?  Well, I think you should explore all the options available to your office to get and receive these drugs.  Look at your calculations again.  Review your history of drug usage and I think most important is, how many Medicare patients and how many private patients are serviced?  Again, look at the drug reimbursements, revisit the slide that I showed you earlier on drug purchase prices and make sure you are getting your drugs at the lowest possible purchase price and look at the dollar outlay.  Of course, the most important thing I think is, think of your patients and what is going to be best for them. 

What say urologists?  There was a survey that was reported in the Urology Times in September 2005, 214 responses to this e-mail were received and the question was, “Are you likely to participate in the CAP program in 2006?”  As you can see, not many people were too enthusiastic about this program.  Less than 8% said yes.  One-third said positively no.  Thirty-eight percent said they are not sure and to my surprise, a little bit more than one-fifth of the participants or 22.4% said, “I’m not familiar with the CAP at all.”

Page 28, slide 1.  Will you enroll?  I can tell you now that most urology offices that I have visited say no. 

Operator, I think that finishes the formal presentation.  I know we have a little bit more time, maybe we could go to some questions.

Thank you Dr. Ferragamo.  Ladies and gentlemen, I would like to remind you that this portion of the teleconference is also being recorded.  If you have a question at this time, please press *1 on your touchtone telephone.  If your question has been answered or you wish to remove yourself from the queue, please press # key.  Please limit yourself to one question at a time so that everyone may have a chance to participate.  If you have another question you may reenter the queue by pressing *1. 

Q & A Session:

Our first question comes from Courtney Page from The Coding Institute.  Please state your question.

Question:  Hi Dr. Ferragamo.  This is Courtney from The Coding Institute.  I have a few questions that have been e-mailed in to me.  The first that I have is, will Medicare or the OIG audit penalize or fine urologists who change LHRH injection administrations or formulations for cost effective for economic reasons?

Answer:  Okay Courtney.  Your question is, will the Medicare or the OIG penalize physicians that eventually change maybe formulations or timeframes with administration of drugs?  That’s a very good question.  I don’t think the OIG or the government or Medicare will penalize or fine anyone for switching from one drug or one formulary to another.  I think the physician should determine what is best for his patient and then do that.  I don’t think the government should interfere or determine what is best for the individual patient.  Now he may want to change the drug based on time.  A patient may not want to come in every three or four months and may request that he receive the one-year implant.  The physician may want to see the patient every three months and the patient feels he wants to get the injection every three months when he comes in.

There should be no interference by the government or OIG into how the LHRH drugs are administered, or which ones, since all the LHRH drugs are medically equivalent.  There is no rule, regulation, or law or anything that I know of that would give the government or OIG authorization to do this.  Now, also consideration should be given to the fact that you are practicing in a private practice and that you cannot and you should not afford to lose revenue based on the providing of drugs.  You have to consider the economics and the cost effectiveness of one drug versus another. 

Actually, in my opinion, and I can also say that I have spoken to Ray Painter who is the President of the Physicians Reimbursement Service, probably the best system that is available for coding for urology, and he feels the same way.  If you can justify changing the drugs based on the economics and cost effectiveness of that drug, then I don’t believe that the government or the OIG will take any action if you switch drugs.  I can’t be 100% sure about that, but as far as I know there is no legal way they can do that.  I think that answers that.

Question:  I’ll ask another question I have.  Can one bill for both a Lupron IM injection and a Zoladex IV infusion during the same encounter?  Do you have to use one or two injection infusion codes?

Answer:  Okay.  If you are doing both, if you are giving a patient a Lupron injection and a Zoladex IV infusion, you can do both at the same time.  I think when you are talking about Zoladex and you said IV, I think you are talking of Zometa so you would be using Zometa and Lupron.  Now you would give the Lupron with the injection code G0356 and you would bill also the Lupron dosage J9217.  You would also be giving the IV infusion of Zometa which would be G0347, that’s your IV infusion; and you would be giving the J code J3487 (I think it is) times 4 units in box 24G.  Yes, you can give both the infusion of Zometa and the Lupron injection and get paid for both administration codes because one is IM and one is intravenous. 

Question:  Thank you.  Another question I have is how would you handle the coding when a patient is sent into your office from a skilled nursing home for a Lupron injection?

Answer:  Okay.  That is a little bit off the topic but it is a very good question.  That has produced a great deal of problem to many urologists who did not know that a patient coming from a skilled nursing facility their care is paid for strictly by Part A Medicare.  No Part B Medicare would take place.  That is not 100% true.  The first thing I think you should find out when a patient comes from a nursing home: is this patient in a skilled nursing bed situation or is it just a nursing home?  If the patient is in a skilled nursing facility, there are certain services in urology that you will not be paid for.  The nursing home should be paying you, but many times that is a problem. 

Certainly, with the giving of drugs such as Lupron, Zoladex and BCG you cannot get paid for Part B Medicare, you must seek payment from the nursing home.  I think most urologists, if they don’t have a previous contract with the skilled nursing facility in which they do not have an agreement, I think the best way to handle that is when you send the patient back to the skilled nursing facility, in your recommendations, in your consult, in your documentation back to the nursing home, you will indicate “please administer Lupron--whatever the dose is--every month or every 3 months.”  In that particular case you put the burden on the skilled nursing facility to administer the dose of medicine that you have ordered, which would be your recommendation. 

Question:  Thank you.  We have time for another one.  Our Blue Shield carrier denied a properly coded J drug code for Lupron J9217, indicating further documentation required.  What documentation are they looking for?

Answer:  Okay.  In other words, if your Blue Shield carrier denies a properly coded J code for Lupron, indicating that they need more documentation.  I would first check and see that you have the proper G code and billing.  I would want to be sure that the particular Blue Cross/Blue Shield does accept the G code for your injection.  Most Blue Shield Blue carriers will accept the G doe.  I’m sure there is an occasional carrier that is still looking for the 96400.  The other thing that some Blue Shield/Blue Cross carriers want is they want you to indicate in box 19 the national drug code, the NDC of the drug that you are using as well as its name and the dosage.  That should be put in box 19.  Those are the only reasons I can think of why they may not want to pay that. 

Question:  Okay.  My next question is, since the CAP program is on hold, when will urology offices need to decide on whether to enroll in the program?

Answer:  It looks like they are going to ask urology practices in the early part of 2006 to enroll and they will probably come up with a date probably between January and March, or February and April to have you enroll in that program.  Most urology offices at the present time with the present bill as it is written are not going to join.  They hope to initiate to start the program, so they would need to have enrollment at least before they want to start the program July 2, 2006. 

Question:  Can a PA or NP provide supervision in an office setting for a nurse’s evaluation and drug administration without a physician being present in the office?  How would one go for this scenario? 

Answer:  I think we showed a slide on that.  The PA or NPP can provide supervision for the nurse.  This is somewhat controversial but as far as I know, (and many offices are doing this) the PA can provide supervision for Medicare let’s say, but he would bill in his name and numbers and get 85% of the global. 

For private carriers, the NP, the NPP, or the nurse or medical technician could administer treatment, in other words could give the medication under the guidance of general supervision meaning that the physician is nearby and can get back to the office in a reasonable time to give help if required.  Yes, a PA can provide supervision to a nurse or an NP who is administering the Lupron but you would bill for him in his name and numbers. 

Question:  My urologist wants to bill Medicare for a Lupron 7.5 mg injection but give the patient the drug kit to bring to Florida where his wife, who is a nurse, will give him the injection next month while they are on vacation.  Is this possible and will Medicare approve this billing?

Answer:  It is possible; if your wife is a nurse can she give you an injection of Lupron?  Absolutely, if she is qualified she can do that.  We teach non-medical people to give the injections.  The problem is that Medicare tells you that they will only pay for the drug if this drug is administered by you or someone that you assign to administer the drug in your office environment.  In other words, you cannot buy the drug, give it to the patient, he takes it and goes to Florida with it and his wife gives it to him a month or so later, I think as the question indicated. and you cannot expect Medicare to pay you for that drug when you bought it for the patient.  So for that drug to be paid by Medicare, you yourself or someone that you assign to administer that drug must be in your office and then you can bill for it.  Otherwise, the patient has to buy the drug himself. 

Comment:  Thanks.  I think that all the questions I have. 

If there are no further questions, I would like to turn the program back to Dr. Ferragamo. 

Thank you very much Erika, it has been my pleasure to give this conference and I just want to mention the very last slide in the handout.  That slide gives many of the numbers where you can reach me.  As you know, many of you have called me, if you have any questions on coding please call me and I will be happy to help you.  Please continue to use the listserv that we have provided.  I know that many of the coders enjoy using it and it is quite chock full of information for coding and we appreciate all that have used this.  We certainly appreciate the willingness of many of our loyal friends and coders who have spent the time on the listserv helping others with questions they have asked.  Thank you very much and thank you for attending this teleconference. 

This is the conclusion of “Critical CAP Considerations for Your Urology Practice” national teleconference.  We hope you enjoyed this session.  Please complete your teleconference evaluation form and return it to The Coding Institute at the address listed on the form.  Dr. Ferragamo, The Coding Institute and I would like to thank you for your attendance.  To end this call, simply hang up your phone.  Goodbye.