January 2008 Practice Update (part two)

Medicare 2008 Physician Reimbursement Update
During next Thursday's State of the Union speech, President Bush is expected to address his proposal for amending the Medicare physician fee formula. Bush is required by law to send a Medicare savings plan to Congress after he releases his fiscal year 2009 budget proposal because Medicare trustees last year triggered a "Medicare funding warning." The warning is issued when trustees for two consecutive years predict that federal general fund revenue must be used to pay for 45 percent or more of total Medicare costs within seven years. It is anticipated that a fix could cost between $12 billion and $15 billion over five years. At issue will be the Pay/Go rules, which require the cost to be offset by reductions or revenue elsewhere in the budget.

Democrats and Republicans both support legislation to reverse a 10 percent reduction in Medicare reimbursements to physicians. The goal will be for Congress to pass Medicare legislation that will stop a 10.6 percent cut to Medicare physician fees for 18 months. Last month President Bush signed the Medicare, Medicaid, and SCHIP Extension Act of 2007, which delayed the physician fee cut for six months and extended SCHIP through March 2009. The bill increased Medicare physician fees by 0.5 percent during that period. ASH continues to work with other specialty societies and organized medicine to prevent the scheduled cuts from being implemented. Additional information and online advocacy tools will be forwarded to ASH members as soon as details on the Medicare package are released.

CMS Releases Instructions on New Reporting Requirements on Claims for the Administration of Erythropoiesis-Stimulating Agents (ESAs)
Effective January 1, 2008, hemoglobin or hematocrit levels must be reported with all Medicare billings for the administration of ESAs furnished to an individual for the treatment of anemia in connection with cancer treatment. This new requirement is the result of a provision in the Tax Relief and Health Care Act legislation of 2006. Below in an FAQ format are guidelines to assist providers in complying with this new requirement. For additional information, please see Transmittal 1412 "Reporting of Hematocrit or Hemoglobin Levels on All Claims for the Administration of ESAs" on the Centers for Medicare and Medicaid Services (CMS) Web site.

When do I need to start reporting hematocrit levels?

This requirement is effective for all claims requesting payment for the administration of ESAs with dates of service on and after January 1, 2008.

Which claims are affected by this new rule?

• All claims billing for the administration of an ESA (J0881, J0882, J0885, J0886, and Q4081)
• All claims for the administration of a Part B anti-anemia drug (other than ESAs) used in the treatment of cancer that are not self-administered.

Where on the claim do I report the test results?

For professional paper claims, test results are reported in item 19 of the Form CMS-1500 claim form. For electronic claims (837P), providers report the hemoglobin or hematocrit readings in Loop 2400 MEA segment, specifically, MEA01=TR (for test results), MEA02=R1 (hemoglobin) or R2 (for hematocrit), and MEA03=the test results.

Do I need to report any modifiers on these claims?

Yes. Effective January 1, 2008, all non-ESRD claims for administrations of ESAs reporting either the most recent hematocrit or hemoglobin level, must contain one of the following three modifiers:

• EA: ESA, anemia, chemo-induced
• EB: ESA, anemia, radio-induced
• EC: ESA, anemia, non-chemo/radio

Professional claims that are billed without the required modifiers will be returned.

Do I need to draw the hemoglobin or hematocrit level each time an ESA is administered?

No you do not. CMS has clarified in the 2008 Final Physician Rule that this mandate does not mean that the hemoglobin or hematocrit level should be drawn each time an ESA is administered. The requirement is that "the most recent" hemoglobin or hematocrit level be reported on the claim. Thus, the provider should report the most recent level preceding the ESA administration. CMS recognizes that in some instances the same hemoglobin or hematocrit value might be reported on more than one claim.

ASH Continues to Track Local Carrier Policies on ESA Coverage for MDS in 2008
ASH will continue to monitor the development of local carrier policies concerning ESA coverage. Visit the Resources for Practitioners section to learn more about local Medicare carrier draft policies concerning ESA coverage for MDS patients. Please contact Government Relations and Practice Specialist Stephanie Kart or call 202-776-0544 for additional assistance and insight on the ESA coverage policy for your state.

Highlights of ASH – Early Registration
The advance registration deadline for Highlights of ASH is January 25. Register before then and save on your registration for Highlights of ASH in either Seattle, WA, on February 1-2 or in Austin, TX, on February 8-9. Don't miss your chance to hear renowned experts present their analyses of the most influential studies straight from the 2007 ASH Annual Meeting – register today. But don't worry, if you miss the advance registration deadline you may still register on site in either Seattle or Austin.