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Prepared by: Medical Compliance Services, Miller School of Medicine/University of Miami

and Compliance Concepts, Inc. March 2014

Office of Billing Compliance 2014 Professional Coding, Billing and

Documentation Program

Radiation Oncology

What is a Compliance Program?

A centralized process to promote honest, ethical behavior in the day-to-day operations of an organization, which will allow the organization to identify, correct, and prevent illegal conduct.

It is a system of: FIND – FIX – PREVENT

The University of Miami implemented the Billing Compliance Plan on November 12, 1996. The components of the Compliance Plan are:

1. Policies and Procedures 2. Having a Compliance Officer and Compliance Committees 3. Effective Training and Education 4. Effective Lines of Communication (1-877-415-4357 or 305-243-5842) 5. Disciplinary Guidelines 6. Auditing and Monitoring 7. Detect Non-Compliance Issues and Develop Corrective Action Plans 2 2 2

7 Elements of an Effective Compliance Program

The Government In order to address fraud and abuse in the Healthcare Field, the

government has on-going reviews and investigations nationally to detect any actual or perceived waste and abuse.

The Government does believe that the majority of Healthcare providers deliver quality care and submit accurate claims. However, the amount of money in the healthcare system, makes it a prime target for fraud and abuse.

Centers for Medicare and Medicaid Services (CMS) Estimates > $50 Billion In “Payment Errors” Annually in Healthcare

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OIG reported that in FY 2013 that $5.8 billion was recovered from auditing providers

Health Care Laws There are five important health care laws that have a significant impact on how we conduct business:

False Claims Act

Health Care Fraud Statute

Anti-Kickback Statute

Stark Law

Sunshine Act Requires manufacturers of drugs, medical devices and biologicals

that participate in U.S. federal health care programs to report certain payments and items of value >$10 given to physicians and teaching hospitals. 4

False Claims Act : United States Code Title 31 §3729-3733

What is a False Claim?

A false claim is the knowing submission of a false or fraudulent claim for payment or approval or the use of a false record that is material to a false claim.

OR Reckless disregard of the truth or an attempt to remain ignorant

of billing requirements are also considered violations of the False Claims Act.

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This certification forms the basis for a false claim.

How do you create a False Claim? One method is to submit a claim form to the government

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•Audits are being conducted for all payer types based on the medical necessity of E/M levels. The audits are generally expressed in two ways:

• Frequency of services (how often the patient is seen) and,

• Intensity of service (CPT level).

What Are We Seeing Out There?

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Elements of Medical Necessity

CMS’s determination of medical necessity is separate from its determination that the E/M service was rendered as billed.

Complexity of documented co-morbidities that clearly influenced physician work.

Physical scope encompassed by the problems (number of physical systems affected by the problems).

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Referring Page: http://www.cgsmedicare.com/kyb/coverage/mr/articles/em_volume.html November 2012

E/M Coding: Volume of Documentation versus Medical Necessity

• Word processing software, the electronic medical record, and

formatted note systems facilitate the "carry over" and repetitive "fill in" of stored information.

• Even if a "complete" note is generated, only the medically reasonable and necessary services for the condition of the particular patient at the time of the encounter as documented can be considered when selecting the appropriate level of an E/M service.

• Information that has no pertinence to the patient's situation at that specific time cannot be counted.

An ISO 9001:2008 certified company

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Office of the Inspector General (OIG) Audit Focus Annually OIG publishes it "targets" for the upcoming year. Included is:

Cutting and Pasting Documentation in the EMR REMEMBER: More volume is not always better in the medical record, especially in the EMR with potential for cutting/pasting, copy forward, pre-defined templates and pre-defined E/M fields. Ensure the billed code is reflective of the service provided on the DOS.

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Medical Record Documentation Standards

Pre EMR: “If it isn’t documented, it hasn’t been done.”

- Unknown

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Post EMR: “If it was documented, was it really done and

was it medically necessary to do.”

- Reviewers

Quality & Cost: Emphasis on Pay-for- Performance PQRS & Meaningful Use

Practitioner reimbursement will likely be tied to outcomes soon. Some experts say that the CMS penalties for not participating in

the Physician Quality Reporting System (PQRS) signal that the pay-for-performance trend is not fading away and will likely will be adopted by private payers.

“I think we’re slowly transitioning out of fee-for-service and into a system that rewards for quality while controlling cost,” says Miranda Franco, government affairs representative for the Medical Group Management Association. “The intent of CMS is to have physicians moving toward capturing quality data and improving metrics on [them].”

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Guidelines for Teaching Physicians, Interns, Residents and

Fellows

For Billing Services, All Types of Services Involving a Teaching Physician (TP) Requires Attestations In EHR or Paper Charts

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E/M IP or OP: TP must personally document at least the following: That s/he performed the service or was physically present during the

key or critical portions of the service when performed by the resident; AND

The participation of the teaching physician in the management of the patient.

Example: ‘I saw and examined the patient and agree with the resident’s note…’

Time Based E/M Services: The TP must be present and document for the period of time for which the claim is made. Examples :

Critical Care Hospital Discharge (>30 minutes) or E/M codes where more than 50% of the TP time spent counseling or

coordinating care 15

Evaluation and Management (E/M)

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Minor – (< 5 Minutes & 0 -10 Day Global): For payment, a minor procedure billed by a TP requires that s/he is physically present during the entire procedure. Example: "I was present for the entire procedure."

Endoscopy Procedures (excluding Endoscopic Surgery): TP must be present during the entire viewing for payment.

The viewing begins with the insertion and ends with the removal. Viewing of the entire procedure through a monitor in another room

does not meet the presence requirement. Example: "I was present for the entire viewing."

Major – (>5 Minutes) SINGLE Procedure / Surgery — When the teaching surgeon is present or

performs the procedure for a single non-overlapping case involving a resident, he/she or the resident can document the TP’s physical presence and participation in the surgery.

Example: “I was present for the entire (or key and critical portions) of the procedure and immediately available.”

Medical Student documentation for billing only counts for ROS and PFSH

Procedures

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Unacceptable TP Documentation

Assessed and Agree Reviewed and Agree Co-signed Note Patient seen and examined and I agree with

the note As documented by resident, I agree with the

history, exam and assessment/plan 17

Working With NP's and PA's (NPP's) The NP or PA MUST BE AN EMPLOYEE OF THE PRACTICE AND CANNOT BE A HOSPITAL EMPLOYEE TO UTILIZE ANY OF THEIR DOCUMENTATION FOR PHYSICIAN BILLING AS SHARED Shared visit with an NPP may be billed under the physician's name

only if:

The physician provides a face-to-face portion of the visit and

The physician personally documents in the patient's record the portion of the E/M encounter with the patient they provided.

If the physician does not personally perform or personally and contemporaneously document their face-to-face portion of the E/M encounter with the patient, then the E/M encounter may only be billed under the PA/ARNP's name and provider number

Procedures must be billed under the performing provider & not the supervisor. They cannot be “shared” 18

National ‘12 CMS Data For Speciality E/M

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2%

14%

52%

24%

7%

0%

10%

20%

30%

40%

50%

60%

99211 99212 99213 99214 99215

National Dist.

Top Procedure Codes Billed in 2013

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Top 5 E&M Description %

99213 OFFICE/OUTPT 50%

99204 OFFICE/OUTPT 11%

99214 OFFICE/OUTPT VISIT,EST,LEVL IV 10%

99212 OFFICE/OUTPT VISIT,EST,LEVL II 9%

99205 OFFICE/OUTPT VISIT,NEW,LEVL V 8%

All other E/M Codes

12%

Total 100.0%

Top 5 Procedure

Description %

77300 RADIATION THERAPY,DOSIMETRY PLAN 26%

77421 STEREOSCOPIC X-RAY GUIDANCE 16%

77427 RADIATION,MANGEMENT,5 TX'S 14%

77014 CT GUIDANCE PLACEMENT RAD THERAPY FIELDS 13%

77334 RADN TREATMENT AID(S) COMPLX 8%

All other Procedure

Codes

12%

Total 100.0%

2014 CPT Code Changes Review Interprofessional consultations New codes to report interprofessional (“doctor-to-doctor”)

telephone/Internet consulting. Code 99446 is defined as an interprofessional

telephone/Internet assessment and management service provided by a consultative physician, including a verbal and written report to the patient’s treating/requesting physician or other qualified health care professional, and involves 5 to 10 minutes of medical consultative discussion and review. 99447: 11 to 20 minutes of medical consultative discussion and review 99448: 21 to 30 minutes of medical consultative discussion and review 99449: 31 minutes or more of medical consultative discussion and

review Medicare Does Not Pay This Service 21

2014 CPT Code Changes Review Interprofessional consultations The services will typically be provided in complex

and/or urgent situations where a timely face-to-face service with the consultant may not be possible. The written or verbal request, its rationale, and the conclusion for telephone/Internet advice by the treating/requesting physician or other qualified health care professional should be documented in the patient’s medical record.

Medicare allowable $0.00

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A team of specialized experts provide all aspects of patient careRadiation Oncologists NursesRadiation Therapists Medical DosimetristsMedical Physicists

Machines don’t treat cancer. People do.

Radiation Oncology Continuum/Flow

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E&M Simulation Treatment Planning

Physics Checks Treatment Delivery

Weekly Management Follow-up

Physician Orders

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Patient Continuum

All Procedures need written

directives ACR

CT for Placement of Fields

Dosimetry Calcs; Micro

Dosimetry

Simulation

Special Physics Consult, Special Tx Procedure,

Port films

Treatment Planning: Brachy, 2D, 3D, IMRT

Tx Devices, Continuing

Medical Physics

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The signature affixed to this document signifies the physician's review and approval of the entire document, including the dose distribution plan (when applicable), basic dosimetry calculations, verification calculations, treatment devices, and medical necessity documents (3-D and IMRT treatment planning document).

Sample Wording for Dose Distribution Plans

Physician Supervision Rules

General – furnished under a physicians “general” supervision.

Direct – present, in area and immediately available.

Personal – must be in attendance and in the room.

How to Interpret “Direct” Supervision

Professional Supervision In a hospital campus the physician must be immediately available, on

campus. The physician should not be performing another procedure or

involved with another patient encounter.

Hospital Supervision The majority of Radiation procedures performed or supervised by a

physician fall under “direct” supervision.

Both 77421 and 77014 have direct supervision - what does that mean?

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Both 77421 and 77014 now have direct supervision what does that mean MORE......

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77421 CPT Insiders View Documentation Required

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The documentation for the IGRT, 77421 procedure, would consist of the

therapist recording exactly what was performed with the patient's name,

date and signature. Remember the documentation must be labeled IGRT,

what type, "Stereoscopic X-ray guidance for localization of target

volume for the delivery of radiation therapy", who, what, when, where

and why. The physician then according to the AMA will, "The radiation

oncologist reviews the images daily and compares with previous shifts.

Feedback by the physician is given to the therapists about the adequacy

of registrations and, if necessary, about the steps necessary to improve

future registrations as well as for the required treatment

modifications". AMA 2006

Indications for IGRT

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Three-dimensional conformal therapy · Intensity Modulated Radiation Therapy · Particle Beam Therapy · Stereotactic Radiosurgery (SRS) · Stereotactic Body Radiation Therapy

Medicare Supervision Rules Apply to IGRT Codes Rules

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General supervision: The physician is not necessarily on-site. The services of the facility are provided under his or her supervision and control, however, and the physician is responsible for the calibration of the equipment, the training of the technologists, and overall operations. (76950-BAT)

Direct supervision: The physician must be physically on the premises and in the suite of offices where the tests are being performed. In the office setting, the physician must be present in the office suite and immediately available. This is defined as within earshot (not just reachable by beeper, and not merely in the same building). (77014- IGRT/CT Based or KV IGRT 77421)

Medicare Supervision Summary of Common IGRT Codes

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•77014 (CT-guidance) : Direct supervision - Freestanding and Hospital Based can bill technical if performed and documented but packaged for Hospital must be on claim •77421 (stereoscopic x-rays: Direct Supervision

Physician must approve prior to the next treatment in order to bill both technical and professional and both freestanding an hospital can bill both components if performed and documented however technical is packaged for Hospitals but must be on the claim.

•76950 : BAT - General supervision : Freestanding and Hospital can bill technical when performed and documented. Packaged for Hospital but must be on claim

Codes for IGRT

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•Ultrasound : CPT 76950 aka BAT •Stereoscopic X-ray : CPT 77421 (KV Based IGRT) •Computerized Tomography : CPT 77014 (CT based IGRT)

•Cone beam CT •Tomotherapy •CT-on-Rails

• Fluoroscopy – 76000 •Port film - 77417

Tomotherapy /Cone-Beam CT /CT-on-Rails

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•ASTRO currently recommends that CPT® code 77014; Computed tomography guidance for placement of radiation therapy fields, be used for CT based IGRT. •It is important to note that in order to meet the criteria for CT based IGRT, a radiation oncologist, medical physicist, or trained therapist under the supervision of the radiation oncologist must review the fused CT images and supervise any patient repositioning

IGRT

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Do not bill 77421 and 77014 for the same patient on the same day Do not bill 77421 and 77417 for the same patient on the same day Do not bill 77421 and 76950 for the same patient on the same day It is critical that appropriate documentation be made for physician involvement and for the technical aspects of all IGRT codes. This work is in addition to the physician work involved with the weekly management CPT® code 77427.

BID (Patients Treated 2 times daily) The same ‘repeat service’ modifier (76 or77) will be used on the second image guidance service performed each day. Remember that the first IGRT service performed for the patient in the morning must be reviewed and approved by the physician prior to the second treatment that day. Each IGRT service must be reviewed and approved/accepted by the physician prior to the next patient treatment, so it would not be acceptable for the physician to review both the am and pm images at the end of the day – in this case, you would report a single IGRT service.

Who is responsible for billing?

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Patient Bill

Every discipline plays a role in the charge capture process

Physician

Physicist

Therapist

Nurse

Support Staff

Dosimetrist Physician

77295 Therapeutic radiology simulation-aided field setting; 3-dimensional

Revised – Therapeutic radiology simulation3-dimensional radiotherapy plan, including dose-aided field setting volume histograms 3-dimensional

CPT® 2014 revised 77295 so it better reflects current practice.

The code now emphasizes the physics and dosimetry planning work

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Radiation Therapist Treatment SIMPLE TREATMENT DELIVERY Codes 77402 – 77406)

SINGLE Port Parallel Ports No Devices SIMPLE Devices

INTERMEDIATE TREATMENT DELIVERY – 77407 – 77411)

Two Separate areas treated 3 or more ports on a single area Multiple Devices (including wedges) Tangential Ports without devices

COMPLEX TREATMENT DELIVERY (77412-77416)

3 or more areas treated Custom Devices Rotational Beam Compensator Special particle beam (e.g., electrons, neutrons)

IMRT TREATMENT DELIVERY CODE (77418) Proton Treatment Delivery – (77520-77525)

Radiation Therapist Treatment Establishment of Energy Level – Photon Delivery Daily Kilovoltage Treatment Delivery – Superficial and/or Orthovoltage 77401 Daily Treatment Delivery – Simple

77402 – Co-60, accelerator up to 5 MV maximum energy 77403 – Accelerator 6-10 MV maximum energy 77404 – Accelerator 11-19 MV maximum energy 77406 – Accelerator, 20 MV or greater maximum energy

Daily Treatment Delivery – Intermediate

77407- Co-60, accelerator up to 5 MV maximum energy 77408- Accelerator 6-10 MV maximum energy 77409 - Accelerator 11-19 MV maximum energy 77411 - Accelerator, 20 MV or greater maximum energy

Daily Treatment Delivery – Complex

77412 - Co-60, accelerator up to 5 MV maximum energy 77412 – Gamma Knife – Not used MDACC 77413 - Accelerator 6-10 MV maximum energy 77414 - Accelerator 11-19 MV maximum energy 77416 - Accelerator, 20 MV or greater maximum energy 77418 – IMRT any energy

Charges Associated with the Radiation Therapist

The professional values are related to the amount of time and effort

expended by the physician in the care of a patient during the course of radiation therapy.

Technical complexity is related to the difficulty encountered by the

radiotherapist on the treatment machine in terms of set up and daily treatment delivery to the patient.

Institutional treatment delivery is a technical (hospital or

freestanding facility) component reported under these technical-only codes. Technical treatment delivery is reported on a daily basis by all institutions.

Medicare requires that these codes be separated with the physician

component being billed on a weekly basis (77427) and the treatment delivery being billed per treatment fraction.

Charges Associated with the Radiation Therapist

TREATMENT DELIVERY CODING GUIDELINES A treatment delivery code is reported for each treatment session

In the case of hyperfractionation, there are 2 treatment sessions on the same day, therefore 2 delivery codes could be reported. If 2 different energies are used during the same treatment session, then the single code that corresponds to the highest energy used is reported. For Electrons, since the energies vary widely, the coding is based on the maximum beam capability of the equipment.

The number of treatment delivery codes reported will depend

on the number of fractions delivered. Only one code reported per treatment session.

Patient Service Charges Professional Charges (Bill on CMS 1500)

Charges prompted by the physician’s involvement into a process designed to provide care for the patient. The physician’s “intellectual” involvement directs not only his or her direct involvement but also the Physics charges that are required for patient care.

Technical Charges (Hospital bill on UB04) Charges rendered by the treatment center for provision

of all of the equipment and personnel that the physician must use to deliver treatment. These include the treatment unit, examination rooms, simulators, and other procedures not directly supplied by the physician but required via the treatment plan.

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CMS is Comparing, so what does that mean?

The professional and technical complexity level must match.

Physician billing must communicate with hospitals. Must share records and documentation.

Billing Staff will have to be adequately trained to on determination of complexity

Billing Staff for Hospitals and Doctors must communicate

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IMRT and Medical Necessity

Each chart should contain a patient specific statement by the treating physician documenting the medical necessity of performing IMRT rather than performing conventional or 3D planning and delivery detailing patient specific goals and requirements of the treatment plan, including the specific dose constraints for the target(s) and nearby critical structures.

Although it may be apparent from the patient history, each chart should meet the LCD for IMRT From First Coast: LCD ID Number L28892 LCD Title: Intensity Modulated Radiation Therapy (IMRT)

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Modifier Reminders

Modifier 25: Significant, Separately Identifiable E/M by the Same Physician/Group on the Day of a minor Procedure: on the day a procedure the patient's condition required a significant, separately identifiable E/M service above and beyond the usual care associated with the procedure that was performed. Modifier 59: Distinct Procedural Service: Under certain circumstances, indicate that a procedure or service was independent from the services performed on the same day. Modifier GC: Service involved a resident or fellow. Payment not affected.

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CCI Audit Reviews for Radiation Oncology:

Support for medical necessity of IMRT in documentation ( review LCDs and NCDs)

Providing services without proper physician supervision

Weekly E/M code medical necessity to repeat specific history areas

Frequency of visits after treatment

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• Increased specificity of the ICD-10 codes requires more detailed clinical documentation to code some diagnoses to the highest level of specificity.

Coding and documentation go hand in hand ICD-10 based on complete and accurate documentation,

even where it comes to right and left or episode of care. ICD-10 should impact documentation as physicians are

required to support medical necessity using appropriate diagnosis code—this is not an easy situation.

Will not change the way a physician practices medicine

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ICD-10 Implementation –Example

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HIPAA Final Reminders for All Staff, Residents, Fellows or Students Health Insurance Portability and Accountability Act – HIPAA

Protect the privacy of a patient’s personal health information Access information for business purposes only and only the records you

need to complete your work. Notify Office of HIPAA Privacy and Security at 305-243-5000 if you

become aware of a potential or actual inappropriate use or disclosure of PHI, including the sharing of user names or passwords.

PHI is protected even after a patient’s death!!!

Never share your password with anyone and no one use someone else’s password for any reason, ever –even if instructed to do so. If asked to share a password, report immediately.

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Any Questions

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Available Resources at University of Miami, UHealth and the Miller School of Medicine

If you have any questions or concern regarding coding, billing, documentation, and regulatory requirements issues, please contact: Gemma Romillo, Assistant Vice President of Clinical Billing

Compliance and HIPAA Privacy Officer; or Iliana De La Cruz, RMC, Director Office of Billing Compliance

Phone: (305) 243-5842 Officeofbillingcompliance@med.miami.edu

Also available is The University’s fraud and compliance hotline via the web at www.canewatch.ethicspoint.com or toll-free at 877-415-4357 (24hours a day, seven days a week).

Office of billing Compliance website: www.obc.miami.edu

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