radiation oncology coding & compliance denials
TRANSCRIPT
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Radiation Oncology Coding & Compliance Denials, Documentation & Updates
AAMD 2020
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Presenter
Adam Brown BSRT(T), CMDDirector, Client Services
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Disclaimer
This presentation was prepared as a tool to assist attendees in learning about documentation, charge capture and billing processes. It is not intended to affect clinical treatment patterns. While reasonable efforts have been made to assure the accuracy of the information within these pages, the responsibility for correct documentation and correct submission of claims and response to remittance advice lies with the provider of the services. The material provided is for informational purposes only.
Efforts have been made to ensure the information within this document was accurate on the date of presentation. Reimbursement policies vary from insurer to insurer and the policies of the same payer may vary within different U.S. regions. All policies should be verified to ensure compliance.
CPT® codes, descriptions and other data are copyright 2019 American Medical Association (or such other date of publication of CPT®). All Rights Reserved. CPT® is a registered trademark of the American Medical Association. Code descriptions and billing scenarios are references from the AMA, CMS local and national coverage determinations (LCD/NCD).and standards nationwide.
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ObjectivesReview Authoritative Guidance and the many tools and websites available as resources
Details of Current Payer Denials & Documentation Reviews
Review of 2020 Supervision Changes
Preparing for 2021 E/M Updates
Billing Highlights & Updates to COVID-19 Response
Q&A
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Coding Guidance
Authoritative Guidance American Medical Association (AMA)– The Centers for Medicare and Medicaid Services (CMS) American Hospital Association (AHA) Commercial Insurance Payers
Opinions Specialty Societies Healthcare Consultants– Billing Companies– Other medical entities
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ResourcesFederal Register
CMS manuals and publications
Local contractor resources
American Medical Association•CPT® Manual•CPT® Assistant •Clinical Examples in Radiology
HCPCS Level II codes
ICD-10-CM codes
State regulations
Other payer policies
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National Coverage Determination (NCD) National Rules
Local Coverage Determination (LCD) Local Rules
Internet Only Manuals – Searchable
Transmittals – Written Updates
CMS Publications
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List of Searchable IOMs
Medicare Benefit Policy
Manual
Medicare Claims
Processing Manual
Medicare Program Integrity Manual
Medicare NCD
Manual
Medicare Secondary
Payer Manual
Medicare Managed
Care Manual
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• Published annually• Divided into chapters by code range• Provides additional instruction and guidance published quarterly• Edits include:
– Procedure to Procedure (PTP)– Medically Unlikely Edits (MUE)
NCCI Policy Manual
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Current Payer Denials & Documentation Reviews
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OIG Findings of 3-D Planning
Medicare Could Have Saved Millions of Dollars in Payments for Separately Billed Three-Dimensional Conformal Radiation Therapy Planning Services
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OIG Statement
“We recommend that the Centers for Medicare & Medicaid Services (CMS) implement billing requirements (including, for example, a bundled payment similar to that for IMRT) and system edits to prevent additional payments for 3D-CRT planning services that are billed before (e.g., up to 14 days before) the procedure code for the 3D-CRT treatment plan is billed, which could have saved Medicare as much as $125.4 million during CYs 2008 through 2017 and as much as $13.6 million in CY 2018.” Source: Office of Inspector General June 2019
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Specifics
• Recommendation from OIG to CMS• CMS agreed with findings• Specialty societies responded
Stay Tuned for Potential Changes in Future!
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Payer Denials for 3-D Planning
• #1 Payer (MAC) denial states – “Payment for codes 77014, 77280, 77285, 77290, 77305, 77306, 77307,
77310, 7315, 77316, 77317, 77318, 77326, 77328, or 77336 are included in the APC Payment for CPT® code 77295 (3D-CRT planning). These codes should not be reported in addition to HCPCS code 77295 when provided prior to or as part of the development of the 3D-CRT plan.”
• #2 Payer (MAC) denial states – CMS instructed them to deny 77290, 77370, 77336 when done prior to the
77295.– Stated CMS is following the same simulation guidelines for the 3D Planning
(77295) as they do for the IMRT Planning (77301). They’ve referenced the NCCI which nothing is listed, Novitas stated it hasn’t been made public yet.
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Current CMS Transmittals
• Medicare Claims Processing Manual, Chapter 4– 200.3.1 - Billing Instructions for IMRT Planning and Delivery“Payment for the services identified by CPT codes 77014, 77280, 77285, 77290, 77295, 77306 through 77321, 77331, and 77370 are included in the APC payment for CPT code 77301 (IMRT planning). These codes should not be reported in addition to CPT code 77301 when provided prior to or as part of the development of the IMRT plan.”
• NCCI Policy Manual Chapter 9– “14. Intensity modulated radiotherapy (IMRT) plan (CPT code 77301) includes therapeutic
radiology simulation-aided field settings. Simulation-aided field settings for IMRT shall not be reported separately using CPT codes 77280-77290. Although procedure-to-procedure edits based on this principle exist in NCCI for procedures performed on the same date of service, these edits shall not be circumvented by performing the two procedures described by a code pair edit on different dates of service.
– 15. CPT codes 77280-77290 (Simulation-aided field settings) shall not be reported for verification of the treatment field during a course of intensity modulated radiotherapy (IMRT) treatment.”
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What Is Happening & What To Do
• Code 77290 = simulation and 77295 = 3-D plan– Due to NCCI edits, cannot bill 77290 same date as 77295– If 77290 was performed prior to 77295, it could be billable
• APC 5613 currently contains codes 32553, 49411, 55876, 77295, 77301, and C9728
– Current CMS national reimbursement rate $1,245.34
• Appears denials by some MACs have set an edit to the APC, not just the code 77301
• Appeal• Request supporting statements about this specific to 77295• Provide CMS guidance which addresses 77301
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Palmetto GBA Focused Reviews
• Palmetto Part A Active Medical Reviews
• January 2020 Palmetto GBA created tool for IMRT– https://palmettogba.com/internet/eLearn3.nsf/IntensityModulatedRadiation
Therapy/story_html5.html
• Info on documentation, medical necessity and specifically code 77338
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Coding Guidance, Palmetto vs. CMS
Palmetto Standards for Billing NCCI Policy Manual
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Palmetto Targeted Probes
• Reviews by nurses• Prepayment reviews for code 77338
– 45 days to respond with requested documentation, or claim denied and can be referred to RAC or UPIC
– 20-40 claim samples, results in 1:1 teleconference or webinar of errors– Focus likely on 77338 and 77385 per guidance from Palmetto
• Appeal any denial per CMS guidance • Documentation for code 77338 includes a fluence map from plan or
QA• Billable as one device per IMRT plan regardless of number of fields or
arcs in plan
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Aetna IGRT Billing Guidance
• Aetna Radiation Therapy Payment Policy– Codes, including 77014, not reimbursed 60 days pre or post 77301– Created issue for CBCT at time of Tx delivery
• Effective February 7, 2018 per post on www.astro.org– Bill 77387 in place of 77014, even physicians
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Humana APC Reviews & Code 77014
• APC reviews – will deny entire claim if documentation not submitted or supportive of specific codes
– Will continue targeted reviews until entity provides documentation and no findings or can fight review
– Once prove documentation exists, will move on to next provider
• Appeal, Appeal, Appeal!• Humana requires 14 days between 77301 and CBCT (77014)
– ASTRO provided draft letter March 10, 2020– Creates delays in treatment, potential effects
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Misc. Other Payer Denials
• Recently, ASTRO members reported denials from Medicare Administrative Contractors (MACs) for CPT code 77014, CT Image Guidance. The MACs incorrectly required practices to have Advanced Diagnostic Imaging (ADI) accreditation to bill for the technical component of 77014. The Centers for Medicare and Medicaid Services confirmed that this issue has been corrected, and practices should resubmit improperly denied claims for reimbursement.
• CMS corrects inappropriate denials associated with CT image guidance
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Misc. Other Payer Denials
• Missing signatures of physicist on treatment planning documentation denied
– Specifically basic dosimetry calculations to support physicist work
• Services billed over MUE denied – Medical necessity by physician needed to support higher quantity
• Complex treatment devices denied as order did not specify (irregular blocks, special shields, compensators, wedges, molds or casts) per definition, but stated multi-leaf collimation
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Takeaways of Payer Reviews & Denials
• Review payer policies• Ensure documentation supports the procedure accurately• Appeal if documentation is present to support• We are working with ASTRO on some of the payer denial issues• Keep posted for updates
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Review of 2020 Supervision Changes
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HOPPS 2020 Supervision Changes eff. 1/1/2020
• Proposed & Finalized to change to General Supervision– Sought comments whether radiation oncology and chemotherapy administration
should be excepted and still require direct supervision• CMS stressed this does not prevent hospitals and physicians to set direct
supervision for services– Believes this allows for providers flexibility to set the supervision as appropriate and
necessary• Supervision is not physician work – two very different things
– Supervision applies to the ancillary staff work and technical billed charges – Physician personal work is still required for physician services and codes with
professional components, if service is not telehealth approved code, physician physical presence is still required to bill services
• Supervision is the location of the physician relative to the ancillary staff working under the direction of the physician
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Supervision Not Changed For…
Per state and federal laws
supersede CMS
Brachytherapy & use of radioactive
sources
Therapeutic services in the
office or freestanding
center*
Does not apply to physician work
*Waiver during PHE
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Changes in Supervision Related to COVID-19
• Prior to PHE, CMS non-waiver physician supervision of ancillary staff in office/freestanding center
– Direct supervision definition – “Direct supervision in the office setting does not mean that the physician must be present in the same room with his or her aide. However, the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the aide is performing services.”
• Changes under waiver effective March 1, 2020 through end of PHE • CMS adjusted physician supervision of ancillary staff in office/freestanding
center– Under PHE must be provided through interactive real-time audio-video
telecommunication technology– This is minimum requirement, determination of physician if some services require in-
person presence
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Preparing for 2021 E/M Updates
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E/M Outpatient Visit Changes 2021
Deletion code 99201 by AMA, recognized by CMS
Creation of add-on code for prolonged services from AMA 99xxx & complexity code, GPC1X, by CMS
Elimination of history and/or physical exam in determining billable code level
Documentation based on either time or MDM, using the AMA CPT® guidelines
Summary by AMA of changes https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf
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Medicare Learning Network Evaluation and Management Services Guide:
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-
ICN006764.pdf
New vs. Established Patient
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2021 New Patient Visit Codes per AMA
CPT® Code DefinitionTotal Time in
Minutes on Date of Encounter
99201 Deleted for 2021 -
99202 Office or other outpatient visit for the evaluation and management of a new patient, which requiresa medically appropriate history and/or examination and straightforward medical decision making. 15-29
99203 Office or other outpatient visit for the evaluation and management of a new patient, which requiresa medically appropriate history and/or examination and low level of medical decision making. 30-44
99204 Office or other outpatient visit for the evaluation and management of a new patient, which requiresa medically appropriate history and/or examination and moderate level of medical decision making. 45-59
99205 Office or other outpatient visit for the evaluation and management of a new patient, which requiresa medically appropriate history and/or examination and high level of medical decision making. 60-74
For services 75 minutes or longer, Prolonged Services code 99XXX is available as an add-on to 99205.
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2021 Established Pt. Visit Codes per AMA
CPT® Code DefinitionTotal Time in
Minutes on Date of Encounter
99211Office or other outpatient visit for the evaluation and management of an established patient, thatmay not require the presence of a physician or other qualified health care professional. Usually, thepresenting problem(s) are minimal.
No time as part of this code in
2021
99212Office or other outpatient visit for the evaluation and management of an established patient, whichrequires a medically appropriate history and/or examination and straightforward medical decisionmaking.
10-19
99213Office or other outpatient visit for the evaluation and management of an established patient, whichrequires a medically appropriate history and/or examination and low level of medical decisionmaking.
20-29
99214Office or other outpatient visit for the evaluation and management of an established patient, whichrequires a medically appropriate history and/or examination and moderate level of medical decisionmaking.
30-39
99215Office or other outpatient visit for the evaluation and management of an established patient, whichrequires a medically appropriate history and/or examination and high level of medical decisionmaking.
40-54
For services 55 minutes or longer, Prolonged Services code 99XXX is available as an add-on to 99215.
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New Complexity Services Code by CMS
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New Prolonged Services E/M Code from AMA
Prolonged office or other outpatient evaluation andmanagement service(s) (beyond the total time of the primaryprocedure which has been selected using total time), requiringtotal time with or without direct patient contact beyond theusual service, on the date of the primary service; each 15minutes (List separately in addition to codes 99205, 99215 foroffice or other outpatient Evaluation and Managementservices)
99xxx, full code to be released at AMA 2021 code release August/September 2020
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2021 AMA Medical Decision Making
• Straightforward– Self-limited– Minimal or no data review/analyzed– Minimal risk from treatment (including no treatment) or testing. (Most would consider this effectively as no risk)
• Low– Stable, uncomplicated, single problem– Two documents or independent historian– Low risk (i.e., very low risk of anything bad), minimal consent/discussion
• Moderate– Multiple problems or significantly ill– Count: 3 items between documents and independent historian, or interpret or confer– Would typically review with patient/surrogate, obtain consent and monitor, or there are complex social factors in
management
• High– Very ill– Same concepts as Moderate– Need to discuss some pretty bad things that could happen for which physician or other qualified health care professional will
watch or monitor
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2021 Time-Based per AMA
The AMA stressed the following items at the CPT® Symposium, November 2019 as included in Time when provided by physicians or other qualified healthcare professionals:
– Preparing to see the patient (eg, review of tests)– Obtaining and/or reviewing separately obtained history– Performing a medically necessary appropriate examination and/or evaluation– Counseling and educating the patient/family/caregiver– Ordering medications, tests, or procedures– Referring and communicating with other health care professionals (when not
reported separately)– Documenting clinical information in the electronic or other health record– Independently interpreting results (not reported separately) and communicating
results to the patient/family/caregiver– Care coordination (not reported separately)
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Total Time Levels per AMA
New Patient Visits in 2021 Established Patient Visits in 2021
New Patient E/M Code Typical Time (2020) Total Time (2021)
99201 10 minutes Code deleted
99202 20 minutes 15-29 minutes
99203 30 minutes 30-44 minutes
99204 40 minutes 45-59 minutes
99205 50 minutes 60-74 minutes
New Patient E/M Code Typical Time (2020) Total Time (2021)
99211 5 minutes Time component removed
99212 10 minutes 10-19 minutes
99213 15 minutes 20-29 minutes
99214 25 minutes 30-39 minutes
99215 40 minutes 40-49 minutes
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Reminder 90-Day Follow-Up Period Still Applies
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Billing Highlights & Updates to COVID-19 Response
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Telehealth Technology Criteria – Review
• Telehealth services provided by “interactive telecommunication system” – During this PHE to mean “multimedia communications equipment that includes, at a
minimum, audio and video equipment permitting two-way, real-time interactive communication between the patient and distant site physician or practitioner”.
– Systems include FaceTime, Skype, Zoom, Go to Meeting etc.
• If no video capabilities or cannot be performed, the service is not billable under telehealth
• Not every service can be performed by telehealth or approved as part of waiver
• Remote does not = telehealth• No enforcement of HIPAA for good faith practices using these systems
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Update on Modifier CR Revised 4/23/2020
• COVID-19 Frequently Asked Questions (FAQs) on Medicare Fee-for-Service (FFS) Billing – actively updated by CMS
https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf
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Review of Common Modifiers During PHE by CMS
• Applied to Approved Telehealth Service Codes on Part B Claim
• Ex. 99201-99215, 77427-95• Applied to Approved Waiver Service Codes on Part B
Claim• Ex. 99441-99443-CR• Applied to Visit Codes When Visit Results in a Test for
COVID-19 or Order for a Test – to remove cost sharing• Ex 99201-99215, 99221-99223-CS
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Reminders on ICD-10 Coding
• World Health Organization creates ICD-10 codes• Effective April 1, 2020 emergency ICD-10 code
– U07.1 – COVID-19, virus identified
• If documentation lists "suspected," "possible," "probable," or “inconclusive” COVID-19, do not code U07.1
– Assign code or encounter or Z20.828 Contact with and (suspected) exposure to other viral communicable diseases
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Questions?
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