11 IMRT 12-4-09

IMRT Planning & Dosimetry December 2-4, 2009 AMAC® Copyright 2009

www.amac-usa.com 770-693-6031 [email protected]

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IMRT

Presentation by James E. Hugh III, MHA, ROCC®, CHBMEContributions by Linda L. Lively, MHA, CCS-P, RCC, ROCC®, CHBME

Las Vegas, Nevada December 2 - 4, 2009

12/4/2009 1Copyright AMAC® 2009

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AgendaNew CodeIMRT Bundling IssuesCorrect Coding Initiative Edits 15.3Possible Clinical Staging ExamplesACR IMRT Guideline ExamplesIMRT and Associated CodesHelical SystemsV l t i S t

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Volumetric Systems Documentation ExamplesTypical Income Examples

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77338 – Multileaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction

NEW CODES

modulated radiation therapy (IMRT), design and construction per IMRT plan

• Do not report 77338 more than once per IMRT plan

• For Immobilization in IMRT treatment see 77332‐77334

• Do not report 77338 in conjunction with 0073T

This is only for MLCs used in IMRT, ”ONLY”!

• Professional $226.18 Technical $253.36

• Hospital APC $190.62

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1,795,879

2,082,279

1,750,000.00

2,100,000.00

IMRT Delivery 77418

16%

626,946

1,059,503

1,460,211

700,000.00

1,050,000.00

1,400,000.00

, ,

23%

38%

69%

233,874

0.00

350,000.00

1 2 3 4 5 62002 2003 2004 2005 2006 2007

168%

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$916,861,080

$1,062,098,290 $1,050,000,000.00

IMRT Delivery Costs 77418

$354,239,800

$604,024,950

$777,046,050

$916,861,080

$300 000 000 00

$450,000,000.00

$600,000,000.00

$750,000,000.00

$900,000,000.00

71%

29%

18%

16%

$133,886,400

$0.00

$150,000,000.00

$300,000,000.00

1 2 3 4 5 62002 2003 2004 2005 2006 2007

165%


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99,436

111,429

105,000.00

120,000.00

IMRT Planning Procedures 77301

39,188

61,115

82,130

45,000.00

60,000.00

75,000.00

90,000.0012%

21%

34%

56%

17,333

0.00

15,000.00

30,000.00

1 2 3 4 5 62002 2003 2004 2005 2006 2007

126%




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$135,293,675

$153,883,625

$125,000,000

$150,000,000

IMRT Planning Costs 77301

14%

$53,528,100

$83,589,225

$111,608,250

$50,000,000

$75,000,000

$100,000,000 21%

34%

56%

$22,910,825

$0

$25,000,000

1 2 3 4 5 62002 2003 2004 2005 2006 2007

134%


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IMRT 77301IMRT 77301 Bundling Issues




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IMRT 77301 Bundling IssueAfter analyzing all the transmittals and corrections to transmittals, it is evident what the intent of CMS has been since 2002. Services “directly” related to the planning aresince 2002. Services directly related to the planning are bundled. The key is when the actual plan starts and ends. The start occurs once the physicist begins to design the beams or portals and doses to the tumor; the end occurs when the physics plan is accepted and approved by the physician and physicist.

The majority of the codes in question are not related, such as: 77336, 77290, and most of the time 77370. The other codes: 77336, 77 90, and most of the time 77370. The other codes:77305‐77321 and 77295 would never be charged as they are physics plans, and we would not have two physics plans for the same treatment. One may only use and charge one physics plan for each set‐up until a boost or cone down is planned.

Copyright AMAC® 200912/4/2009 9

National Correct Coding InitiativeCorrect Coding Solutions, LLC ‐ A Medicare Contractor

P.O. Box 907, Carmel, IN 46082‐0907Fax: 317‐571‐1745August 15, 2006

“CMS t t fi th t NCCI dit l l t i f d“CMS wants to confirm that NCCI edits only apply to services performed on the same beneficiary by the same provider on the same date of service . The NCCI edits have not been developed with the intent that they are necessarily applicable to services on the same beneficiary by the same provider but on different dates of service. Although some edits might be applicable in such situations, it would be inappropriate for a Carrier to apply NCCI edits in this fashion as part of the NCCI program. However, each NCCI edit is based on a rationale/policy, and this information is available to Carriers . This is one source of information that Carriers may utilize in performing their medical review activities.”

Copyright AMAC® 200912/4/2009

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Correct Coding Initiative Edits 15.3 g(Hospitals under 15.2)

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77301 Edits Version 15.3

Modifier0=not allowed

Column 1 Column 2

0 not allowed1=allowed9=not applicable

77301 77014 0

77301 77261-77263 0

77301 77280 - 77290 0

77301 77295 0

77301 77305 - 77315 0

77301 77321 0

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Modifier

Column 1 Column 2

0=not allowed1=allowed9=not applicable

77301 77326 - 77328 0

77301 77331 0

77301 77332 - 77334 1

77301 77336 0

77301 77370 0

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Modifier0=not allowed


Column 1 Column 2

0=not allowed1=allowed9=not applicable

77301 77401 - 77416 1

77301 77417 0

77301 77421 0

77301 77422 -77423 1

77301 77431 1

77301 77432 0

77301 77470 0

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Clinical Staging Example:

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Example: Clinical StagingMonday Tuesday Wednesday Thursday Friday

Staging Physics planning Verification Physics Treatment

Simulation –77290 (laser, tattoo, immobilize)

77301 IMRT plan 77300 – doseVerification MU (or different date)

77370 –Physics Consult

Treatment - 77418

Immobilize77334(vac-loc, alpha-cradle, aquaplast)

Devices – 77338 MLCs, 77334 Wedges Compensator (or different date)

Final Verification N/A isocenter check77280

CT – 77014 (technical only)

77300 – doseVerification MU (or different date)

Film Dosimetry77331 N/C

N/A IGRT Daily CT, Fluoro, MV/KV or US

77470 N/A N/A N/A D i 7733877470 –Special Procedure

N/A N/A N/A Devices 77338 MLCs, 77334 Wedges Compensator (or different date)

77263 –Professional Prescription

N/A N/A N/A N/A

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Physician Orders

Procedures performed need written directives or orders:orders:

• Non Physician Performed Services:

− Continuing weekly physics (77336)

− Treatments (77418)

− Port Films (77417)

− IGRT (what kind 77421 77014 76950)

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IGRT (what kind, 77421, 77014, 76950)

− Physics (Plans, QA, Verifications 77301)

− Preparation and set up (77290, 77334, 77014)

− Therapists, Nurses, Dosimetrists, Physicists


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Physician Orders Orders Dates & Doctor Initials

CT for placement of fields __________ location

Simulation (immobilization set up)

Simulation check (isocenter)Simulation check (isocenter)

3-D physics plan

MLCsIMRT physics planDose calculations

IGRT – when;_____ what; Fluoro, CT, U/S, KV/MV

Special dosimetry Medical Necessity_____________Date of measurement __________ not for QA

Continuing Weekly Physics

Special Physics ConsultReason - ____________________ (non standard IMRT)

Original Order Date & Signature: ________________________




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ACR IMRT Guidelines (example)

There are many guidelinesThere are many guidelines, www.astro.orgATC Guidelines

AAPMwww.acr.org

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Radiation OncologistThe qualifications and responsibilities of the radiation oncologist shall be clearly defined and should include the following:1. Participate in and approve the immobilization/repositioning system in consultation with other members of the team.

2 Define the goals and requirements of the treatment plan including the2. Define the goals and requirements of the treatment plan, including the specific dose constraints for the target(s) and nearby critical structures.

3. Delineate tumor and specify and approve target volumes, preferably using appropriate International Commission on Radiation Units and Measurements (ICRU) methodology.

4. Contour critical normal structures not clearly discernible on cross‐section.

5. Review and approve all critical structures contoured.6. Perform final evaluation and approve final intensity‐modulated treatment plan for implementation.

7. Review and approve all implementation and verification images (simulation and/or portal images).

8. Participate in peer review of contours and IMRT treatment plans in conjunction with other members of the team.




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Qualified Medical PhysicistThe responsibilities of the Qualified Medical Physicist shall be clearly defined and should include the following:1 Perform acceptance testing commissioning and implementation of the IMRT1. Perform acceptance testing, commissioning, and implementation of the IMRT treatment‐planning system and all subsequent upgrades, including the system’s interface with the treatment delivery software and hardware units.

2. Understand the limitations and appropriate use of the radiation therapy treatment planning (RTP) system, including the characteristics of the dose optimization software, the precision of generated IMRT patient and beam geometry, and the applicability of dose calculational algorithms to different clinical situations.

3. Establish and manage a QA program for the entire IMRT system, to include the planning system, the delivery system, and the interface between these systems.

4. Act as a technical resource for the IMRT team.5. Consult and participate with the radiation oncologist and other team members in implementing the immobilization/repositioning system for the patient.

6. Participate in review of contours and anatomic structures for the IMRT plan.7. Review each patient’s IMRT plan for technical accuracy and precision.8. Provide physical measurements for verification of the IMRT plan.


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IMRT Treatment Delivery

IMRT dose delivery must use an MLC, a binary collimator (tomotherapy), or a pencil beam with leaves or other collimating ( py) p gdevices that project to a nominal beam width of 1 cm or less at the treatment unit isocenter. The exact delivery method is currently restricted to the above techniques that have the ability to reproduce the highly modulated intensity patterns resulting from the treatment planning process delineated above. Such delivery methods include, for example, multiple static segment treatment (step‐and‐shoot), dynamic segment treatment (sliding window),(step and shoot), dynamic segment treatment (sliding window), binary‐collimator tomotherapy, and intensity‐modulated arc techniques.




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Documentation

Documentation of delivered doses to volumes of target and non target tissues, in the form of dose volume histograms and

t ti ti l i d t t t direpresentative cross‐sectional isodose treatment diagrams, should be maintained in the patient’s written or electronic record.

As noted above, various treatment verification methodologies, including daily treatment unit parameters, films confirming proper patient positioning, and records of physical measurements confirming treatment dosimetryphysical measurements confirming treatment dosimetry, should also be incorporated into the patient’s record.


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Dose Delivery Verification by Physical Measurement

The medical physicist should assure verification of actual radiation doses being received during treatment delivery.

Prior to the start of treatment, accuracy of dose delivery should be documented by irradiating a phantom containing either calibrated film to sample the dose distribution or an equivalent measurement system to verify that the dose delivered is the dose planned In addition the dose to a smalldelivered is the dose planned. In addition, the dose to a small region should be verified using an ionization chamber.




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IMRT Codes

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Medical NecessityWhy is the patient being treated?What is the form of treatment?Why are you treating in this fashion and not another method?____ (Patient Name) ____ has prostate cancer. It was clear that there were no maneuvers that would be available to reduce the GTV, CTV or PTV to allow for an adequate and appropriate distribution other than the use of intensity modulated radiation therapy. Because of the potential significant morbidity of treatment to the

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p g yimmediately adjacent bladder and rectum, IMRT was chosen to keep that risk of damage to a minimum. It was also clear that with 3D conformal treatment, we would not have been able to shape the dose of radiation to the convex structure of the prostate gland, minimizing the dose of the immediately adjacent normal tissue, without the use of IMRT.




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Medical Necessity: ExamplesBCBS

IMRT of the prostate is considered medically necessary in patients with non‐metastatic prostate cancer for dose escalation >75 Gy.IMRT is considered medically necessary in the treatment of patients with head and neck cancer, with the exception of patients with early stage larynx cancer (stage I and II).IMRT is considered medically necessary in patients with CNS lesions with close proximity to the optic nerve or brain stem.IMRT is considered medically necessary in patients with pediatric tumors (e.g., Ewing Sarcoma, Wilms' Tumor).IMRT is considered medically necessary in patients with squamous cell carcinoma of the anus.IMRT is considered medically necessary for all primary malignant gynecologic tumors ( t i f ll i t b ) h d i t i l i di t th l f ll

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(uterus, cervix, ovary, fallopian tube) when dosimetric planning predicts the volume of small intestine receiving doses > 45 Gy would result in unacceptable risk of small intestine injury (V45 > 10% or V49 > 5%).IMRT is considered medically necessary for locally advanced rectal adenocarcinoma when dosimetric planning predicts the volume of small intestine receiving doses > 45 Gy would result in unacceptable risk of small intestine injury (V45 > 10% or V49 > 5%).


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Medical Necessity: ExamplesAETNA

IMRT planning may be clinically indicated when one or more of the following conditions are present:following conditions are present:The target volume is in close proximity to critical structures that must be protected. The volume of interest must be covered with narrow margins to adequately protect immediately adjacent structures. An immediately adjacent area has been previously irradiated and abutting portals must be established with high precision. The target volume is concave or convex, and the critical normal tissues are

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within or around that convexity or concavity. Dose escalation is planned to deliver radiation doses in excess of those commonly utilized for similar tumors with conventional treatment.




www.amac-usa.comMedical Necessity: ExamplesAETNA

According to the coding guide (ASTRO, 2007), the most common sites that currently support the use of IMRT include:Primary, metastatic or benign tumors of the central nervous system, including the brain, brain stem, and spinal cord. , pPrimary, metastatic tumors of the spine where spinal cord tolerance may be exceeded by conventional treatment. Primary, metastatic or benign lesions to the head and neck area, including:

− Orbits − Sinuses − Skull base − Aerodigestive tract Salivary glands

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− Salivary glandsCarcinoma of the prostate Selected cases of thoracic and abdominal malignancies Selected cases (i.e., not routine) of breast cancers with close proximity to critical structures Other pelvic and retroperitoneal tumors thaat meet requirements for medical necessity (as noted above) Reirradiation that meets the requirements for medical necessity (as noted above).


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IMRT Treatment Delivery 77418

“Single or multiple fields/arcs, via narrow spatially g p / , p yand temporarily modulated beams (e.g., binary, dynamic, MLC, per treatment session)” AMA

LCD’SL30316 (Noridian and Cahaba), L6336 (Palmetto) and

( ilbl )

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L26834 (Trailblazer)




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Intensity Modulated Radiation Therapy Planning

77301 – IMRT planning requires delineation of a tumor bearing volume and a number of normal tissue volumes, whose tolerance to radiation is less than that of the tumor. Only one IMRT plan should be reported per course of therapy; however, if the clinical condition changes and treatment parameters are altered, such as in a “boost,” then an additional plan may be reported with appropriate

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documentation.LCD’SL7987 (Palmetto), L23754 (Noridian) and L26833 (Trailblazer)

Medical Necessity12/4/2009 Copyright AMAC® 2009

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IMRT Planning 77301:“Intensity modulated radiotherapy plan, including dose‐volume histograms for target and critical structure partial tolerance specifications (Dose plan is optimizedpartial tolerance specifications. (Dose plan is optimized using inverse or forward planning technique for modulated beam delivery—e.g., binary, dynamic MLC to create highly conformal dose distribution. Computer plan distribution must be verified for positional accuracy based on dosimetric verification of the intensity map with verification of treatment set up and interpretation of verification methodology).”of verification methodology).




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IMRT Planning 77301

1. Multiple boosts?p2. 3-D with IMRT?3. IMRT with 3-D?


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Simulations

Simple Simulation – 77280• Isocenter check• Isocenter check

Complex Simulation• Tangents, blocks, MLC, wedges (EDW STD), immobilization device, rotation

Documentation• Date, patient name, area, port #’s, description, devices,

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ate, pat e t a e, a ea, po t s, desc pt o , de ces,body position, head, tattoos, comments.

• ONE PER DAY




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77470 – Special Treatment Procedure

IMRT “________ is receiving definitive irradiation for is being treated with IMRT and_______. ___ is being treated with IMRT and

receiving chemotherapy. The patient will be set up, planned and positioned daily for allowance for movement and require extra work and time involved.”__________________________, MD


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Dosimetry (77300)“Basic radiation dosimetry calculation, central axis depth dose, TDF, NSD, gap calculation, off axis factor, tissue in homogeneity factors, calculation of nonionizing radiation surface and depth , g pdose, as required during course of treatment, only when prescribed by the treating physician.”“The typical course of radiation therapy will consist of one to six dosimetry calculations, depending on the complexity of the case. (However, radiation treatments to the head/neck, prostate, and Hodgkin’s disease may require eight or more calculations). Frequency in excess of the upper end of this range will require

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Frequency in excess of the upper end of this range will require supporting documentation.”Per Gantry Angle only

Separate verification of plan calculations need to be performed




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Physics Consults (77336 and 77370)

77336 “Continuing medical physics consultation, including assessment of treatment parameters, quality assurance of dose delivery, and review of patient treatment documentation in support of the radiation oncologist, reported per week of therapy.”

77370 “Special medical radiation physics consultation”“The special medical radiation physics consultation code is used when the radiation oncologist makes a direct request to the qualified medical physicist for a special consultative report or for specific physics services on an individual patient. Such a request may be made when the comple it of the treatment plan is of s ch ma nit de that a thoro hcomplexity of the treatment plan is of such magnitude that a thorough written analysis is necessary to address a specific problem or when the service to be performed requires the expertise of a qualified medical physicist. The clinical indication that justified the request for the special physics consultation should also be documented.”


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Treatment Devices (77333‐77334)

77333 “Treatment devices, design and construction; intermediate (multiple blocks, stents, bite blocks,intermediate (multiple blocks, stents, bite blocks, special bolus)”77334 – For Non MLC compensator based IMRT (Compensator based IMRT use 77334 for compensators) or Immobilization devices "Treatment devices, design and construction; complex (irregular blocks special shields compensators wedges molds

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blocks, special shields, compensators, wedges, molds or casts)” MLCs and immobilization77338 – Multileaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction per IMRT plan




www.amac-usa.comMedical Necessity

Physics Planning

Verification

Verification

VerificationPhysician Physician approvalapproval


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Helical Arc SystemsyTomotherapy




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Usually Helical Systems Have the Following:

1 1 helical rotation1. 1 helical rotation2. 1 Dose calculation (verified)

1 MLC (questionable on segmentation)

3. The more complicated the plan the longer the treatment


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Volumetric Modulated Arc Therapy (VMAT) Systems




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Usually Volumetric Systems Have the Following:

1. 1+ Rotation/Arc1. 1+ Rotation/Arc2. 1‐10 Dose calculations (verified)

1‐10 MLCs (dependant upon the orders, equipment, and verification systems)

3. The more complicated the plan the longer the treatment


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VERIFICATION FORVolumetric Systems

• Many new software packages today toMany new software packages today to verify control points, for example:

• “Dosimetry Check”

• “Matrixx”

“D lt 4”• “Delta4”

• Need input from Planning system




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Documentation Examples


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Standard Linac SystemsStandard Linac Systems




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Usually Standard Linac systems have the following:

1 5 11 gantry angles1. 5 ‐ 11 gantry angles2. 5 – 11 dose calculations (verified)3. 5 – 11 MLCs4. The higher number of gantry angles the

more complex and longer the treatment


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Documentation Examples




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Payments for 2009Payments for 2009 and 2010

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PATIENT MIX MPFS PHYSICIAN2009

Professional2010

ProfessionalPercentage of

Change

Breast IMRT $2,321 $2,258 -2.71%Breast Standard $2,558 $2,595 1.44%Prostate IMRT 40 fractions $3,603 $3,358 -6.80%Prostate IMRT Seed Boost 25 fractions $2,573 $2,388 -7.19%Prostate Standard $3,623 $3,677 1.50%Lung IMRT $2,420 $2,684 10.91%Lung Standard $3,062 $3,105 1.39%Brain IMRT $2,385 $2,193 -8.06%Radiosurgery Multisession brain body Non robotic $1,643 $1,635 -0.49%Radiosurgery single session brain Non Robotic $1,930 $1,932 0.12%Radiosurgery single session brain Robotic $1,930 $1,932 0.12%Radiosurgery Multisession brain body robotic $2,272 $2,283 0.48%Abdominal IMRT (pancreas, liver, body) $3,261 $3,257 -0.12%Abdominal Standard $3,255 $3,300 1.38%Palliative $1,220 $1,217 -0.30%Head & Neck IMRT $3,894 $3,527 -9.42%Hyperthermia Interstitial (additional) $556 $564 1.48%H th i S fi i l ( dditi l) $636 $659 3 58%Hyperthermia Superficial (additional) $636 $659 3.58%HDR GYN/Lung (no external beam) $1,517 $1,506 -0.72%HDR Prostate 3 fractions over two days $1,712 $1,699 -0.77%HDR Breast (no external beam) multicatheter $2,876 $2,875 -0.02%IGRT Ultrasound tumor localization $1,169 $1,174 0.50%IGRT Fluoro-Ray tumor localization $346 $348 0.50%IGRT CT tumor localization $1,702 $1,725 1.35%IGRT KV MV X-Ray tumor localization $779 $783 0.50%

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PATIENT MIX MPFS PHYSICIAN 2009 Technical 2010 Technical Percentage of Change

Breast IMRT $16,456 $15,927 -3.21%Breast Standard $9,583 $9,548 -0.37%Prostate IMRT 40 fractions $25,377 $24,086 -5.09%Prostate IMRT Seed Boost 25 fractions $16,816 $15,991 -4.91%Prostate Standard $13,331 $13,315 -0.11%Lung IMRT $21,635 $21,050 -2.70%Lung Standard $10,760 $10,690 -0.65%Brain IMRT $14,137 $13,390 -5.28%

Radiosurgery Multisession brain body Non robotic $10,929 $10,740 -1.73%

Radiosurgery single session brain Non Robotic $3,690 $3,472 -5.91%

Radiosurgery single session brain Robotic $5,381 $5,162 -4.08%

Radiosurgery Multisession brain body robotic $19,795 $19,578 -1.10%Abdominal IMRT (pancreas, liver, body) $22,980 $22,112 -3.78%Abdominal Standard $11,747 $11,702 -0.38%Palliative $3,358 $3,356 -0.05%Head & Neck IMRT $26,021 $24,476 -5.94%Hyperthermia Interstitial (additional) $2,977 $2,998 0.72%Hyperthermia Superficial (additional) $3,030 $3,317 9.47%HDR GYN/Lung (no external beam) $3,044 $2,857 -6.16%HDR Prostate 3 fractions over two days $3,421 $3,145 -8.08%

HDR Breast (no external beam) multicatheter $6,262 $5,682 -9.25%IGRT Ultrasound tumor localization $1,659 $1,551 -6.49%IGRT Fluoro-Ray tumor localization $3,462 $3,552 2.59%IGRT CT tumor localization $5,698 $5,582 -2.04%IGRT KV MV X-Ray tumor localization $3,751 $3,538 -5.68%

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PATIENT MIX HOSPITAL2009 final Payments

2010 Final Payments Percent Change

Breast IMRT $13,878 $13,428 -3.24%Breast Standard $9,063 $9,037 -0.29%Prostate IMRT 40 fractions $22,734 $21,062 -7.35%Prostate IMRT with Seed Boost 25 fractions $14,598 $13,627 -6.65%Prostate Standard $12,894 $12,862 -0.25%Lung IMRT $17,725 $17,736 0.06%Lung Standard $10,808 $10,808 0.01%g $ , $ ,Brain IMRT $12,429 $11,418 -8.14%Radiosurgery multi-session non robotic $9,374 $9,391 0.18%Radiosurgery single session non robotic $8,045 $7,781 -3.29%Radiosurgery single session robotic $8,045 $7,781 -3.29%Radiosurgery multi-session robotic $18,620 $17,999 -3.33%Abdominal IMRT $19,982 $19,088 -4.47%Abdominal Standard $11,410 $11,395 -0.13%Pallative cases brain and bone (mets) $3,352 $3,355 0.07%Head & Neck IMRT $23,713 $21,649 -8.70%Hyperthermia Interstitial (additional) $2,231 $2,250 0.84%Hyperthermia Interstitial (additional) $2,231 $2,250 0.84%Hyperthermia Superficial (additional) $2,231 $2,250 0.84%HDR GYN/Lung (no external bean) $6,289 $6,380 1.45%HDR Breast (no external bean) multicatheter $11,357 $11,680 2.84%IGRT Ultrasound X-Ray tumor localization $0 $0 0.00%IGRT Flouro-Ray tumor localization $0 $0 0.00%IGRT CT Tumor localization $0 $0 0.00%IGRT KV MV X-Ray tumor localization $0 $0 0.00%

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IMRT code payments for 2009 and 2010

CPT DescriptionProfessional

Payment Rate 2010

Professional Payment Rate

2009

RED IS lower

BLACK Higher

PERCENTAGE INCREASE OR

DECREASE

77301 Radiotherapy dos plan, imrt $405.60 $400.69 $4.91 1%y77418 Radiation tx delivery, imrt $0.00 $0.00 $0.00 N/A

CPT DescriptionTechnical

Payment Rate 2010

Technical Payment Rate

2009

RED IS lowerBLACK Higher


DECREASE

77301 Radiotherapy dos plan, imrt $1,770.63 $1,756.05 $14.58 0.83%77418 Radiation tx delivery, imrt $503.46 $516.83 $13.37 -2.59%

CPT DescriptionAPC Final

Payment Rate 2010

APC Final Payment Rate

2009

RED IS lowerBLACK Higher


DECREASE

77301 Radiotherapy dos plan, imrt $927.34 $892.90 $34.44 3.86%

77418 Radiation tx delivery, imrt $421.22 $410.83 $10.39 2.53%


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AUDIT




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Ray D. Ashon, MD#666324 linac DriveAudit, Montana 11111

Date: 2/2/09ICN: 2 345 23 83 234HIC: 3244566743AAcct.# 4888564587654RE: everyday PatientPhys/supl: Z34333

Dear Doctor or Supplier:We are processing a claim for everyday patient received on 1/2/09, and we cannot complete this processing without the requested information below. Please answer each question and return this letter within 30 days.Please return this letter with the requested information. If the requested information is not returned in 45 days, processing of the claim will be decided by the information present. Payment may be reduced or denied if this information has not been received.

Copy of report, physician orders, and medical necessity from 12/27/09 through 12/28/09 for 77418 for $1800.SincerelyMedicare Part B800‐333‐3333


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OH, NO!

WHAT DO THEY WANT?

WHY ME?




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These are standard letters to the provider of care or suppliers,These are standard letters to the provider of care or suppliers, 1842 (a) (1) (c) Social Security Act. Everyone receives these letters at one time or another as required by CMS of all their contractors. These may be “pre‐payment” or “post‐ payment” review. Most of these audits are based on the average dollars or utilization of the code(s) by providers and are compared to all the providers in the CMS contractors area of interest.

They may even supply you a graph to show where you areThey may even supply you a graph to show where you are statistically in relation to your peers. You could be average and not outside the norm and still be audited.


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Please follow these simple rules:1. Hire competent people

2. Read the letter and the request slowly from the payor

3. Supply the payor only what they are asking

4. Do not give the payor any more information than has been requested

5 Go to the paper or electronic record and copy parts of5. Go to the paper or electronic record and copy parts of the documentation needed

6. Never say, “Why didn’t I document better!”




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Elements of a Complete Medical Record may i l dinclude:

1. Physician orders and/or certifications of medical necessity

2. Patient questionnaires associated with physician services3. Progress notes of another provider referenced in your

own notes4. Treatment logs5. Related professional consultation reports6. Procedure, lab, X‐ray and diagnostic reports


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We reviewed the payors rules concerning code 77418. We then searched the medical chart and decided on the following documentation:decided on the following documentation:

1. Consult contained the diagnosis, so we used page 3 of theconsult and did not supply pages 1 and 2 medical necessity

2. The last page of the consult also contained the “PLAN” thatdescribed why we were going to use IMRT and not 3‐Dconformal therapy medical necessity

3. We supplied the “written prescription,” “directive,” or “order”that stated use IMRT for 40 fractions at 72Gy ordersthat stated use IMRT for 40 fractions at 72Gy orders

4. Supplied the electronic record of the charge capture recordand verify system showing these two dates of treatment onlyprocedures performed on 12/27 and 12/28


11 IMRT 12-4-09

Documents

Transcript of 11 IMRT 12-4-09