2021 Coding and Documentation Radiation Oncology

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2021 Coding and DocumentationRadiation Oncology


Notices

When a third‐party payer is involved, the determination of reimbursement for services is the decision of the individual insurance company based on the patient’s policy and the third‐party payer guidelines. No guidance can adequately address reimbursement issues for the hundreds of insurance payers that exist. Efforts have been made to ensure the information was valid at 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. Therefore, it is essential that each payer be contacted for their individual requirements.

CPT® codes, descriptions and other data are copyright 2020 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.

The websites listed in this presentation are current and valid as of the date of this presentation. However, webpage addresses and the information on them may change or disappear at any time and for any number of reasons. The attendee is encouraged to confirm or locate any URLs listed here that are no longer valid.


Presenters

Ron DiGiaimo, MBA FACHECEO

Revenue Cycle Coding [email protected]


Federal Register

• Document actions of Federal agencies and forum for public review and comment

• Publications include: Presidential Documents, Rule & Regulations, Proposed Rules and Notice

HOPPS

MPFS


• CPT® codes listed in either Column 1 or Column 2• Indication:

0 – Rule “zero chance of getting paid” = Modifier not allowed1 – Rule “one chance of getting paid” = Modifier allowed9 – Rule no longer applicable “typically in place originally in error”

Column 1 Column 2 Effective Date Deletion Date Indication

77295 77300 20160101 20160101 9

77300 77331 20031001 0

77321 77336 20031001 1

PTP Edits NCCI National Correct Coding Initiative


Medically Unlikely Edits (MUEs)

Predetermined quantity allowed for a particular CPT® code on a date of

service

Automated prepayment edit to prevent inappropriate payment

May be claim line or date of service edit

CodeMUE Value

MAI MUE Rationale

77300 103 Date of Service Edit: Clinical

Clinical: Data

77336 12 Date of Service

Edit: Policy

Code Descriptor /

CPT Instruction


NCCI Policy Manual

“2. Continuing medical physics consultation (CPT code 77336) is reported “per week of therapy”. It may be reported after every five radiation treatments. (It may also be reported if the total number of radiation treatments in a course of radiation therapy is less than five.) Since radiation planning procedures (CPT codes 77261‐77334) are generally performed before radiation treatment

commences, the NCCI contains edits preventing payment of CPT code 77336 with CPT codes 77261‐77295, 77301‐77318, and 77332‐77334. Because

radiation planning procedures may occasionally be repeated during a course of radiation treatment, the edits allow modifier 59 to be appended to CPT code 77336 when the radiation planning procedure and continuing medical physics

consultation are reported on the same date of service.”


Exception 1 ‐ 90 E&M Billing Rule

Techniques that do not allow billing of treatment

management codes or stated otherwise

Brachytherapy (Medicare)

Superficial

Intraoperative


Exception 2 – 90 Day Rule

Visits for “new” medical conditions can be charged during the 90‐day follow‐up period.

Not related to the malignancy treated

Not related to any condition managed during the course of

therapy


Facility Clinic Visits

G0463 Hospital outpatient clinic visit for assessment and management of a patient•Hospital outpatient only•Reimburses for facility overhead and costs•Does not differentiate between new and established•Documentation required


Simple planning requires a single treatment area of interest encompassed in a single port or simple parallel opposed ports with simple or no blocking.77261Intermediate planning requires three or more converging ports, two separate treatment areas, multiple blocks, or special time dose constraints.77262Complex planning requires highly complex blocking, custom shielding blocks, tangential ports, special wedges or compensators, three or more separate treatment areas, rotational or special beam considerations, combination of therapeutic modalities.

77263

Clinical Treatment Planning – Organ Limits Time


Utilization

Billable once per course, with exception of new problem

Applicable for most treatment techniques

Documentation must support date of service and complexity

More than radiation therapy

prescription


Special Treatment Procedure

Special treatment procedure (eg, total body irradiation, hemibody radiation, per oral or endocavitary irradiation)77470

Reported for extra work required by the physician & staff for special procedures

Allowed once per course of therapy even with more than one

qualifier

Requires documentation to

support the additional time and/or effort


IMRT Simulations

Not separately billable with IMRT planning code, CPT®

77301

Practice Expense included with 77301

(MPFS)

Bundled per Medicare Claims Processing Manual (HOPPS)


Examples of Treatment Devices 77332‐77334

Simple

Pre‐made electron block

Simple bolus

Treatment bra

Breast board

Intermediate

Bite block

Customized bolus

Pituitary head holder

Complex

Aquaplast masks

Alpha cradles

Vac‐Lok™

Custom molds/shields


MRI Planning Images

Clinical Examples in Radiology “Question: If a radiation oncology patient has an MRI study of the pelvis for the treatment planning process, what is the appropriate CPT® code to report? Answer:When computed tomography (CT) or magnetic resonance imaging (MRI) is ordered for radiation therapy treatment planning, and additional interpretation is requested to evaluate extent of tumor and/or metastatic spread, this procedure should be coded as a diagnostic procedure. If a CT or MRI study is done simply for port verification and no interpretation is issued, only the technical component (TC) should be reported. Code 77014‐TC, Computed tomography guidance for placement of radiation therapy fields, is reported for the CT study, and code 76498‐TC, Unlisted magnetic resonance procedures (e.g., diagnostic, interventional), is reported for the MRI study.”


Isodose Planning Includes Calculations

Isodose Plan

77306

77307

77321

Beam Modifiers

77332

77333

77334

Used when 3D or IMRT requirements are not met


Multiple Plans

When multiple plans are performed, the one used for treatment is billable

Separate non‐contiguous treatment sites support a single complex plan

(77307)

Medically necessary boost plans are separately billable


Documentation

Physician and physicist approvals required

Documentation must support date of service billed

Documentation of isodose plan is required in addition to treatment devices and

calculations


3D Planning

3D Plan

77295

Beam Modifiers

77332

77333

77334

Calculations

77300

Respiratory Management

77293 (if applicable)


3D Plan

3‐dimensional radiotherapy plan, including dose‐volume histograms77295

Volume of Interest

Critical Structure(s)


Exception to the Rule

Noridian Healthcare Solutions“In those uncommon circumstances where there is a substantial change in either patient anatomy or tumor conformation where a second CT dataset is required to produce an accurate, efficacious and safe “cone‐down”

plan, a second 77295 charge may be appropriate. When the physician deems this to be the case, the medical necessity for the second 77295 simulation

must be documented.”


Documentation

Printed or electronically archived plan

Evidence of physician and physics approval

3D reconstruction of the tumor volume & critical structure(s)

Dose Volume Histogram (DVH)


IMRT

IMRT Plan

77301

IMRT Device

77338(or 77334 for compensator)

Secondary Calculations

77300


77293(if applicable)


IMRT Medical Necessity Statement by Dr. Rad Onc

Why does this patient require IMRT over other

forms of treatment?


First Coast Service Options


IMRT Plan

Intensity modulated radiotherapy plan, including dose‐volume histograms for target and critical structure partial tolerance specifications

77301

Requires inverse planning for highly conformal dose distribution

Not utilized for forward planning

QA documentation is required

including physician review


Planning Process Includes:

Simulation Isodose planning Target delineation

Beam verification and QA


77338 IMRT Device Documentation

May be supported by

MLC within plan or separate fluence


IMRT Calculations (77300)

Separate and distinct service from IMRT planning within the treatment planning computer

Billing date is the date of the “secondary” calculation(s)


Stereotactic Techniques

SRS SBRT

138


SRS Defined

Complete course in 1 fraction

Intracranial May include multiple lesions


SBRT Defined

Complete course in five

fractions or less

Treatment to the body

Includes fractionated SRS

May include multiple lesions


MLN Matters: MM8572

In addition, for the planning services, hospitals must report the specific CPT code that accurately describes the service provided. The planning services may include but are not limited to CPT® code 77290, 77295, 77300, 77334, or 77370, listed in Table 3 below.

CPT® Codes that are Reportable for SRS Planning Services Effective January 1, 2014

Code Long Descriptor

77290 Therapeutic radiology simulation‐aided field setting; complex

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

77300

Basic radiation dosimetry calculation, central axis depth dose calculation, tdf, nsd, gap calculation, off axis factor, tissue inhomogeneity factors, calculation of non‐ionizing radiation surface and depth dose, as required during course of treatment, only when prescribed by the treating physician

77334 Treatment devices, design and construction; complex (irregular blocks, special shields, compensators, wedges, molds or casts)

77370 Special medical radiation physics consultation

142


Dosimetry Planning

CPT® Assistant October 2007“The current recommendation is to use any appropriate CPT codes normally

associated with SRS planning in place of the deleted HCPCS codes. Available codes include CPT code 77295, Therapeutic radiology simulation‐aided field setting; 3‐

dimensional); 77300, Basic radiation dosimetry calculation, central axis depth dose calculation, TDF, NSD, gap calculation, off axis factor, tissue inhomogeneity factors, calculation of non‐ionizing radiation surface and depth dose, as required during course of treatment, only when prescribed by the treating physician; 77301, Intensity modulated radiotherapy plan, including dose‐volume histograms for target and critical structure partial tolerance specifications; or 77370, Special

medical radiation physics consultation, depending on the modality of treatment delivery used. Treatment devices (ie, CPT codes 77332‐77334) are also reported

separately from the planning and delivery codes if appropriate. ”


Important Reminder

Regardless of whether one or more lesions are

treated, CPT code 77295 or 77301 should only be used

once for the entire episode.


Continuing Medical Physics

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

77336

Billable once per five fractions

Applicable for single fraction or two fraction courses

Three or more fractions are

required in final week

Documentation required to

support physics review and parameters checked


NCCI Policy Manual

“Continuing medical physics consultation (CPT code 77336) is reported “per week of therapy.” It may be reported after every five radiation treatments. (It may also be reported if the total number of radiation treatments in a course of radiation therapy is less than five.) Since radiation planning procedures (CPT codes 77261‐77334) are generally performed before radiation treatment

commences, the NCCI contains edits preventing payment of CPT code 77336 with CPT codes 77261‐77295, 77301‐77318, and 77332‐77334. Because

radiation planning procedures may occasionally be repeated during a course of radiation treatment, the edits allow modifiers 59 or ‐X{EPSU} to be appended to CPT code 77336 when the radiation planning procedure and continuing medical

physics consultation are reported on the same date of service.”


Special Physics Consult

Special medical radiation physics consultation77370

Must be ordered by a physician for a specific reason

Billed on the date of the consultative

report

Requires expertise of a qualified

medical physicist


Documentation

Request by the physician for a specific reason

Report by the physicist addressing the specific request

Physician review and approval of

report


Specific Problem

A simple check‐off box in the patient chart is not sufficient and a description of the purpose of the consult is necessary. The

request must be specific to the patient and must address the

particular problem or service that requires the expertise of a qualified medical physicist.


Proton Therapy Techniques

Pencil Beam Scanning

Passive Scattering


Proton Therapy

Pencil Beam Scanning (PBS)• Intensity modulated proton therapy

• Typically do not utilize compensators or apertures–New treatment units may have Adaptive Aperture™

Passive Scattering• Traditional/Classic Proton Therapy

• Utilizes compensators and apertures


Dosimetry Planning

3D3D Plan

Beam Modifiers

Basic Dosimetry Calculations

IMPTIMRT Plan

IMRT Device (if applicable)



3D

3D Plan

77295

Beam Modifiers

77334

Calculations

77300


77293 (if applicable)


Compensators/Apertures

Considered complex treatment device(s)

CPT® 77334

Documentation including physician signature required


IMPT

IMRT Plan

77301

IMRT Device

77338* *Only if utilizing

MLC


77300


77293(if applicable)


Proton Delivery

Proton treatment delivery, simple, without compensation77520

• Single treatment area• Single non‐tangential or non‐oblique port• Without compensation

Proton treatment delivery, simple, with compensation77522

• Single treatment area• Single non‐tangential or non‐oblique port• With compensation


Proton Delivery

Proton treatment delivery, intermediate77523• One or more treatment areas• Two or more ports, or• One or more tangential or oblique ports• Custom blocks and compensators


Proton Delivery

Proton treatment delivery, complex77525• One or more treatment areas• Two or more ports per treatment area• With matching or patching fields and/or multiple isocenters• Custom blocks and compensators


Medical Necessity

Support for the technique

Expectation of a long‐term benefit

Evidence of a dosimetric

advantage over other forms of

radiation therapy


IORT – No Vault Necessary

Intraoperative radiation treatment delivery, x‐ray, single treatment session77424Intraoperative radiation treatment delivery, electrons, single treatment session

77425

Intraoperative radiation treatment management77469


Radiation Oncology Alternative Payment Model


Timeline – May be delayed or eliminated?

July 2019

RO APM Proposed Rule published with potential start date of January 1, 2020 or April 1, 2020

Fall 2019

Regulatory Agenda indicates final action required by 2022

September 18,2020

RO APM Final Rule published with January 1, 2021 implementation date

October 21, 2020

CMS announces delayed implementation

July 1, 2021

2021 OPPS Final Rule finalized implementation

date delay

January 1, 2022

Revised implementation date signed into law

12/27/20 (cannot start before this date)


Alternative Payment Model

Departure from fee‐for‐service reimbursement method

Episodic payments based on diagnosis

Modality agnostic Site‐neutral

Required participation of 30% of eligible

episodes


Key Points

Mandatory At least a 4‐year program

Participants selected randomly

via CBSA

Includes typical radiation

oncology settings16 cancer types

Common treatment techniques


Episodic Payment

90‐DAY EPISODE OF CARE

50% OF PAYMENT AT INITIATION

50% OF PAYMENT AT COMPLETION


Episode Triggers

Episode Triggers

HCPCS

Professional per cancer type

Technical per cancer type

Modifier

V1 Start of Episode

V2 End of Episode


Episode Timeline

Consultation

E/M services are not included within the model and will continue to be paid FFS

Day 1

Start of Professional EpisodeClinical Treatment Planning

(77261‐77263) performed and billed

HCPCS and SOE modifier billed

Before day 29

Start of Technical or Dual Episode

Technical service performed and billed

HCPCS and SOE modifier billed

90 days

End of Professional EpisodeHCPCS and EOE modifier billed

End of Technical EpisodeHCPCS and EOE modifier billed

28 days

Clean PeriodServices performed during this

time paid FFS

New episode

New episode would be triggered after clean period


Map courtesy of Health Management Associates


Excluded Participants

State of Maryland State of Vermont U.S. Territories Ambulatory surgical centers (ASCs)

Critical access hospitals (CAHs)

Prospective Payment System (PPS)‐exempt

cancer hospitals

Participates in or identified as eligible to participate in

Pennsylvania Rural Health Model


Low Volume Opt‐Out

< 20 Episodes

Based on recent claims data

CMS will notify 30 days prior

Participant must attest on or before December 31st for

next year


Cancer Types

16 cancer types selected

Commonly treated with radiation

Majority of all incidence of cancer types

Demonstrated pricing stability


Cancer Type ICD‐10 CodesAnal C21.xx Bladder C67.xx

Bone Metastases C79.5x

Brain Metastases C79.3x

Breast C50.xx, D05.xx Cervical C53.xx CNS Tumors C70.xx, C71.xx, C72.xx Colorectal C18.xx, C19.xx, C20.xx

Head and NeckC00.xx, C01.xx, C02.xx, C03.xx, C04.xx, C05.xx, C06.xx, C07.xx, C08.xx, C09.xx, C10.xx, C11.xx, C12.xx, C13.xx, C14.xx, C30.xx, C31.xx, C32.xx, C76.0x

Liver C22.xx, C23.xx, C24.xx Lung C33.xx, C34.xx, C39.xx, C45.xxLymphoma C81.xx, C82.xx, C83.xx, C84.xx, C85.xx, C86.xx, C88.xx, C91.4x Pancreatic C25.xx Prostate C61.xx Upper GI C15.xx, C16.xx, C17.xx Uterine C54.xx, C55.xx


ExclusionsExclud

ed • Benign neoplasms• Cancers rarely treated with radiation • Skin cancer diagnoses• Kidney (excluded per Final Rule)• Y‐90 procedures


Modalities

Includ

ed • 3D• IMRT• SRS• SBRT• Proton • IGRT• Brachytherapy

Not In

clud

ed • IORT• Hyperthermia• SIRT• Electronic Brachytherapy• Neutrons• Radiopharmaceutical Therapy• Superficial/Orthovoltage


Beneficiaries

Must be made aware of the RO Model via RO Model Beneficiary

Notification Letter

Responsible for cost‐sharing (typical 20%)

Patients are not able to opt‐out of model


Pricing Methodology

1• Set national base rates

2• Trend factor adjustment

3• Geographic adjustment

4• Case mix & historical experience adjustment

5• Discount factor adjustment

6• Incorrect payment withhold

7• Beneficiary coinsurance adjustment

8• Sequestration adjustment


Table 3 ‐National Base Rates by Cancer Type (in 2018 Dollars)

RO Model‐Specific Placeholder Codes

Professional or Technical

Cancer Type Base Rate

MXXXX Professional Anal Cancer $3,001.19MXXXX Technical Anal Cancer $16,543.53MXXXX Professional Bladder Cancer $2,688.35 MXXXX Technical Bladder Cancer $13,291.62 MXXXX Professional Bone Metastases $1,398.14 MXXXX Technical Bone Metastases $5,971.73 MXXXX Professional Brain Metastases $1,601.70 MXXXX Technical Brain Metastases $9,648.92 MXXXX Professional Breast Cancer $2,081.47 MXXXX Technical Breast Cancer $10,128.61 MXXXX Professional Cervical Cancer $3,829.34 MXXXX Technical Cervical Cancer $17,581.18 MXXXX Professional CNS Tumor $2,510.55 MXXXX Technical CNS Tumor $14,711.14 MXXXX Professional Colorectal Cancer $2,449.38 MXXXX Technical Colorectal Cancer $12,039.84


Table 3 ‐National Base Rates by Cancer Type (in 2018 Dollars)

RO Model‐Specific Placeholder Codes

Professional or Technical Cancer Type Base Rate

MXXXX Professional Head and Neck Cancer $3,019.00

MXXXX Technical Head and Neck Cancer $17,485.19

MXXXX Professional Liver Cancer $2,082.23

MXXXX Technical Liver Cancer $11,976.09

MXXXX Professional Lung Cancer $2,181.23

MXXXX Technical Lung Cancer $11,993.83

MXXXX Professional Lymphoma $1,690.41

MXXXX Technical Lymphoma $7,854.53

MXXXX Professional Pancreatic Cancer $2,394.14

MXXXX Technical Pancreatic Cancer $13,384.14

MXXXX Professional Prostate Cancer $3,260.97

MXXXX Technical Prostate Cancer $20,248.82

MXXXX Professional Upper GI Cancer $2,585.57

MXXXX Technical Upper GI Cancer $13,530.21

MXXXX Professional Uterine Cancer $2,435.59

MXXXX Technical Uterine Cancer $11,869.29


Peer Reviews

Audit and feedback on treatment plans

• 50 percent of new patients in PY1, • 55 percent of new patients in PY2, • 60 percent of new patients in PY3, • 65 percent of new patients in PY4, • 70 percent of new patients in PY5 preferably before starting treatment


Collection of Clinical Data

• Basic clinical information not available in claims or captured in the proposed quality measures

• Specific cancer types– Prostate, breast, lung, bone and brain metastasis

• Beginning January 1, 2022*– Change per 2021 OPPS Final Rule, may change due to delayed start to 2022

Cancer stage Disease involvement

Treatment intent

Specific treatment plan information


What Happens When…

Multiple diagnoses under the RO Model are treated simultaneously? • CMS will assess:

– Cancer diagnoses included on E/M services 30 days prior to start of episode date, on the episode start date, or during the 29 days after the episode start date

– Diagnosis codes assigned to treatment planning and delivery services– Number of codes per diagnosis across the line items

• Diagnosis with the most line items is the assigned cancer type and used in determining the base‐rate assigned

• RO participant can choose which HCPCS code to include– Example, patient has breast cancer and brain metastases

• Participant would select the breast HCPCS code for reporting • If beneficiary has breast cancer and brain metastases, but treatment only for brain metastases, the RO participant must report the brain metastases HCPCS code



Multiple diagnoses treated, one under the RO Model and the other not? • Services related to the RO Model diagnosis are billed per the guidelines for the RO Model

• Services related to the non‐included cancer type are billed FFS with the corresponding ICD‐10 and HCPCS codes to Medicare



Episode initiated for a diagnosis under the RO Model and another diagnosis under the RO Model is identified and requires treatment during the episode? • For example, a lung cancer patient diagnosed with brain metastasis during the lung treatment course– The episode base‐rate for lung cancer includes the possibility of brain or bone metastases also treated during the episode

– No additional episodes reported or FFS payments made for the additional diagnosis


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2021 Coding and Documentation Radiation Oncology

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