Radiation Oncology Coding & Compliance Denials ...

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Radiation Oncology Coding & Compliance Denials, Documentation & Updates

AAMD 2020


Presenter

Adam Brown BSRT(T), CMDDirector, Client Services


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.


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


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


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


National Coverage Determination (NCD) National Rules

Local Coverage Determination (LCD) Local Rules

Internet Only Manuals – Searchable

Transmittals – Written Updates

CMS Publications


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


• 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


Current Payer Denials & Documentation Reviews


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


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


Specifics

• Recommendation from OIG to CMS• CMS agreed with findings• Specialty societies responded

Stay Tuned for Potential Changes in Future!


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.


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.”


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


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

https://palmettogba.com/internet/eLearn3.nsf/IntensityModulatedRadiationTherapy/story_html5.html


Coding Guidance, Palmetto vs. CMS

Palmetto Standards for Billing NCCI Policy Manual


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


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

http://www.astro.org/


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


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


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


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


Review of 2020 Supervision Changes


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


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


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


Preparing for 2021 E/M Updates


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

https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf


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

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf


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.


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.


New Complexity Services Code by CMS


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


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


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)


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




New Patient E/M Code Typical Time (2020) Total Time (2021)

99211 5 minutes Time component removed






Reminder 90-Day Follow-Up Period Still Applies


Billing Highlights & Updates to COVID-19 Response


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


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

https://www.cms.gov/files/document/03092020-covid-19-faqs-508.pdf


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


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


Questions?

Contact [email protected]

Radiation Oncology Coding & Compliance Denials ...

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