Clinical Treatment Planning

Transcription

1 Radiation Therapy Services Benefits to Change for the CSHCN Services Program Effective October 1, 2008, benefits for radiation therapy services will change for the Children with Special Health Care Needs (CSHCN) Services Program. The CSHCN Services Program may reimburse physicians, radiation treatment centers, and hospitals (inpatient and/or outpatient) for radiation therapy services. Radiation therapy services include, but are not limited to, the following: Clinical treatment planning Stereotactic radiosurgery (SRS) Proton- or neutron-beam therapy Intensity modulated radiation therapy (IMRT) Clinical brachytherapy Radiation treatment management and delivery Medical radiation physics, dosimetry, and treatment devices Prior authorization is required for stereotactic radiosurgery, proton- or neutron-beam treatment delivery, and IMRT. Prior authorization is not required for all other radiation therapy services. Providers may refer to the 2008 CSHCN Services Program Provider Manual, Section 25, Radiation Therapy Services, on page 25-1 for more information. The following radiation therapy benefits will change for the CSHCN Services Program: Clinical Treatment Planning For the clinical treatment planning procedure codes T-77285, T-77290, T-77295, and T , radiation treatment centers, outpatient facilities, and hospitals may be reimbursed for the technical component only. Providers may refer to the 2008 CSHCN Services Program Provider Manual, Section , Clinical Treatment Planning, on page 25-3 for more information. Stereotactic Radiosurgery In addition to the procedure codes listed in the 2008 CSHCN Services Program Provider Manual, Section , Stereotactic Radiosurgery, on page 25-5, the following procedure codes for stereotactic radiosurgery may be reimbursed by the CSHCN Services Program: Procedure Codes /I/T G0251

2 Prior Authorization Requirements Prior authorization requirements for SRS may also include trigeminal neuralgia refractory to medical management. Providers may refer to the 2008 CSHCN Services Program Provider Manual, Section , Stereotactic Radiosurgery, on page 25-5 for additional prior authorization requirements and medical conditions. SRS is considered investigational and not a benefit of the CSHCN Services Program for all other indications including, but not limited to, epilepsy and chronic pain. Proton- and Neutron-Beam Treatment Delivery In addition to the procedure codes listed in the 2008 CSHCN Services Program Provider Manual, Section , Proton Beam Therapy, on page 25-4, procedure code 2/F- S8030 may be reimbursed by the CSHCN Services Program. Procedure codes and for neutron beam treatment delivery may be reimbursed by the CSHCN Services Program. Physicians, radiation treatment centers, or outpatient facilities may bill the total component for neutron beam treatment delivery. Prior Authorization Requirements Prior authorization requirements for proton beam treatment delivery may include, but are not limited to, diagnoses indicating one of the following medical conditions: Melanoma of the uveal tract (iris, choroid, ciliary body) Post-operative treatment for chordomas or low-grade chondrosarcomas of the skull or cervical spine Prostate cancer Pituitary neoplasms Other central nervous system tumors located near vital structures Prior authorization for neutron beam treatment delivery (procedure codes and ) may be considered for malignant neoplasms of the salivary glands. Other diagnoses may be considered after review of documentation of medical necessity along with a review of current literature supporting the requested use. This information updates the 2008 CSHCN Services Program Provider Manual, Section , Proton Beam Therapy, on page 25-4; and Section , Radiation Treatment Delivery/Port Films, on page Intensity Modulated Radiation Therapy (IMRT) Procedure code T must be prior authorized and may be considered after review of documentation of medical necessity along with a review of current literature supporting the requested use. This information updates the 2008 CSHCN Services Program Provider Manual, Section , Radiation Treatment Delivery/Port Films, on page 25-5.

3 Clinical Brachytherapy In addition to the procedure codes listed in the 2008 CSHCN Services Program Provider Manual, Section , Clinical Brachytherapy, on page 25-4, the following procedure codes for brachytherapy may be considered for reimbursement by the CSHCN Services Program: Procedure Codes 2/F /F /F /F /8/F /8/F /8/F /F /F /F / /8/F Providers may refer to the 2008 CSHCN Services Program Provider Manual, Section , Clinical Brachytherapy, on page 25-4, for more information. Radiation Therapy Radiation Treatment Delivery The following procedure codes for radiation treatment delivery/port films listed below may be billed in addition to procedure codes and when provided in the office setting: Procedure Codes T T T T T T T T T T T T T T T /I/T This information updates the 2008 CSHCN Services Program Provider Manual, Section , Radiation Treatment Delivery/Port Films on page Procedure code is discontinued and may no longer be billed for radiation treatment delivery. Procedure codes T-77371, T-77372, and T are included in the Stereotactic Radiosurgery section of this article. Evaluation and Management (E/M) Visits and Hospital Care All initial and follow-up hospital care (office and hospitals) and consultations will be denied if provided on the same day as brachytherapy. Physicians and radiation treatment centers may bill the total component of any laboratory or radiological procedures they actually perform. All drugs given during the course of radiation therapy must be billed separately for appropriate reimbursement. If complications occur on the same day as a therapeutic radiology service, or if medical visits are necessary for services unrelated to the radiation treatment, additional care will be considered for reimbursement on an appeal basis. CSHCN Services Program benefits will include payment for the technical portion of radiation therapy services (excluding proton beam which is reimbursed for the total

4 component only) provided in an inpatient hospital setting. Hospitals must use revenue code 333 when submitting charges for radiation therapy services. Clinical brachytherapy services will include admission to the hospital and daily care. Initial and subsequent hospital care will be denied if billed with the same date of service as clinical brachytherapy services. An office visit billed with the same date of service by the same provider as clinical treatment planning and clinical brachytherapy will be included in the therapeutic radiology procedure. Normal follow-up care performed by the same physician on the day as any therapeutic radiology service will be denied. Any other E/M office visit will not be reimbursed when billed with the same date of service by the same provider as the radiation treatment or radiation treatment complication. Providers may appeal denied claims using modifier 25 indicating the additional visit was for a separate, distinct service unrelated to the radiation treatment or radiation treatment complication. Documentation that supports the provision of a significant, separately-identifiable E/M service must be maintained in the client's medical record and must be made available to the CSHCN Services Program upon request. The following procedure codes in Column A will be denied as part of another service when billed with the same date of service by the same provider as the procedure codes in Column B: Column A (Deny) Column B (Pay) , , , , 2-2/F-19296, 2/F , , , , , , , , , , 4/I-76000, 4/I/T-76942, 4/I/T-76965, 4/I/T-77002, 4/I/T-77012, 4/I/T-77021, 4/I/T-77031, 4/I/T-77032, , , , , /I-76000, 4/I/T-76942, 4/I/T /F /F-61793, 6/I/T-77421, 6-G0339, 6-G G0251 6/I/T G0339 2/F /F , , , 6-G , , , 6-G0339, 6- G , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 6/I/T-77781, 6/I/T-77782, 6/I/T-77783, 6/I/T-77784, 6/I/T-77789

5 99354, /8/F-55860, 2/8/F /8/F , , , /I/T , , , , 6/I/T /I/T , , , , 6/I/T /I/T-77781, 6/I/T , , , 6/I/T-77781, 6/I/T /I/T-77782, 6/I/T , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 1-M , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , /I-77261, 6/I-77262, 6/I-77263, 6/I-77280, 6/I/T-77285, 6/I/T-77290, 6/I/T-77295, T , T-77301, T-77305, T-77310, T , T-77413, T-77414, T-77416, T , T-77418, , , , /I-77261, 6/I-77262, 6/I-77263, 6/I-77280, 6/I/T-77285, 6/I/T-77290, 6/I/T-77295, T , T-77301, T-77305, T-77310, T , T-77413, T-77414, T-77416, T , T-77418, , , , , /I-77261, 6/I-77262, 6/I-77263, 6/I-77280, 6/I/T-77285, 6/I/T-77290, T-77300, T , T-77305, T-77310, T-77315, T , T-77327, T-77328, T-77332, T , T-77334, T-77401, T-77402, T , T-77404, T-77406, T-77407, T , T-77409, T-77411, T-77412, T , T-77414, T-77416, T-77417, T-

6 , , , , 1-6/I-77261, 6/I-77262, 6/I-77263, 6/I-77280, 99341, , , , 1-6/I/T-77285, 6/I/T-77290, 6/I/T-77295, T , , , , , T-77301, T-77305, T-77310, T , T-77413, T-77414, T-77416, T , T , , , /I-77261, 6/I-77262, 6/I-77263, 6/I-77280, 6/I/T-77285, 6/I/T-77290, 6/I/T-77295, T , T-77301, T-77305, T-77310, T , T-77413, T-77414, T-77417, T , , , , , 6/I-77261, /I /I-77261, 6/I /I /I/T-76376, 4/I/T /I-77280, T /I/T-76376, 4/I/T-76377, 6/I /I/T /I/T-76376, 4/I/T-76377, 6/I-77280, 6/I/T- 6/I/T /I/T-76376, 4/I/T-76377, 4/I/T-77014, 6/I- 6/I/T , 6/I/T-77285, 6/I/T-77290, /I/T-70450, 4/I/T-70460, 4/I/T-70470, T /I/T-70480, 4/I/T-70481, 4/I/T-70482, 4/I/T-70486, 4/I/T-70487, 4/I/T-70488, 4/I/T-70490, 4/I/T-70491, 4/I/T-70492, 4/I/T-70496, 4/I/T-70498, 4/I/T-71250, 4/I/T-71260, 4/I/T-71270, 4/I/T-71275, 4/I/T-72125, 4/I/T-72126, 4/I/T-72127, 4/I/T-72128, 4/I/T-72129, 4/I/T-72130, 4/I/T-72131, 4/I/T-72132, 4/I/T-72133, 4/I/T-72191, 4/I/T-72192, 4/I/T-72193, 4/I/T-72194, 4/I/T-73200, 4/I/T-73201, 4/I/T-73202, 4/I/T-73206, 4/I/T-73700, 4/I/T-73701, 4/I/T-73702, 4/I/T-73706, 4/I/T-74150, 4/I/T-74160, 4/I/T-74170, 4/I/T-74175, 4/I/T-75635, 4/I/T-76376, 4/I/T-76377, 4/I/T-76380, 4/I/T-76950, 4/I/T-77014, 6/I-77261, 6/I-77262, 6/I-

7 77263, 6/I-77280, 6/I/T-77285, 6/I/T , 6/I/T-77295, T-77305, T-77310, T , T-77413, T-77414, T-77416, T , 6/I/T-77421, , , , , , , , , /I/T-76376, 4/I/T-76377, 4/I/T-77014, 1- T /I/T-76376, 4/I/T-76377, 4/I/T-77014, T- T /I/T-76376, 4/I/T-76377, 4/I/T-77014, T- T , T /I/T-76376, 4/I/T T /I/T-76376, 4/I/T-76377, T T /I/T-76376, 4/I/T-76377, T-77326, T- T T T T-77332, T T /I/T-76376, 4/I/T-76377, T T /I/T-76376, 4/I/T 76377, T-77401, T- T /I/T-76376, 4/I/T-76377, T-77401, T- T , T /I/T-76376, 4/I/T-76377, T-77401, T- T , T-77403, T /I/T-76376, 4/I/T 76377, T-77401, T- T , T-77403, T-77404, T /I/T-76376, 4/I/T 76377, T-77401, T- T /I/T-76376, 4/I/T-76377, T-77401, T- T , T /I/T-76376, 4/I/T-76377, T-77401, T- T , T-77408, T /I/T-76376, 4/I/T-76377, T-77401, T- T , T-77408, T-77409, T /I/T-76376, 4/I/T-76377, T-77401, T- T-77413

8 /I/T-76376, 4/I/T-76377, T-77401, T , T /I/T-76376, 4/I/T-76377, T-77401, T , T-77413, T , 4/I/T-76506, 4/I/T-76511, 4/I/T , 4/I/T-76513, 4/I/T-76516, 4/I/T , 4/I/T-76529, 4/I/T-76536, 4/I/T , 4/I/T-76645, 4/I/T-76700, 4/I/T , 4/I/T-76770, 4/I/T-76775, 4/I/T , 4/I/T-76805, 4/I/T-76810, 4/I/T , 4/I/T-76816, 4/I/T-76818, 4/I/T , 4/I/T-76825, 4/I/T-76826, 4/I/T , 4/I/T-76828, 4/I/T-76830, 4/I/T , 4/I/T-76856, 4/I/T-76857, 4/I/T , 4/I/T-76872, 4/I/T-76873, 4/I/T , 4/I/T-76885, 4/I/T-76886, 4/I/T , 4/I/T-76932, 4/I/T-76936, 4/I/T , 4/I/T-76942, 4/I/T-76945, 4/I/T , 4/I/T-76948, 4/I/T-76965, 4/I/T , 4/I/T-76975, 4/I/T-76977, 4/I/T , 6/I-77261, 6/I-77262, 6/I-77263, T , T-77310, T-77315, T-77326, T , T-77328, , , , T-77401, T-77402, T-77403, T , T-77406, T-77407, T-77408, T , T-77411, T-77412, T-77413, T , T-77416, , , , , , , 6- G0339, 6-G , , , , , , , /I/T-76950, , , , , , , , , 6/I/T-77421, , , , , , , , , , 6/I/T-77421, , , , , , , , , , , T T T

9 For more information, call the TMHP-CSHCN Services Program Contact Center at