Coding Updates for Dosimetry Services Presented at AAMD Annual Meeting Monday, June 22, 2015 Grande Lakes Hotel Orlando, FL
Contact Information Revenue Cycle Inc. 1817 W. Braker Lane Bldg. F, Suite 200 Austin, Texas 78758 www.revenuecycleinc.com (512) 583-2000
Presenters Tamara Syverson, BSRT(T) Director Provider Consulting Scott Plemmons, RT(R)(T) Consultant
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 payor may vary within different U.S. regions. All policies should be verified to ensure compliance. CPT codes, descriptions and other data are copyright 2014 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), the ASTRO/ACR Guide to Radiation Oncology Coding, the ACRO Practice Management Guide and common practice standards nationwide.
Objectives Educate Attendees on Changes in Coding for Dosimetry Services Discuss the Differences Between Hospital and Freestanding Provide Information on Work Flow Processes Discuss Recommendations for Documentation
Our Policy Consistent with Medicare Guidelines Local Coverage Determinations Medicare Manuals CCI/OCE Edits CPT Definitions & Advice for AMA Published OIG Compliance Standards Professional Society Publications In Absence of Published Guidelines Revenue Cycle Inc. experience and observations nationally
Rules & Regulations Authoritative Guidance: Federal Register Centers for Medicare & Medicaid Services (CMS) National Coverage Determinations (NCD) Local Coverage Determinations (LCD) Medicare Manuals Coding Edits: NCCI, OCE, MUE American Medical Association (AMA) Commercial Payor Policies
Coding Changes Overview Freestanding departments CT guidance included in the initial simulation process New CPT codes for isodose plans and brachytherapy planning Multiple new G codes for treatment delivery and IGRT Hospitals New CPT codes for planning, treatment delivery and IGRT Simulation
Simulation Freestanding Centers The Practice Expense (PE) was updated to include the cost the CT and is no longer separately billable Hospitals The CT continues to be packaged and is separately billable but is reimbursed at $0 for Medicare
BUT WAIT!!
New Changes With Simulation Billing Per new ASTRO coding update 6/12/15 Simulation followed by 2 or 3D course Simulation and CT (hospital only) remains billable When the course is to be IMRT.. The simulation is now bundled for physicians and freestanding and not billable Ongoing OIG reviews in the hospital setting Treatment devices are still billable per payor guidelines Included on the OIG Fiscal Year 2015 Work Plan Mid-Year Update Published May 2015
Radiation Therapy Code Revisions Not all of the newly introduced radiation therapy CPT codes for 2015 were adopted for MPFS use in 2015 The timing of the release of new codes by the AMA and RUC is creating an issue for CMS Postponement until 2016 will allow for proper valuation and review of impact on stakeholders Deleted 2014 codes for treatment delivery, planning and IGRT will still be deleted; however, new Gcodes will be used for some of the new replacement and/or revised codes for 2015
Coding For Isodose Planning Planning Codes 77306 Teletherapy isodose plan; simple (1 or 2 unmodified ports directed to a single area of interest), includes basic dosimetry calculation(s) 77307 Teletherapy isodose plan; complex (multiple treatment areas, tangential ports, the use of wedges, blocking, rotational beam, or special beam considerations), includes basic dosimetry calculation(s) 77321* Special teletherapy port plan, particles, hemibody, total body i.e., protons, neutrons and electrons *Do not bill 77300 in conjunction with 77321 per AMA
2015 Isodose Planning Changes Summary 2014 isodose planning codes deleted 2 new codes created to replace simple and complex Includes calculations Codes to be used for HOPPS and MPFS 2015 HOPPS 2014 CPT 2015 MPFS 77306 77305 77306 No code 77310 No code 77307 77315 77307
Brachytherapy Isodose Plan Codes 77316 77317 77318 Brachytherapy isodose plan; simple (calculation[s] made from 1 to 4 sources, or remote afterloading brachytherapy, 1 channel), includes basic dosimetry calculation(s) Intermediate (calculation[s] made from 5 to 10 sources, or remote afterloading brachytherapy, 2-12 channels), includes basic dosimetry calculation(s) Complex (calculation[s] made from over 10 sources, or remote afterloading brachytherapy, over 12 channels), includes basic dosimetry calculation(s)
2015 Brachytherapy Isodose Planning Changes Summary 2014 isodose planning codes deleted 3 new codes created Include calculations Codes to be used for HOPPS and MPFS 2014 CPT 2015 HOPPS 2015 MPFS 77326 77316 77316 77327 77317 77317 77328 77318 77318
Basic Dosimetry Calculation 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 Not billable with the brachytherapy isodose plan 77316-77318 Decay factor calculations on subsequent dates may be billed Noridian Brachytherapy LCD states: Requires supporting documentation, including physician signature
IGRT Image Guided Radiation Therapy (IGRT) utilizes various imaging technologies to account for changes in the position of the intended target before or during treatment delivery. Hospital 77387 Guidance for localization of target volume for delivery of radiation treatment delivery, includes intrafraction tracking, when performed Physicians and Freestanding Cancer Centers G6001 (76950) - Ultrasonic guidance for placement of radiation therapy fields G6002 (77421) - Stereoscopic x-ray guidance for localization of target volume for the delivery of radiation therapy. G6017 (0197T) - Intra-fraction localization and tracking of target or patient motion during delivery of radiation therapy (e.g. 3D positional tracking, gating, 3D surface tracking), each fraction of treatment. 77014 - Computed tomography guidance for placement of radiation fields
2015 IGRT Changes Hospital Outpatient: 76950, 77421 and 0197T deleted January 1, 2015 77014 no longer associated with IGRT Only billable for treatment planning CT 77387- TC separately billable for 3D delivery when supported 77387 -TC bundled with IMRT delivery codes, not separately billable Physician & Freestanding: MPFS not recognizing AMA IGRT code changes in 2016 G-codes created for 76950, 77421 and 0197T G6001, G6002 & G6017 77014 used for CBCT (physicians and FSCs)
Image Guidance CY2014 Codes AMA New Codes Hospital Use CMS Final Codes CY2015 Physician & FSC Use CY2016 Codes HOPPS & MPFS Use 76950 77387 G6001 77387 77421 77387 G6002 77387 0197T 77387 G6017 77387 77014* 77387 *continue to use 77014 77387 *77014 was not deleted, per AMA it is no longer billable for IGRT, this will only apply to hospitals in 2015. Hospitals will continue to report 77014-TC for the treatment planning CT, but will no longer report 77014 for the CBCT. Physicians and FSCs will report 77014 for CBCT at time of treatment for CMS patients since they are not following AMA guidelines for imaging in 2015.
Treatment Delivery Changes 77403, 77404, 77406, 77408, 77409, 77411, 77413, 77414, 77416, 77418 and 0073T deleted New CPT codes for hospital outpatient locations G-codes created for use in freestanding facilities
HOPPS Treatment Delivery Code Descriptor 77401 Radiation treatment delivery, superficial and/or ortho voltage, per day 77402 Radiation treatment delivery, > 1 MeV; simple 77407 Radiation treatment delivery, > 1 MeV; intermediate 77412 Radiation treatment delivery, > 1 MeV; complex Simple: All of the following criteria are met (and none of the complex or intermediate criteria are met): single treatment area; one or two ports; and two or fewer simple blocks Intermediate: Any of the following criteria are met (and none of the complex criteria are met): two separate treatment areas; three or more ports on a single treatment area; or three or more simple blocks Complex: Any of the following criteria are met: three or more separate treatment areas; custom blocking; tangential ports; wedges; rotational beam; field-in-field or other tissue compensation that does not meet IMRT guidelines; or electron beam
CPT 77401 2015 Update CPT Manual: Energies below the megavoltage range may be used in the treatment of skin lesions. Superficial radiation energies (up to 200kV) may be generate by a variety of technologies and should not be reported with megavoltage (77402, 77407, 77412) for surface application. Do not report clinical treatment planning (77261, 77262, 77263), treatment devices (77332, 77333, 77334), isodose planning (77306, 77307, 77316, 77317, 77318), physics consultation (77336), or radiation treatment management (77427, 77431, 77432, 77435, 77469, 77470, 77499) with 77401. When reporting 77401 alone, physician evaluation and management, when performed, may be reported with the appropriate E/M codes.
HOPPS Treatment Delivery (IMRT) Code 77385 77386 Descriptor Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; simple Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; complex Simple: Any of the following: prostate, breast, and all sites using physical compensator-based IMRT Complex: Includes all other sites if not using physical compensatorbased IMRT
2015 IMRT Treatment Delivery 2014 codes deleted for HOPPS Two new codes created Simple Complex G-codes created for MPFS IGRT included for HOPPS IGRT possible for MPFS 2015 HOPPS 2014 CPT 2015 MPFS 77385-simple 77386-complex 77418 G6015 77385-simple 0073T G6016
Freestanding Treatment Delivery Code Descriptor G6003 G6004 G6005 G6006 G6007 G6008 G6009 G6010 G6011 G6012 G6013 G6014 G6015 G6016 Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks; up to 5 MeV Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks; 6-10 MeV Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks; 11-19 MeV Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks; 20 MeV or greater Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks; up to 5 MeV Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks; 6-10 MeV Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks; 11-19 MeV Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks; 20 MeV or greater Radiation treatment delivery, 3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; up to 5 MeV Radiation treatment delivery, 3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 6-10 MeV Radiation treatment delivery, 3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 11-19 MeV Radiation treatment delivery, 3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 20 MeV or greater Intensity modulated treatment delivery, single or multiple fields/arcs, via narrow spatially and temporally modulated beams, binary, dynamic MLC, per treatment session Compensator-based beam modulation treatment delivery of inverse planned treatment using 3 or more high resolution (milled or cast) compensator Copyright 2015 RCI convergent All Rights Reserved. beam Do modulated Not Duplicate. fields, per treatment session
2015 Conventional Treatment Delivery 2015 HOPPS 2014 CPT 2015 MPFS 77401 77401 77401 77402 77402 G6003 77402 77403 G6004 77402 77404 G6005 77402 77406 G6006 77407 77407 G6007 All but 3 deleted Remaining 3 adjusted to remove energy dependence G-codes created for MPFS 77407 77408 G6008 77407 77409 G6009 77407 77411 G6010 77412 77412 G6011 77412 77413 G6012 77412 77414 G6013 77412 77416 G6014
C-APC for SRS HOPPS Only C-APC for GammaKnife SRS, only the treatment is reimbursed. All ancillary charges are reported with cost, but not reimbursed separately Includes simulation, planning, calculations, devices, physics and imaging codes Physicians (Rad Onc and Neuro) will continue to report services on CMS1500 and reimbursed separately
C-APC Course Info HOPPS Only Category Pre-Sim CPT 2015 APC 2015 SI CPT Description CO-60 SRS - National Average 2014 National APC Rate 2015 National APC Rate Quantity 2015 Quantity Billed due to Packaging 2014 Total APC Pmt 2015 Total APC Pmt G0463 0634 Q3 Hospital outpt clinic visit $ 92.53 $ 96.22 1 0 $ 92.53 $ - 77470 0412 S Special radiation treatment $ 413.22 $ 507.55 1 0 $ 413.22 $ - 77014 N Ct scan for therapy guide $ - $ - 1 0 $ - $ - Simulation 77290 0305 S Set radiation therapy field $ 311.37 $ 314.43 1 0 $ 311.37 $ - 77334 0303 S Radiation treatment aid(s) $ 213.49 $ 215.54 1 0 $ 213.49 $ - 77370 0304 S Radiation physics consult $ 114.65 $ 113.12 1 0 $ 114.65 $ - Planning 77295 0310 S 3-d radiotherapy plan $ 1,036.39 $ 1,038.12 1 0 $ 1,036.39 $ - 77300 0304 S Radiation therapy dose plan $ 114.65 $ 113.12 5 0 $ 573.25 $ - 77334 0303 S Radiation treatment aid(s) $ 213.49 $ 215.54 2 0 $ 426.98 $ - Treatment 77371* 0067 J1 Srs multisource $ 3,591.65 $ 9,765.40 1 1 $ 3,591.65 $ 9,765.40 77336 0304 S Radiation physics consult $ 114.65 $ 113.12 1 0 $ 114.65 $ - $ 6,888.18 $ 9,765.40 Total for Medicare Only $ 2,877.22 Course of Therapy Variance % Change 41.77% The example course illustrated is a Stereotactic Radiosurgery course. It assumes a complex initial simulation to one area which will require complex blocking. The example course assumes 5 portals utilizing 2 unique blocking patterns. The total number of fractions is 1. It is further noted, due to CY2015 proposed packaging all ancillary codes are reported on the claim forms, the payment is only made for the C-APC 0067. Associated reimbursement only appears in the CY in which it applies. *For 2015 SRS all services performed in order to deliver the single fraction of SRS are packaged into the reimbursement for the treatment delivery. All ancillary codes are reported with cost listed, but are not separately reimbursed. The quantities for 2015 reflect the cost reporting quantities with the only reimbursement for 77371.
Surgical APCs Code 57155 (Insertion of uterine tandem and/or vaginal ovoids for clinical brachytherapy) moved once again from APC 0193 to 0192 CY2014 payment APC 0193= $1,375.20 CY2015 APC payment 0192= $487.06 a 63% reduction! IORT codes 77424 & 77425 finalized move from APC 0065 to C-APC 0648 (Level IV Breast and Skin Surgery) APC 0065 deleted, leaving MRgFUS codes and MEG codes 95965 and 95966 being moved to APC 0446
What s Coming for 2016??? Calculations appear to be bundled with 3D planning New treatment delivery codes for electronic brachytherapy Handling and loading (77790) for LDR brachytherapy Transition of the 2015 G code to current CPT codes Be sure to watch for Proposed Rule updates to be released soon!!
Questions?