EMR Documentation & Coding Updates for Radiation Oncology

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1 EMR Documentation & Coding Updates for Radiation Oncology Presented: August 16, 2013 AAMD Region I Meeting Anchorage, AK

2 Contact Information Revenue Cycle Inc W. Braker Lane Bldg. F, Suite 200 Austin, Texas (512)

3 Presenters Adam Brown, BSRT(T), CMD Consultant Kelli Weiss, RT(R)(T) Executive Director

4 Disclaimer This presentation was prepared to assist with interpreting the 2014 Medicare Physician Fee Schedule and Hospital Outpatient Prospective Payment proposed rules. Interpretations and figures are the presenters understanding of the material and analysis of data. 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 2013 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.

5 Objectives Reimbursement Trends and Proposed Changes Current Issues Facing Oncology Practices Electronic Medical Record (EMR) Documentation

6 Billing Scenarios Hospital Outpatient Freestanding Facility Technical Services HOPPS Physician Services (-26) MPFS Global Billing Split Billing Pro & Tech Services MPFS Physician Services (-26) MPFS Technical Services (TC) MPFS HOPPS is reported on a UBO4 and MPFS is reported on a CMS1500

7 HOPPS and MPFS Payment Systems HOPPS Payments based on costs Adjusted by a wage index Grouped into APC s Example : Tx Devices 77332, and Historically the same payment rate under HOPPS MPFS Codes have RVUs CF is applied to all codes GPCI s Codes can be split into Global, TC, 26 payment Example: Tx Devices 77332, 77333, Historically different payment rates under MPFS

8 Annual Updates to Rules Stay up to date Stay informed Get involved Hospital Outpatient: Hospital Billing Technical Charges Physician/Facility: Physician Practicing in a Hospital Setting & Freestanding Facilities

9 Proposed versus Final Rule Proposed CMS s plan, intent, thoughts for rules, regulations & reimbursement for upcoming year Final Determined after consideration & debate occurs based on comments received Proposed Rules Consideration of Comments Sept 6 is Deadline for Comments Final Rule Nov 1 (approx)

10 MPFS Highlights & Components Proposed CY2014 Conversion Factor $ % reduction Medicare uses a resource-based relative value scale (RBRVS) to reimburse physicians. Under this system, medical procedures are ranked according to the relative costs of resources required to perform the procedures: RVU for physician work RVU for practice expense RVU for professional liability insurance Geographic Practice Cost Index (adjusts each different type of RVU) for a particular locality in the country Conversion Factor (used to convert RVU s into dollar amounts) The comparisons on the upcoming slides assume the reduction will not occur.

11 Historical Conversion Factors Year CF Pre-Legislation CF Post Legislation Variance CY 2006 $ CY 2007 $ $ % CY 2008 $ $ % CY 2009 $ $ % CY 2010 $ $ $ (Jan-May) 27.12% CY 2010 CY 2011 $ $ $ (June-Nov) 29.89% $ $ $ (Dec-Dec 31st) 29.89% CY 2011 $ $ % CY 2012 $ $ % CY2013 $ $ % Proposed CY 2014 $ ??? ($ *)

12 MPFS Estimated Course Comparisons $25, $20, $15, $10, $5, $- Estimated 2013 Course Collections Global CF = $ Estimated 2014 Course Collections Global CF = $

13 Proposed Stereotactic Robotic versus non-robotic no longer needed (stated in the proposed rule) it is our understanding that most services currently furnished with linac-based SRS technology, including services currently billed using the non-robotic codes, incorporate some type of robotic feature. Related to proposed changes in HOPPS: and to be used Deletion of existing four G codes G0339 and G0340 will be maintained for MPFS (where they exist), but Seeking comments on direct PE inputs for and 77373

14 HOPPS Highlights 1.8% increase resulting in a proposed conversion factor for CY 2014 of $ Transitioning to more of a prospective payment system We are proposing to define a comprehensive APC as a classification for the provision of a primary service and all adjunctive services provided to support the delivery of the primary service. HOPPS CY2014 Proposed Rule

15 Proposed Packaging Of Services Packaging based on review of categories of services, which may be a component of a primary service: Integral Ancillary Supportive Dependent Adjunctive items

16 Packaging in Radiation Oncology Proposed to change ancillary services previously assigned a status indicator of X to status indicator Q1 Q1 codes include: Simulations, Treatment Devices, Treatment Planning Q1 services will be packaged when provided with a service assigned a status indicator of S, T, or V S codes include: Treatment Delivery If a Q1 code and a S code are reported for the same date, the S code will be paid

17 But Wait Packaging also in effect when only ancillary services are reported Q1 codes are considered minor claim procedures If multiple Q1 codes reported on this same date without an S code: Considered a pseudo single procedure claim Paid based on the highest reimbursed Q1 code at a quantity of 1

18 Proposed Status Indicator Q1 Codes CPT Descriptor Set radiation therapy field Set radiation therapy field Set radiation therapy field Set radiation therapy field Radiation therapy planning Radiation therapy dose plan Radiotherapy dose plan imrt Teletx isodose plan simple Teletx isodose plan intermed Teletx isodose plan complex Special teletx port plan Brachytx isodose calc simp Brachytx isodose calc interm Brachytx isodose plan compl Special radiation dosimetry Radiation treatment aid(s) Radiation treatment aid(s) Radiation treatment aid(s) Radiation physics consult Design mlc device for imrt Radiation physics consult Packaged with SI S Treatment Delivery Codes

19 Packaging What will be paid? D Simulation Basic dosimetry calculations Treatment devices

20 Stereotactic G Codes APC 0067 G Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; linear accelerator based APC 0066 G Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum five sessions per course of treatment G0339* - Image-guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session or first session of fractionated treatment G Image-guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum five sessions per course of treatment Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions

21 Protons Violation of the 2 times rule within APC 0664 due increased volume of claims Requires adjustment of APC groups Proposed changes include: Reassign CPT codes and from APC 0664 to APC 0667 Revise title of APC 0067 to Proton Beam Radiation Therapy Delete APC 0064

22 Intraoperative Radiotherapy (IORT) Current CPT codes and describe: Placement and removal (if performed) of an applicator into the breast for radiation therapy Delivery of radiation therapy when performed intraoperatively Proposed to delete HCPCS code C9726 Placement and removal (if performed) of applicator into breast for radiation therapy

23 Supervision Proposed to let the enforcement instruction to expire at the end of 2013 All outpatient therapeutic services furnished in hospitals and CAH would require a minimum of direct supervision Exceptions: Services with general supervision designation Nonsurgical extended duration therapeutic services designated with general supervision requirement Payment/HospitalOutpatientPPS/Downloads/CY2013-OPPS-General-Supervision.pdf

24 Clinic Visits Discontinue the current use of and and emergency department visits Proposing to create alphanumeric Level II HCPCS codes Clinic visit: GXXXC: APC 0634 Describes all levels of clinic visits ( ) No longer recognizes a distinction between new and established patients Type A ED visit: GXXXA: APC 0635 Type B ED visit: GXXXB: APC 0636

25 HOPPS Estimated Course Comparisons $50, $45, $40, $35, $30, $25, $20, $15, $10, $5, $- Estimated 2013 Course Medicare Allowable Estimated 2014 Course Medicare Allowable

26 CPT 2014 Proposed APC S N Q Q Q Q Q Q1 G0251 Linac SBRT - National Average; 5 Fractions 2014 Propo sed SI CPT Description 2013 APC Rate 2014 APC Rate Special radiation B Qty Billed 2014 Qty billed w/pack aging 2013 Total APC 2014 Total APC Pmt Pmt treatment $ $ 1, $ $ 1, Ct scan for therapy guide $ - $ $ - $ - Set radiation therapy field $ $ $ $ Radiation treatment aid(s) $ $ $ $ - Radiation physics consult $ $ $ $ - Set radiation therapy field $ $ 1, $ $ 1, Radiation therapy dose plan $ $ $ $ - Radiation treatment aid(s) $ $ $ $ - Linear acc based stero radio $ $ $ 4, $ S Sbrt delivery - $ 2, $ 12, Radiation physics Q1 consult $ $ $ $ - Total for Medicare Only $ 7, $ 16, Proposed Course of Therapy Variance $ 8, % Change %

27 Results of Packaging Example For a standard simulation procedure, there are typically 3 services: the simulation, immobilization and imaging. Under previous reimbursement changes, the imaging was already packaged therefore; no change is seen for the imaging code. The total reimbursement for the same services would be increased for 2014 even with the packaging result. The primary outcome is the combination of the items provided on the same date of service into a single payment for the highest reimbursed service. Procedure 2013 APC Payment Payment Result Procedure 2014 APC Payment $ $ $ $ x 1 $ $ x 1 $ $0.00 $ $0.00 Total Payment $ Total Payment $ Packaging Results Packaged into the Packaged into the 77290

28 Commenting CMS will accept comments on the proposed rule until September 6, Submit electronic comments on this regulation to: Follow the instructions for "submitting a comment and refer to file code: CMS-1600-P for MPFS CMS-1601-P for HOPPS

29 Why Does This Matter?

30 The Obama Administration In 2010 the proposed budget requested $1.7 billion to fight health care fraud. The Administration estimated for every dollar spent by the Department of Health & Human Services to fight health care fraud & reduce improper payments, about $1.55 is saved or averted. Projects this would generate $9.9 billion in savings over 10 years Presidential Memorandum states: The Obama Administration is committed to reducing payment errors and eliminating waste, fraud, and abuse in Federal programs. On March 10, 2010, the Administration expanded the use of Payment Recapture Audits, a process of identifying improper payments where highly skilled accounting specialists and fraud examiners use state-of-the-art tools and technology to examine payment records and uncover problems such as duplicate payments, payments for services not rendered, overpayments, and fictitious vendors.

31 Common Errors Physician Orders & Medical Necessity Not Located Incomplete &/or Missing documentation Incorrect Dates of Service Utilized for Billing Incorrect CPT Codes Missing and/or Late signatures Billing Under the Incorrect Physician Billing Under the Incorrect Location

32 Physician Orders & Medical Necessity All services must have a formal written order by the MD & be supported by medical necessity Contrary to Opinions, This Concept Does Apply to Radiation Oncology Payor guidelines clearly state the requirement Medicare manuals state the requirement Recovery audits currently underway in which this area is a concern

33 Quotes WPS LCD ID Number L30316, Titled Radiation Oncology Including Intensity Modulated Radiation Therapy (IMRT) Indications and Limitations of Coverage and/or Medical Necessity Radiation oncology services are considered medically reasonable and necessary when the following conditions are indicated and documented in the patient's medical records.

34 Recovery Audit Detail - IMRT

35 Recovery Audit Detail SRS & SBRT

36 Ways to Avoid Mistakes Development of an internal compliance plan Daily charge and documentation review Charges are only exported or submitted when documentation is present and complete Opportunity to correct errors prior to submission to payor Daily interface verification audits Ensure charges exported over the interface are received on the other end

37 More Ways to Avoid Mistakes Internal audits against claim forms to identify problems Identifies scrubber issues Verifies correct quantities are submitted Verifies correct isodose planning Identify interface concerns Opportunity for staff training and corrective actions

38 Compliance Plan Recommendations From OIG Development of a compliance program including: Conduct internal monitoring and auditing Implement compliance and practice standards Designate a compliance officer or contact Conduct appropriate training and education Respond appropriately to detected offenses and develop corrective action Develop open lines of communication with employees Enforce disciplinary standards through well-publicized guidelines

39 Also Include Your processes to ensure compliance Documentation processes Charge capture Charge review Chart audits & findings Correction of errors Staff education Resources

40 Questions

41 Current Payor Issues RAC Audits for Medical Necessity IMRT SRS/SBRT

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