Stereotactic Radiosurgery & Stereotactic Body Radiation Therapy - Billing Basics. Presented: June 19, 2013 AAMD Annual Meeting San Antonio, TX

Transcription

1 Stereotactic Radiosurgery & Stereotactic Body Radiation Therapy - Billing Basics Presented: June 19, 2013 AAMD Annual Meeting San Antonio, TX

2 Presenters Kelli Weiss, RT(R)(T) Executive Director Tamara Syverson, BSRT(T) Director Provider Consulting

3 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 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.

4 Objectives Reimbursement Trends and Recent Changes Describe the Stereotactic Process of Care Educate Attendees on Applying Proper Coding Provide Guidance on Appropriate Documentation Emphasize Utilization of Current Reference Materials

5 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

6 Proposed vs. Final 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 Final Rule

7 Potentially Misvalued Codes It is a requirement to review RVUs no less often than every 5 years. Seven categories of services for examination Fastest growth Substantial changes in PE Recently established new technologies and services Multiple codes frequently billed in conjunction with a single service Codes with low RVUs that are often billed multiple times for a single treatment Codes not subject to review since the implementation of the RBRVS Other codes determined by the Secretary

8 CY 2013 Potentially Misvalued Codes IMRT Treatment Delivery (CPT code 77418) Based on Medicare utilization data indicating both fast growth in utilization and frequent billing with other codes SBRT Treatment Delivery (CPT code 77373) Identified by the RUC as a recently established code describing services that use new technologies PE RVU variance = % Proposed/-14.75% Final PE RVU variance = % Proposed/-20.48% Final Time is a main contributor to the possible reduction for these codes

9 For CY 2013 More Codes Were Identified After identifying the potential Practice Expense (PE) differences for IMRT and SBRT, additional codes were placed on a list for review: Set radiation field Radiotherapy dose plan imrt Design mlc device for imrt Srs linear based Sbrt delivery Radiation treatment delivery Radiation tx delivery imrt Hyperthermia treatment Hdr brachytx

10 H.R. 8 - American Taxpayer Relief Act of 2012 Law lowers hospital outpatient payments for Cobalt 60 radiosurgery, to the level of linear accelerator based radiosurgery Effective April 1, 2013 APC 0127 APC Medicare Nat Avg Payment Rate $7, Medicare Nat Avg Payment Rate $3,300.64

11 Historical HOPPS Stereotactic PMT Rates $9,000 $8,000 Medicare National Ave. Payment Rates $7,000 $6,000 $5,000 $4,000 $3,000 $2, HOPPS G HOPPS G HOPPS G HOPPS G HOPPS $1,000 $ Apr-13 Calendar Year

12 Proposed Rule CY July 4 th Week As soon as released RCI summarizes Likely to include SRS/SBRT, IMRT and Supervision Summary Webinar: Free to AAMD Meeting Attendees if You Register Info@revenuecycleinc.com

13 Stereotactic Process of Care E&M Clinical Planning Set-Up Simulation Dosimetry Verification or IGRT Treatment Delivery Physics & Treatment Management

14 Clinical Treatment Planning Professional only service Cognitive service including: Interpretation of special testing Tumor localization Treatment volume determination Treatment time/dosage determination Choice of treatment modality, etc.

15 Utilization Guidelines Billable once per course Documentation must support date of service & complexity Provides support for services and procedures to be provided Clinical treatment planning includes interpretation of special testing, tumor localization, treatment volume determinations, treatment time/dosage determinations, choice of treatment modality(ies), selection of appropriate treatment devices and other procedures such as concurrent or sequential chemotherapy or surgery. The documentation must support the separately itemized, specific services provided. Review of records, pathology reports and/or imaging studies are typically part of the basis for claiming either a higher-level E/M service preceding treatment planning, or as a component of this code, but this same work should not be counted as a basis for both services.

16 Payor Guidelines As stated by Palmetto GBA within SBRT LCD:

17 Special Treatment Procedure Special treatment procedure (eg, total body irradiation, hemibody radiation, per oral, or endocavitary irradiation) Utilization Guidelines: Reported for extra work required by the physician & staff for special procedures Allowed once per course of therapy Requires documentation to support the additional time and/or effort

18 Standard of Care As techniques or modalities become standard of care, they are no longer considered special by our payors. The following statement is found within LCDs by Palmetto, Novitas, Noridian and First Coast

19 Set-Up Simulation Professional & Technical Simple simulation of a single treatment area with either a single port or parallel opposed ports. Simple or no blocking Intermediate simulation of three or more converging ports, two separate treatment areas, multiple blocks Complex simulation of tangential portals, three or more treatment areas, rotation or arc therapy, complex blocking, custom shielding blocks, brachytherapy source verification, hyperthermia probe verification, any use of contrast materials.

20 What Really Happens CPT descriptors have not kept up with technology Select code based on the work performed and documented for that date of service

21 Utilization Guidelines Documentation must support the date of service & complexity Simulation process may include use of treatment devices & imaging, which are separately coded Physician signature required for all documentation Noridian Administrative Services LCD states:

22 Treatment Devices Utilized during the Set-Up Simulation process for positioning and immobilization Palmetto, GBA LCD states: Many different types of treatment devices are used in the successful delivery of radiation oncology treatments. Examples include beam-shaping devices, customfabricated patient-immobilization devices, beam-modification devices, and equipment used to shield critical structures. Coding, documentation & utilization guidelines may differ based on the types of devices used and the particular payor.

23 Coding For Treatment Devices Device Codes Simple (simple block, simple bolus) Examples: pre-made electron block, bolus Intermediate (multiple blocks, stents, bite blocks, special bolus) Examples: Bite block, customized bolus Complex (irregular blocks, special shields, compensators, wedges, molds or casts) Examples: Aquaplast masks, alpha cradles, Vac-Lok, custom molds Note: The Stereotactic Head Frame is considered a complex treatment device in most parts of the country, however, in some LCDs it is considered an intermediate device.

24 Utilization Guidelines Documentation must support date of service for design or construction and complexity LCDs may have specific coding instructions Physician involvement required Palmetto, GBA LCD states:

25 Imaging Following the Set-Up Simulation, imaging performed for treatment planning purposes Computed tomography guidance for placement of radiation therapy fields Utilization Guidelines CT and other imaging is typically performed as part of the simulation procedure and is to be separately coded per the type of image acquired Code also used for IGRT (guidelines may differ)

26 Other Forms of Imaging Clinical Examples in Radiology Volume 9, Issue 1; Winter 2013

27 Stereotactic Planning Process Stereotactic Planning 3D Simulation Beam Modifiers Calculations Key documentation requirements for SRS & SBRT: Medical necessity = why? Intent Potential for cure Performance status

28 Coding for Stereotactic Planning 3D Simulation Three-dimensional (3D) computer-generated 3D reconstruction of tumor volume and surrounding critical normal tissue structures from direct CT scans and/or MRI data in preparation for non-coplanar or coplanar therapy. The simulation uses documented 3D beam's eye view volume-dose displays of multiple or moving beams Treatment device(s) Basic dosimetry calculation(s)

29 Basic Dosimetry Calculation 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 Utilization Guidelines Applicable for all types of dosimetry planning Supporting documentation must support quantity and date of service Requires physician signature

30 Coding For Treatment Devices Beam Modifiers Device Codes Simple (simple block, simple bolus) Examples: pre-made block, asymmetric jaw, bolus Intermediate (multiple blocks, stents, bite blocks, special bolus) Examples: multiple pre-made blocks, beam splitter Complex (irregular blocks, special shields, compensators, wedges, molds or casts) Examples: MLC, compensator, wedge, cone, helmet, collimator

31 Devices for SRS/SBRT Devices will vary depending on SRS/SBRT delivery method Potential Scenarios: One per arc One per unique MLC One per cone One per helmet or helmet change One per unique plug pattern Payor limits may apply to allowed quantities

32 Verification Process IGRT Verification Simulation Inclusive in Procedure Verification Process Process is dependant on treatment modality and medical necessity.

33 Verification for SRS/SBRT Imaging to confirm positioning, beam placement, etc. is required Imaging is inclusive in the SRS and/or SBRT procedure & not separately billable Documentation of verification process should be included within the required procedure note performed by MD.

34 Stereotactic Treatment Delivery MPFS HOPPS Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial G0173 Linear accelerator based stereotactic radiosurgery, lesion(s) consisting of 1 session; multi- complete course of therapy in one session source Cobalt 60 based Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; linear accelerator based Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions G0251 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 G0340 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

35 Utilization Guidelines for SRS/SBRT Billable once per day of treatment regardless of the number of sessions or lesions Coding may vary Freestanding vs. Hospital Outpatient Medicare vs. Commercial Payer Delivery technique (Robotic vs. Non-Robotic)

36 Radiation Oncologist Participation As stated within Novitas Solutions, Inc. LCD:

37 Supporting Documentation As stated within the Documentation Requirements section of the Novitas LCD: Documentation Requirements Documentation should include the date and the current treatment dose. A radiation oncologist and a neurosurgeon must evaluate the clinical aspects of the treatment and document and sign this evaluation as well as the resulting management decisions. A radiation oncologist and medical physicist must evaluate the technical aspects of the treatment and document and sign this evaluation as well as the resulting treatment management decisions.

38 Treatment Management Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session) SBRT, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fx Utilization Guidelines: Billable once per course regardless of number of lesions or sessions & cannot be billed for same course Supporting documentation required

39 Continuing 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 Utilization Guidelines: Reported once per 5 fraction period Billing date maybe date supported by documentation Payor policies could indicate to bill the same date as treatment management Documentation IS necessary whether EMR or paper

40 Special Physics Consult Special medical radiation physics consultation Required Documentation: Request by Physician Report by Physicist custom to the specific request Review of Report by Physician Noridian Administrative Services LCD states:

41 Other Specialties Involved Especially for SRS & SBRT other specialty MDs could be involved: Specific codes available for these other MDs Neurosurgeon and Thoracic surgeon specific codes CPT Code Descriptor Apply SRS Head frame add-on Srs cranial lesion simple Srs cran les simple addl Srs cranial lesion complex Srs cran les complex addl Thorax stereo rad target with tx

42 Payor Issues

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