Transcript Carl R. Bogardus, Jr., M.D. Cancer Care Network, Inc.

Section 11
Covered by pages 1-49
Radiation Therapy
Clinical Treatment
Management
Carl Bogardus, Jr, MD
10:15 -10:45 AM
83
031114
Modified For 04-11-14
TOTAL CARE OF THE
RADIATION ONCOLOGY PATIENT
CLINICAL TREATMENT MANAGEMENT
1
The total care of the radiation oncology patient mandates
direct clinical management by the radiation
oncologist throughout the course of therapy.
It is the radiation oncologist’s role and
responsibility to provide daily
supervision of treatment and handson, face-to-face patient care.
Clinical Treatment Management 2
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Clinical Treatment Management starts with the
acceptance of the patient for treatment.
Clinical Treatment Management ends with the
Clinical End of Treatment report.
Clinical Treatment Management is tied
to 5 days of treatment delivery only as
a convenient means of tracking time for
billing purposes.
4
CPT Radiation Therapy
Treatment Management Codes
77427 - Weekly Radiation Therapy Management,
5 fractions
77431 - Radiation Therapy Management; Short course, 1 or
2 fractions
77432 - Radiation Therapy Management; Stereotactic,
(SRS) 1 fraction
77435 – Radiation Therapy Management; SBRT, SRS, full
course of therapy, up to a max of 5 fractions, (2007)
77469- Radiation Therapy Management; Intraoperative.
Professional billing 77427
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4
Professional billing relates to 5 fractions
of therapy delivered, regardless of the
number of elapsed calendar days and
must be billed as 77427 X 1 per 5 FX
block of treatments.
The billing date for weekly management ,
77427, is usually the first day of each of
the 5 day blocks.
NIB
Most of the Carriers want you to report this way
5 fractions equal one Week, bill first date of week
Historical Background
•It is imperative that each physician document
their direct involvement in all of the procedures
related to a week of treatment management.
•It is expected that each patient will have
as many regularly spaced progress notes
as there are weeks of treatments.
•The complexity and completeness of the note
must reflect the complexity of care for the
patient.
7
WEEKLY UNDER BEAM PROGRESS NOTES
Five Required Review Elements
The physician will be expected to have reviewed as many of
these elements as are applicable to the current course of
treatment management
It is extremely important that these five
critical elements be covered in each note.
I
II
III
IV
V
Chart and dosimetry review
Treatment setup and delivery review
Port film or electronic image review
Under beam evaluation of the patient
Recommendation of therapy
7
8
•The weekly progress note does
not necessarily have to occur on
the same day of each week, but
for a course of therapy there
should be an equal or greater
number of progress notes than
the weeks of management
being billed.
Mon Tues Wed Thurs Fri
Week TX
TX
TX
TX
TX
1
NO PROGRESS NOTE WEEK 1
This causes problems with 77427
Week TX
2
TX
TX
TX
PN
TX
TX
TX
TX
TX
TX
TX
77427
Week TX
4
TX
PN
77427
Week TX
3
TX
9
PN
77427
A weekly note must occur sometime during each 5 day interval
Mon Tues Wed Thurs Fri
Week TX
TX
TX
TX
TX
1
PN Having a note on week 1 is crucial
77427
Week TX
2
TX
TX
TX
PN
TX
TX
TX
TX
TX
TX
77427
Week TX
4
TX
PN
77427
Week TX
3
TX
9
PN
77427
Having a
note on the
last TX date
is very
TX important
PN
77427
EOT
A weekly note must occur sometime during each 5 day interval
WEEKLY PROGRESS NOTE
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9
There is no written directive
stating which day during the
treatment week that the
physician/patient encounter must
occur.
There is no stipulation of the
manner of interaction, only that it
be “face to face”
9
Hall way
Treatment console
Waiting room
Treatment room
Parking garage
Exam room
Which is a valid location for patient/physician encounter?
ALL OF THEM
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10
At each encounter this patient had the opportunity ask
question related to her course of treatment.
At each encounter the patient acknowledges her
interaction with the physician.
At each encounter the physician has the opportunity to
evaluate the patient’s general condition.
At each encounter the physician will use his best
judgment to determine what is needed to evaluate
response to treatment and radiation reactions
There is no written requirement related to length of time
or location of the patient/physician encounter
As long as privacy concerns are met to the
satisfaction of both the physician and
the patient.
20/104
WEEKLY PROGRESS NOTE
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10
The patient /physician encounter is only
one of the 5 required elements of weekly
management
The weekly progress note is a document
covering all aspects of patient care and
management.
Each of the 5 basic elements is further
subdivided into many sub routines that
require individual documentation
10
WEEKLY PROGRESS NOTE
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The production of this supporting
document does not need to
coincide with the physical
examination of the patient.
It is customary done this way
only as a general convenience,
not a requirement
NIB Narrative on page 6
INITIAL EVALUATION
DOSIMETRY TREATMENT IMAGING EXAMINATION
UNDER BEAM PROGRESS NOTES
CLINICAL END OF TREATMENT SUMMARY
The under beam
progress note is a
clinical weekly summary
documenting the
physician’s involvement
in the weekly
management of the
patient
FOLLOW UP NOTES
Using the cascading
Information format, vital
clinical and technical
data may be transferred,
discarded, or added to
each new weekly
document as it is created
NIB
Compliance and audits. These are two words
that most physicians and administrators really
don't like to hear.
With cascading, elements of an E/M document
will copy verbatim into subsequent documents.
Verbatim copying will cause cascading of old
information into new encounter forms without
any change.
Medicare considers that an identically copied
note indicates that the physician was not
actively involved in the creation of the new note.
Templating has HCFA considering severe
penalties when they find large sections of notes
that are 100% copies in subsequent workups.
NIB
All physicians and users should be very
much aware of this potential problem.
They are well advised to carefully read
any areas of their notes that are likely to
change such as;
Chief Complaint,
HPI,
Physical Exam
Review of Systems
Medical decision-making
Other areas may also change.
Do not always use exactly the same time
for every patient or type of encounter.
NIB
Compliance Warning, Cascaded Information
NIB
Original work up
Six week follow-up
All that is really required is a quick review
of the areas of a document where you NIB
know some changes have probably
occurred based upon the patient's clinical
findings and treatment parameters.
Document those changes in the record. If
no changes have occurred, indicate that
you have reviewed that section and it is
truly unchanged from the previous work
up.
EMRs make compliance very easy,
but they also make auditing very
easy.
We Recommend
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NIB
Any cascaded topic that has not been
reviewed on a new document will
clear upon save and record.
If the topic has been opened and any
change has been made, then the
changed topic and its questions and
answers will be saved.
You may indicate “reviewed and save,
no change needed”.
# 1--Chart & Dosimetry Review
15
•Verification of correct summation of dose
•Verify that time and/or monitor units are correct.
•Stop or re-evaluation points are clearly indicated.
•The correct modalities of treatment are indicated.
•The correct beam energy is indicated.
•Proper beam modifiers are in place.
•Tumor dose is compared to the tolerance dose of
critical tissues.
•Critical tissue dose points are carried
•The number of treatment volumes is correct.
•The number of ports is correct.
Document of the first day of treatment
with the first under beam note
#2 Treatment Setup & Positioning
Evaluation
15
It is understood that it is impossible for
the physician to be physically present
during each and every setup, but the
physician should be readily
available for corrective action
should the need arise.
Document of the first day of treatment
with the first under beam note
# 3--Portal Film Review for
Imaging
Radiographic films or electronic or
portal imaging studies are taken at
regular intervals of all of the portals
being treated.
Port film review must be
documented each week in the
under beam progress note, if
imaging is performed.
16
16
# 4--UNDER BEAM
EVALUATION PROGRESS NOTE
Examination of the patient consists of
clinical evaluation, assessment of
tumor response, and case
management.
The radiation oncologist should
physically examine the patient each
week for treatment related side
effects, and tumor response.
17
Under Beam Examination
- Every
patient under treatment,
without exception, should be seen
and examined at least once per week
by the physician.
This is a key element of the weekly
note. The PA can do much of the
work, but the physician must be
involved
17
For under beam visits, these
components are the same as
for other E/M services.
E/M services are included in
weekly management and
cannot be charged separate.
44/104
17
Many factors make up a weekly progress note, the
use of multiple choice questions with many choices
of answers, makes each note unique and reduces the
appearance of “macro copying”
NIB
Pages 17 to 20 give a short
summary of the needed
elements to make up a
compliant progress note.
You should follow these
guide lines to format the
content of your notes.
UNDER BEAM PROGRESS NOTE 21
Every progress note should have the basic
demographic information about the patient.
History of Present Illness
21
A very short version of the patient's
present illness should be presented
limited to only a few sentences
summarizing the case to-date.
22
Current Treatment
Parameters
Area(s) under treatment
Energy/mode
Evaluation of appropriateness
and accuracy of all Treatment
Devices
Current dosage
Planned dosage
Critical structure dosage
Microdosimetry as done
Any corrective action as
required
22
A weekly review of technical factors is
required, once entered, this component
usually will not vary week to week, if any
factors change, then the note must reflect
the changes
Physical Examination
Constitutional
General appearance
Examination of area under treatment must
always be included
Examination of other areas as needed
23
Current Status of any
Treatment Reactions
Skin reactions
GI reactions
Oral cavity reactions
Hematologic profile
Present weight as related
to previous weight
24
Tumor Response
24
Indicate any changes from previous work-up
Significant or subtle changes in tumor size
Expected response at current dose level
Pain Assessment and Management
See Section 3
Page 8
•Full assessment of pain
•Medications and corrective
actions
•Order and document
medications
•Print prescriptions
•Maintain a compliant list of all
medications and prescriptions.
ONCOCHART
#5 Recommendation of
Treatment
• Patient to continue therapy
• Patient placed on hold – state the reason
• Treatment requires modification
• Patient has completed the course of
treatment
•THIS MUST BE COMPLETED BY
THE PHYSICIAN EACH WEEK, NO
OTHER PERSON CAN MAKE THIS
DECISION.
25
Physician orders (CPO)
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25
With electronic records, Clinical
Physician Orders have been
made much easier to deal with.
Multiple paper forms are
eliminated
Orders can be tailored to fit the
case
Orders can be sent electronically
25
Physician work
page has all the
common
procedures that
require orders.
This can be
initiated by any
authorized
person in the
department
A narrative is
produced
which can be
sent
electronically,
faxed, or
printed
ONCOCHART
THIS IS A MEANINGFUL USE REQUIREMENT
Drug Orders in Dept.
Electronic record of physician order for medication
dispensed by nursing staff and signed off by physician.
Compliant with JCAHO and Meaningful Use.
Clinical comment regarding Current
Status
26
• This is a brief narrative summary of a review of any
of the preceding elements that show significant
change, or new developments of importance to the
care of the patient.
ONCOCHART
Coordination of Care
•Routine progress notes should be sent to
the patient’s other physicians to keep them
informed of the case under treatment.
60/104
26
Physician Demographics
•Every progress note should conclude with
a signature of the physician of record and
indication of copies to other physicians or
charts.
•Electronic signature is acceptable if
original signature is on file.
26
27
Check-off and fill-in weekly
summaries are marginally
acceptable, but they must be
legible and complete.
They must show that the
physician has documented
his/her direct involvement in
the production of the weekly
assessment.
NIB
THIS NOTE DOES NOT MEET MEANINGFUL
USE, WHICH IS NOW REQUIRED
This check off note just barely will suffice as a valid
progress note. Demographics, vitals, dose, and some
recommendation of therapy are noted, but the rest is almost
unintelligible, and far too brief, with many key elements
missing, such as a legible signature and physician name.
NIB
This weekly under
beam note is also
marginal in terms
of useful data,
and does not
meet compliance
requirements.
NIB
NIB
Electronically Generated
Progress Notes are Preferable
Clinical end of treatment summary.
The clinical end of treatment summary
is a non reimbursable procedure, but is
absolutely necessary to indicate the
termination of the course of radiation
treatment.
This document should contain sufficient
information to allow the requesting
physician, or any other physician
involved in the care of the case to fully
understand the course of treatment that
was just completed.
Transition of care
If you are attesting for meaningful use a
transition of care record is required, but
it is also very good clinical practice.
The transition of care record, combined
with an end of treatment summary
allows you to transfer a great deal of
meaningful information to the referring
physician for their continued care of the
patient.
Transition of Care Document
Weekly Treatment Management
77427
27
What’s it for?
The physician’s ongoing clinical care during a course of
therapy.
Who normally documents/bills/captures this code?
The physician.
What Documentation is suggested for this code?
A weekly progress note (every 5 fractions) by the physician
What are the common documentation errors with this
code?
Inadequate amount of information in the weekly notes.
Missing progress notes for the given number of fractions.
What are the common billing errors identified?
Billing this code based only on the number of fractions
without adequate documentation (progress notes) existing in
the record.
BID therapy requires a progress note every 5 fractions (2 ½
calendar days)
28
FIBEROPTIC ENDOSCOPY
PROCEDURE CPT 31575
Typical format of endoscopy report
29
FIBEROPTIC ENDOSCOPY
This patient is currently being treated for a T1, N0, M0, squamous cell carcinoma of the right true vocal cord. The patient has just completed his
third week of radiation therapy. He is currently being treated at 180 cGy per day and is currently at 2700 cGy
Procedure: Utilizing a premedication of Pontocaine and Epinephrine applied through nasal atomizer into the right nares, the fiberoptic endoscope
was inserted without difficulty. The nasal vestibule and nasal passages were carefully evaluated and found to be unchanged from the previous
examination of two weeks ago. The endoscope was advanced further and the nasopharynx was clearly visualized. Both eustachian orifices were
clear. A mild amount of dried secretion was noted along the posterior pharyngeal wall. None of this appears to be significant. There is a mild
injection of the mucosa of the nasopharynx but no abnormalities were noted.
The endoscope was then advanced further and the hypopharynx and base of the tongue area were carefully evaluated and found to be unchanged
from previous evaluations. The endoscope was then advanced into the region of the larynx. The epiglottis was noted to be symmetrical and without
lesions. A moderate amount of mucositis is beginning to develop in the area of the larynx. This is most noticeable along the base of the epiglottis.
Laryngeal ventricles are completely within normal limits. Pyriform sinuses are within normal limits. The false cords are beginning to show a very
light edema. There is a moderate amount of mucositis throughout the perilaryngeal area.
The vocal cords move well and oppose midline. The lesion that was previously noted along the anterior aspect of the right cord is beginning to
decrease in size. There is a white membrane that has formed along the area of the right anterior cord primarily in the region of the tumor. There is
no membrane formation on the left cord.
The procedure was terminated without difficulty.
Impression: Expected response at three weeks of therapy with beginning resolution of tumor.
Recommendation: The patient will continue on the planed course of radiation therapy without modification.
C.R. Bogardus, Jr., M.D./nz
MAY BE REPORTED DURING AN ACTIVE COURSE OF TREATMENT
ONCOCHART
30
77417 Therapeutic radiology port Film(s)
Port films are taken on the treatment machine using the
treatment beam to ensure that the treatment setup is as
prescribed by the simulation and dosimetry.
Any changes indicated by the port films must be
corrected or incorporated into the treatment plan.
For coding purposes, real-time or on-line portal
imaging is the same as obtaining port films.
The technical component (i.e. the costs associated with
generating port films) is reportable using code 77417.
70/104
Conformal Treatment Management
•Conformal radiation therapy treatment
management (3-D designed) consists of
clinical management of custom
designed and blocked treatment portals,
directed to a treatment volume of
interest.
•3-D Conformal management (not
SRS, or SBRT) is to be reported
using code 77427
34
77469 Intraoperative treatment
management, single session
• This code is to be utilized when
only 1 fraction makes up the
entire course of treatment
management.
• All management codes are
mutually exclusive per course of
therapy
34
77431
Short Course of Clinical
Treatment Management
•This code is to be utilized when only 1 or 2
fractions make up the entire course of
treatment management.
•Note: This code may not be used to be
reimbursed for the remaining one or
two treatments at the end of a long
course of therapy (ACR, 2001).
77/104
35
Prevention of Heterotrophic
Bone formation
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36
Most commonly done following
major bone trauma
Single treatment of 6 to 8 Gy
All procedures done on one day.
Consult, treatment planning,
simulation, blocks, dosimetry, and
treatment
ICD-9 code 728.13 or V-07.8
36
HETROTROPHIC BONE PREVENTION POST OPERATIVE
Short Course of Clinical
Treatment Management 77431
39
What is this code for?
The physician’s clinical care during a short course of only 1 or 2
fractions.
Who normally documents this code?
The physician.
When is this code normally billed?
The last day of the short course.
What Documentation is needed for this code?
A progress note outlining the short course of therapy.
What are the common documentation errors identified with
this code?
No physician’s note being documented.
What are the common billing errors identified?
Billing this code with Brachytherapy, this is only for external
beam patients.
Do not report for 1 or 2 leftover fractions of at the end of a long
course of therapy.
Chemotherapy
with Radiation
Treatments
85/104
41
Chemotherapy with Radiation Treatments
• Chemotherapy, or the use of drugs to treat cancer, is a
concept that has been with us for over 40 years.
• In the beginning, the drugs were extremely toxic, and
relatively ineffective.
• New drugs have been perfected which are highly
disease selective.
• There are many drugs in use today that target
specific cell lines of malignancy.
• Some of these drugs are used alone, others are used
in combination, and others are used in conjunction
with radiation therapy.
41
•Almost all of the chemotherapeutic
agents are highly toxic and create various
medical problems for the patient in
addition to their beneficial effects against
the malignancy.
•The beneficial effects of these drugs
usually will out weigh the toxic side
effects, and for this reason chemotherapy
plays a very important role in the overall
management scheme of patients with
malignancy.
41
•When chemotherapy is used, the acute and long-41
term effects, must be taken into account by the
radiation oncologist.
•Patients receiving chemotherapy tend to be
sicker and require closer and more careful
attention
•The treatment planning and treatment
management of the course of therapy will
always be complex. This will be true even
in what otherwise, would have been a
simple case.
88/104
Special Treatment Procedure 77470
42
77470 Special treatment procedure (e.g. total body
irradiation,
hemibody irradiation, per oral
endo-cavitary or intra-operative cone irradiation)
This code covers the additional physician
effort and work required for the special procedures
of, total body irradiation, hemibody irradiation,
intracavitary cone use, Brachytherapy, hyperthermia,
concurrent chemotherapy, radiation response
modifiers, stereotactic radiosurgery (single fraction
or fractionated), intra-operative radiation therapy, 3D CRT, IMRT (removed 2012), heavy particles (e.g.
protons/neutrons), and any other special timeconsuming and complex treatment procedure.
42
The code 77470, is designated to cover
the additional time and effort required
of the physician and the hospital
technical staff while performing
and/or managing special treatment
situations.
This code may be reported only one time
per course of therapy.
77470 IS A GLOBAL BILLLING CODE
43
Note the many
different
indications for
reporting the
special treatment
procedure, 77470
SPECIAL TREATMENT PROCEDURE WORKPAGE
ONCOCHART
Can anything better exemplify special
treatment procedure than pediatric
anesthesia?
NIB
A narrative note is absolutely necessary as the backup
documentation for 77470. Simply including a line in a
weekly progress note is not sufficient documentation to
justify the billing of this code. The reasons are all here,
just make certain that they are verbalized.
Special Procedure Note
This patient has just completed three months of multi-drug chemotherapy by Dr. Ishmael. We
have been watching the patient over the last few weeks as the counts have slowly risen to a
respectable level. The patient now has 4500 WBC's and 217,000 platelets. Patient still has
marked alopecia from the chemotherapy.
Considerable time was spent this morning with the patient and the patient's family explaining
the possibility of continued, severe, interactions between the radiation and the just completed
course of chemotherapy. It is anticipated that the patient will be experiencing a marked
increase in skin reactions because of the course of Adriamycin. The treatment portals will be
close to the heart, but every effort will be made to avoid treating any of the myocardium. The
patient and the patient's family do understand the possibility of severe reactions and
difficulties that will probably be experienced during the forthcoming course of radiation
treatments.
The course of radiation therapy over the next six weeks will be carefully coordinated with Dr.
Ishmael. Dr. Ishmael will be available to handle any medical problems that may arise during
this period of time. We will be observing the patient on a daily basis during the first part of
the course of treatment to make certain that reactions are not excessive.
The patient and the patient's family fully understand that the treatments are absolutely
necessary but that the patient will experience considerable discomfort and other interrelated
problems during the next few weeks.
Carl R. Bogardus, Jr., M.D.
92/104
ONCOCHART
43
Multiple reasons for 77470
44
Special Treatment Procedures
77470
What’s it for?
The additional effort involved in caring for patients under highly
complex circumstances.
Who normally documents this code?
Varies widely, but usually the physician.
When is this code normally billed?
Upfront at the same time as the physician’s clinical treatment
planning.
What Documentation is suggested for this code?
A physician narrative explaining medical necessity.
What is the common documentation error identified with thi
code?
Not documenting the code with a separate written document.
What are the common billing errors identified?
Missing the code due to inadequate documentation of the
procedure.
There is no “physical” event to trigger billing, it must be
recognized by circumstances.
SP89/104
46
If the patient is a Medicare recipient and
becomes hospitalized as an inpatient, but
being transported to a freestanding
center each day for treatment, then the
patient must be billed as an inpatient, not
as an outpatient.
Most freestanding centers have
contracts with hospitals to cover these
situations.
Hospital owned departments make
these corrections internally.
HYPERTHERMIA


Covered by codes 77600 to
77620
Payment value of coverage
of treatment by
negotiation with local
insurance carriers
77600 – 77620 ARE GLOBAL BILLING CODES
99/104
46
48
BSD Phased Array hyperthermia unit
HYPERTHERMIA ISOTHERMIC PLAN
NIB
AVAILABLE CODES

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Only the Hyperthermia delivery
codes are specific to Hyperthermia.
77600 Superficial up to 4 cm depth
77605 Deep over 4 cm in depth
77610 Probes (interstitial) 5 or less
probes
77615 Probes (interstitial) 6 or
more probes
77620 Probes ( intracavitary) any
number
New codes were planned for 2009
49
CODES THAT CAN BE USED
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49
77263 Complex treatment planning
77470 Special treatment procedure
77290 Initial set up simulation
77280 Subsequent simulations same area
77305 Isothermic plan, superficial
77310 Isothermic plan deep one port
77315 Isothermic plan deep, multiple ports
77295 Isothermic plan, 3-D planning
77326 Isothermic plan interstitial up to 4 probes
77327 Isothermic plan interstitial, 5-10 probes
77328 Isothermic plan interstitial, over 10
probes
77328 Isothermic plan intracavitary
77300 Basic Dosimetry for heating time
calculations
77300 Calculation of areas of maximal or
minimal heating
PRINCIPLES OF
BILLING, CODING
AND COMPLIANCE IN
RADIATION
ONCOLOGY
BMSi 2014
END 11
END OF SECTION 11
7
MEDICARE (CMS), 2010, REQUIRES
 There shall be a full-time
physician, preferably a radiation
oncologist, per facility, physically
available on a daily basis for direct
supervision of daily treatment, and
management of any patient related
treatment problems.
 The 5 elements of weekly
management must be documented
by this physician for each week of
treatment.
Trail Blazer opinion June 2010
11
For billing radiation treatment
management, 77427, Medicare
expects the radiation oncologist
to bill the weekly management
code for the management related
to five consecutive treatment
delivery sessions and to have seen
the patient at least once during
that time period. The actual
visit could occur anytime
during that time period.
R128BP page 13
Assessment of Quality of Life
Generally done by the
nursing staff but must be
reviewed by the physician
Pain
Ambulation
Social interactions
Memory
Psycho-social adjustment
Nutritional status should always be
mentioned as related to present weight
Physician/patient self assessment of Q of L
51/104
23
Review of Portal Images
31
• Review of current portal films or images
• Comparison with previous portal films or images
• Comparison with simulation films or images
• Comparison with appropriate diagnostic imaging
• Corrective action if necessary
• Review of corrected portal films or images
•Indicate if films not required (electrons, superficial)
ONCOCHART
Total Body or Hemi body
Radiation Therapy
37
Total or hemi body therapy is an extremely
complex procedure requiring a great deal of
physician input, often requiring special testing,
consultations, and physics evaluations.
When only one or two treatments are given for
the entire course of therapy, you should bill
short course of treatment management 77431.
80/104
Valid charges for total body radiation therapy
38
992XX High Complexity Evaluation
77263 Therapeutic Radiology Treatment Planning; Complex
77290 Therapeutic Radiology Simulation; Complex
Simulation may be repeated on different days during
the initial setup procedures.
77300 Basic Radiation Dosimetry Calculation
This may be calculated on many occasions. This may
be reported as many times as performed and
Documented.
77321 Special Teletherapy Port Plan (Electrons, if used)
77336 Continuing Medical Physics Support, 1 charged for 1
to 5 fractions.
77370 Special Medical Radiation Physics Consultation
As Requested By the radiation oncologist.
Usually only 1 of these would be required for a total
body course of treatment.
38
77331 Special Dosimetry (TLD or Diode Microdosimetry)
This may be billed as often as requested to cover all
measured dose points.
77334 Special Shields Special shields for the lungs may be
constructed.
77427 Weekly Megavoltage Treatment Management –22,
If over 2 treatments given, Modifier –22 is used to
increase the billed value.
77431 Short Course Clinical Treatment Management -22
Modifier –22 may be used to increase the value of this
code.
77417 Port Films, 1 charge is allowed per week (5 fractions)
of treatment.
77470 Special Treatment Procedure -22 Modifier –22 may be
used for a one-time charge for the special
treatment procedure.
Review of Laboratory Data (page 18-19)
Laboratory tests, should be discussed and
summarized
Comparison to previous laboratory work
Indicate corrective actions if necessary
Ordering of any new testing as required
Review of Diagnostic Imaging
Studies ( page 19)
Compare with previous imaging studies
Compare with current portal films if
indicated
Ordering of any new testing or imaging as
required
Look at errors on note
Rework incident to


Decrease number of slides
Clean up wording
Month End Crossing
On March 2009 the National Government
Services, a CMS contracting agent "clarified"
the proper reporting of 77427. This is
reported in the Medicare Claims processing
manual (100-04), Chapter 13, Section.1.
In the event that five fractions occur in
two different calendar months or years,
the billing "from and to" dates should
reflect the month in which the most
fractions were performed.
NIB
“Clarified” method of Billing
Orphaned date
Orphaned date
Week Mgmt
Bill first date of “clarified” week
3 Fractions make up this week
This makes the billing more difficult
Orphaned date Orphaned date
Week Mgmt
We then return to a conventional 5 day week but
what do we do with the 2 orphaned dates?
NIB
Even More Difficult with 2 days in each
Crossing Segment
NIB
Which set has the week of management billed, and if
only 2 fractions make up the end of a course, you
cannot bill a week of management, so do we loose
the last week of 77427 management billing?????
Summary of R128BP page 13
INCIDENT TO SERVICES

The Physician direct supervision
requirements are required if the
services are performed within a
hospital, the physician must be
within the hospital, but not
necessarily in the radiation
therapy department, this has
been clearly stated by CMS in the
ruling of April 7, 2000
NIB
ASTRO Comments, 04-30-12
NIB
This illogical scheme of reporting will
make billing and auditing very
difficult for no rational purpose. I
recall this same proposal about the
year 1991 as the code 77427 was
brought into use. This was soon
changed to ignore the monthly
crossing recommendation as being
far too difficult to bill and audit.
If your carrier is forcing you to use
this method, you should protest
Summary of R128BP page 13
INCIDENT TO SERVICES

If the hospital owned radiation
therapy department is not physically
located within, or connected to, the
hospital, i.e., a free standing center
then the physician must be
“Interruptible” and able to intervene
“right away” when Medicare
patients are being treated.
Free standing, non hospital
owned centers are subject to
this requirement

DRR
PORTAL
IMAGE
BLENDED IMAGES
72/104
PORTAL-VISION IMAGES (ARIA-VARIAN)
31
RULE OF 5 ROUND OFF
5
RADIATION THERAPY DRG





There are 523 DRG Codes
Code 409 is the only DRG with
radiation therapy
409 is defined as concomitant
chemotherapy and radiation
therapy during the admission
DRG codes do not include
additional reimbursement for
radiation therapy
This is why you are discouraged
from starting therapy while a
hospital inpatient
45
Clinical Treatment Management
does not cease for nights,
holidays, week ends, or any
other time of non active
treatment delivery
The physician remains
responsible for clinical
management as long as the
patient is under your direct
care.
2
Historical Background
•The original three levels of
complexity descriptors for treatment
management were formulated in the
early 1970’s.
•The term “treatment management” was
used to describe both the supervision of
treatment delivery and the clinical
management of the patient.
2
Historical Background
• In the Fall of 1990, AMA-CPT requested that the ACR
and ASTRO CPT Committees work to devise a weekly
treatment management system that could identify
physician procedures performed, and their
complex interactions.
•The ACR recommended that the AMACPT adopt the new code 77427 weekly
treatment management, effective Jan 1,
1991, we have had this code for 21 years,
and many physicians still have problems
documenting it’s use.
3
Historical Background
•As a key part of the negotiations to
achieve 77427, it was agreed that
• all the items of weekly care and
management will be performed
on a regular basis and
documented by regular under
beam progress notes
3
11
Availability of Physician During
Treatment Management, HOPPS
Medicare is tightening the availability
rules as part of the “Revised Incident To”
ruling of Jan 1, 2009, April 7, 2009, April 1,
2010.
Commercial carriers are also
beginning to pay very close attention
to physician availability.
25/104
THIS IS OUR BEST
INTERPRETATION OF
THE EXISTING
REGULATIONS
Check your local carrier if in
doubt about coverage, especially
in rural areas of limited medical
accessibility
NIB
•General supervision means the procedure is furnished
12
under the physician’s overall direction and control, but the
physician’s presence is not required during the
performance of the procedure. ISODOSE PLAN, BLOCKS,
DOSIMETRY
•Direct supervision in the office setting means the
physician must be present in the office suite and
immediately available to furnish assistance and direction
throughout the performance of the procedure. It does not mean
that the physician must be present in the room when the
procedure is performed. TREATMENT DELIVERY
•Personal supervision means a physician must be in
attendance in the room during the performance of the
procedure. SIMULATION, PATIENT EXAMINATION
The Radiation Oncologist (CMS 2010)
12
 There shall be a full-time radiation oncologist
per facility (Hospital out patient or Free
standing center) immediately available,
interruptible, and able to furnish assistance and
direction throughout the procedure.
 The attending physician or a responsible
physician (Ideally THIS PHYSICIAN SHOULD BE A
RADIATION ONCOLOGIST) must be either in direct
attendance or reasonably accessible during the
time that radiation treatments are being delivered.
30/104
The Responsible Physician

It is not in accordance
with the law for a Non
Physician practitioner
to provide physician
services supervision.
13
Summary of R128BP page 13
INCIDENT TO SERVICES


The CMS requirements clearly state
that if the responsible physician
leaves a free standing center, even
to go to the hospital, then all
Medicare related services must stop
unless coverage is provides
The 15 minute exclusion is not
mentioned, as this was only a
concession to ACR many years ago
and never became part of CMS policy
Coverage under –Q5




14
A Medical Oncologist who has
been credentialed to cover daily
treatment delivery patient care,
Who is working in the same
clinic,
Who is interruptible and able to
respond “Right away”
-Q5 Services provided by a
substitute physician
14
If a physician is unavailable for one
week (5 treatments) then the physician
who is covering will be the Physician of
Record and the Week of Management
must be billed under his name.
The only exception is for locum tenens
coverage where the billing remains in
the original physician’s name.
Covered in section 3 page 8
e-RX Prescribe for Narcotics
This is the token, a random number generator
used to verify electronic narcotic prescribing.
NIB
New DEA controlled drug requirements
DEA regulations require a pharmacy to
receive a new valid signed
prescription.
DEA has further stated that a pharmacy
may not provide a partially or fully
pre-populated form for the
prescribing practitioner.
The physician may either fax narcotic
prescriptions or send electronically if
pharmacy has the capability.
31
•The review and interpretation of port films
is considered as part of the weekly clinical
treatment management by the physician.
•IMRT, Electron or Kilovoltage
treatment may not produce port
films.
•Weekly orthogonal images for
IMRT setup may be billed as port
films
BILLING INPATIENT CARE
FROM A FREESTANDING
CENTER OR HOSPITAL BASED
PROGRAM

94/104
By law, Medicare stipulates
that the technical
component of inpatient
radiation therapy must be
included as part of the DRG
of the admission
45
46
Skilled Nursing Facility
Patients admitted to a skilled nursing
facility (SNF) under the part A benefit or a
Medicare part A stay are considered to be
hospital inpatients, and as such are covered
under a specific DRG of admission.
Treatment of these patients requires the
technical component of treatment to be
billed to the SNF, not Part B.
This may not apply to private insurance
SP98/104
Clinical example
Notice, the weekly management is being billed on
the 1st date of each five-day treatment interval
NIB
The progress notes are occurring regularly on
Monday regardless of the elapsed number of
treatments
Port Films 77417
33
What’s is this code for?
Weekly Port Film or Electronic Portal Imaging.
Who normally documents/bills/captures this code?
Treatment Therapist.
When is this code normally billed?
One time per five fractions, regardless of how many images are
taken.
What Documentation is suggested for this code?
A notation in the chart that portal images were taken, and if any
corrective action was needed.
What are the common documentation errors identified.
The lack of physician participation in the documentation.
What are the common billing errors identified?
Billing an incorrect number of units.
Billing these images professionally (they are technical only).
Verbatim Cut and Paste
NIB
This is from HHS and DOJ
They Really Mean It
NIB