2 TOTAL CARE OF THE RADIATION ONCOLOGY PATIENT CLINICAL TREATMENT MANAGEMENT 1The 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 hands-on, face-to-face patient care.
3 Clinical Treatment Management 2Clinical 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 4CPT Radiation Therapy Treatment Management CodesWeekly Radiation Therapy Management, fractionsRadiation Therapy Management; Short course, 1 or 2 fractionsRadiation Therapy Management; Stereotactic, (SRS) 1 fraction77435 – Radiation Therapy Management; SBRT, SRS, full course of therapy, up to a max of 5 fractions, (2007)Radiation Therapy Management; Intraoperative.
5 Professional billing 774274Professional billing relates to 5 fractions of therapy delivered, regardless of the number of elapsed calendar days and must be billed as 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.
6 Most of the Carriers want you to report this way NIBMost of the Carriers want you to report this way5 fractions equal one Week, bill first date of week
7 Historical Background 7It 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.
8 WEEKLY UNDER BEAM PROGRESS NOTES Five Required Review Elements 7WEEKLY UNDER BEAM PROGRESS NOTES Five Required Review ElementsThe physician will be expected to have reviewed as many of these elements as are applicable to the current course of treatment managementIt is extremely important that these five critical elements be covered in each note.I Chart and dosimetry reviewII Treatment setup and delivery reviewIII Port film or electronic image reviewIV Under beam evaluation of the patientV Recommendation of therapy
9 8The 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.
10 A weekly note must occur sometime during each 5 day interval 9Mon Tues Wed Thurs FriWeek TX TX TX TX TXNO PROGRESS NOTE WEEK 1This causes problems with 77427Week TX TX TX TX TXPN77427Week TX TX TX TX TXPNWeek TX TX TX TX TXPNA weekly note must occur sometime during each 5 day interval
11 A weekly note must occur sometime during each 5 day interval 9Mon Tues Wed Thurs FriWeek TX TX TX TX TXPN Having a note on week 1 is crucial77427Week TX TX TX TX TXPNWeek TX TX TX TX TXPNWeek TX TX TX TX TXPNHaving a note on the last TX date is very importantPN77427EOTA weekly note must occur sometime during each 5 day interval
12 WEEKLY PROGRESS NOTE9There 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”
13 Which is a valid location for patient/physician encounter? 9Parking garageHall wayWaiting roomExam roomTreatment consoleTreatment roomWhich is a valid location for patient/physician encounter?
14 10ALL OF THEMAt 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 reactionsThere is no written requirement related to length of time or location of the patient/physician encounterAs long as privacy concerns are met to the satisfaction of both the physician and the patient.20/104
15 WEEKLY PROGRESS NOTE10The patient /physician encounter is only one of the 5 required elements of weekly managementThe 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
16 10WEEKLY PROGRESS NOTEThe 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
17 UNDER BEAM PROGRESS NOTES NIB Narrative on page 6INITIAL EVALUATION DOSIMETRY TREATMENT IMAGING EXAMINATIONUNDER BEAM PROGRESS NOTESCLINICAL END OF TREATMENT SUMMARYThe under beam progress note is a clinical weekly summary documenting the physician’s involvement in the weekly management of the patientFOLLOW UP NOTESUsing the cascading Information format, vital clinical and technical data may be transferred, discarded, or added to each new weekly document as it is created
18 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
19 Medical decision-making Other areas may also change. NIBAll 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 ExamReview of SystemsMedical decision-makingOther areas may also change.Do not always use exactly the same time for every patient or type of encounter.
20 Compliance Warning, Cascaded Information NIBCompliance Warning, Cascaded Information
22 EMRs make compliance very easy, but they also make auditing very easy. All that is really required is a quick review of the areas of a document where you 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.NIB
23 We RecommendNIBAny 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”.
24 # 1--Chart & Dosimetry Review 15Verification of correct summation of doseVerify 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 carriedThe 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
25 #2 Treatment Setup & Positioning Evaluation 15#2 Treatment Setup & Positioning EvaluationIt 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
26 # 3--Portal Film Review for Imaging 16# 3--Portal Film Review for ImagingRadiographic 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.
27 # 4--UNDER BEAM EVALUATION PROGRESS NOTE 16# 4--UNDER BEAM EVALUATION PROGRESS NOTEExamination 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.
28 Under Beam Examination 17Under 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
29 17For 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
30 17Many 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”
31 NIBPages 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.
32 UNDER BEAM PROGRESS NOTE 21UNDER BEAM PROGRESS NOTEEvery progress note should have the basic demographic information about the patient.
33 History of Present Illness 21History of Present IllnessA very short version of the patient's present illness should be presented limited to only a few sentences summarizing the case to-date.
34 Current Treatment Parameters 22Current Treatment ParametersArea(s) under treatmentEnergy/modeEvaluation of appropriateness and accuracy of all Treatment DevicesCurrent dosagePlanned dosageCritical structure dosageMicrodosimetry as doneAny corrective action as required
35 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 changes22
36 Physical Examination 23 Constitutional General appearance Examination of area under treatment mustalways be includedExamination of other areas as needed
37 24Current Status of anyTreatment ReactionsSkin reactionsGI reactionsOral cavity reactionsHematologic profilePresent weight as related to previous weight
38 Tumor Response 24 Indicate any changes from previous work-up Significant or subtle changes in tumor sizeExpected response at current dose level
39 Pain Assessment and Management See Section 3 Page 8Full assessment of painMedications and corrective actionsOrder and document medicationsPrint prescriptionsMaintain a compliant list of all medications and prescriptions.ONCOCHART
40 #5 Recommendation of Treatment 25#5 Recommendation of TreatmentPatient to continue therapyPatient placed on hold – state the reasonTreatment requires modificationPatient has completed the course of treatmentTHIS MUST BE COMPLETED BY THE PHYSICIAN EACH WEEK, NO OTHER PERSON CAN MAKE THIS DECISION.
41 Physician orders (CPO) 25With electronic records, Clinical Physician Orders have been made much easier to deal with.Multiple paper forms are eliminatedOrders can be tailored to fit the caseOrders can be sent electronically
42 25Physician work page has all the common procedures that require orders. This can be initiated by any authorized person in the departmentA narrative is produced which can be sent electronically, faxed, or printedTHIS IS A MEANINGFUL USE REQUIREMENTONCOCHART
43 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.
44 Clinical comment regarding Current Status 26Clinical comment regarding Current StatusThis 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
45 Coordination of Care26Routine progress notes should be sent to the patient’s other physicians to keep them informed of the case under treatment.60/104
46 Physician Demographics 26Physician DemographicsEvery 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.
47 27Check-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.
48 NIBTHIS NOTE DOES NOT MEET MEANINGFUL USE, WHICH IS NOW REQUIREDThis 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.
50 Electronically Generated Progress Notes are Preferable NIBNIBElectronically GeneratedProgress Notes are Preferable
51 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.
53 Transition of careIf 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.
55 Weekly Treatment Management 77427 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 physicianWhat 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)
57 Typical format of endoscopy report 29Typical format of endoscopy reportFIBEROPTIC ENDOSCOPYThis 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 cGyProcedure: 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./nzMAY BE REPORTED DURING AN ACTIVE COURSE OF TREATMENTONCOCHART
58 77417 Therapeutic radiology port Film(s) 3077417 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 code70/104
59 Conformal Treatment Management 34Conformal Treatment ManagementConformal 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
60 77469 Intraoperative treatment management, single session 34This 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
61 35Short Course of ClinicalTreatment ManagementThis 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
62 Prevention of Heterotrophic Bone formation 36Most commonly done following major bone traumaSingle treatment of 6 to 8 GyAll procedures done on one day.Consult, treatment planning, simulation, blocks, dosimetry, and treatmentICD-9 code or V-07.8
63 HETROTROPHIC BONE PREVENTION 36HETROTROPHIC BONE PREVENTIONPOST OPERATIVE
64 Short Course of Clinical Treatment Management 77431 39Short Course of Clinical Treatment Management 77431What 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.
65 Chemotherapy with Radiation Treatments 41Chemotherapy with Radiation Treatments85/104
66 Chemotherapy with Radiation Treatments 41Chemotherapy with Radiation TreatmentsChemotherapy, 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.
67 41Almost 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.
68 41When chemotherapy is used, the acute and long-term effects, must be taken into account by the radiation oncologist.Patients receiving chemotherapy tend to be sicker and require closer and more careful attentionThe 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
69 Special Treatment Procedure 77470 42Special Treatment Procedure 7747077470 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, 3-D CRT, IMRT (removed 2012), heavy particles (e.g. protons/neutrons), and any other special time-consuming and complex treatment procedure.)
70 77470 IS A GLOBAL BILLLING CODE 42The 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
71 SPECIAL TREATMENT PROCEDURE WORKPAGE 43Note the many different indications for reporting the special treatment procedure, 77470SPECIAL TREATMENT PROCEDURE WORKPAGEONCOCHART
72 Can anything better exemplify special treatment procedure than pediatric anesthesia? NIB
73 A narrative note is absolutely necessary as the backup documentation for 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.
74 Special Procedure Note 43Special Procedure NoteThis 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.92/104ONCOCHART
76 Special Treatment Procedures 77470 44Special Treatment Procedures 77470What’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 this 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
77 46If 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.
78 77600 – 77620 ARE GLOBAL BILLING CODES HYPERTHERMIA46Covered by codes to 77620Payment value of coverage of treatment by negotiation with local insurance carriers77600 – ARE GLOBAL BILLING CODES99/104
81 AVAILABLE CODES49Only the Hyperthermia delivery codes are specific to Hyperthermia.Superficial up to 4 cm depthDeep over 4 cm in depthProbes (interstitial) 5 or less probesProbes (interstitial) 6 or more probesProbes ( intracavitary) any numberNew codes were planned for 2009
82 CODES THAT CAN BE USED 49 77263 Complex treatment planning Special treatment procedureInitial set up simulationSubsequent simulations same areaIsothermic plan, superficialIsothermic plan deep one portIsothermic plan deep, multiple portsIsothermic plan, 3-D planningIsothermic plan interstitial up to 4 probesIsothermic plan interstitial, 5-10 probesIsothermic plan interstitial, over 10 probesIsothermic plan intracavitaryBasic Dosimetry for heating time calculationsCalculation of areas of maximal or minimal heating
83 PRINCIPLES OF BILLING, CODING AND COMPLIANCE IN RADIATION ONCOLOGY BMSi 2014END 11
86 MEDICARE (CMS), 2010, REQUIRES 7There 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.
87 Trail Blazer opinion June 2010 11For 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.
89 Assessment of Quality of Life 23Assessment of Quality of LifeGenerally done by the nursing staff but must be reviewed by the physicianPainAmbulationSocial interactionsMemoryPsycho-social adjustmentNutritional status should always be mentioned as related to present weightPhysician/patient self assessment of Q of L51/104
90 Review of Portal Images 31Review of current portal films or imagesComparison with previous portal films or imagesComparison with simulation films or imagesComparison with appropriate diagnostic imagingCorrective action if necessaryReview of corrected portal films or imagesIndicate if films not required (electrons, superficial)ONCOCHART
91 Total Body or Hemi body Radiation Therapy 37Total Body or Hemi body Radiation TherapyTotal 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 management80/104
92 38 Valid charges for total body radiation therapy 992XX High Complexity Evaluation77263 Therapeutic Radiology Treatment Planning; Complex77290 Therapeutic Radiology Simulation; ComplexSimulation may be repeated on different days during the initial setup procedures.77300 Basic Radiation Dosimetry CalculationThis 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 ConsultationAs Requested By the radiation oncologist.Usually only 1 of these would be required for a total body course of treatment.
93 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 -22Modifier –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.
94 Review of Laboratory Data (page 18-19) Laboratory tests, should be discussed andsummarizedComparison to previous laboratory workIndicate corrective actions if necessaryOrdering of any new testing as requiredReview of Diagnostic Imaging Studies ( page 19)Compare with previous imaging studiesCompare with current portal films if indicatedOrdering of any new testing or imaging as required
96 Rework incident toDecrease number of slidesClean up wording
97 Month End CrossingNIBOn March 2009 the National Government Services, a CMS contracting agent "clarified" the proper reporting of 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.
98 “Clarified” method of Billing Week MgmtOrphaned dateOrphaned dateBill first date of “clarified” week3 Fractions make up this week
99 This makes the billing more difficult NIBOrphaned dateOrphaned dateWeek MgmtWe then return to a conventional 5 day week but what do we do with the 2 orphaned dates?
100 Even More Difficult with 2 days in each Crossing Segment NIBEven More Difficult with 2 days in each Crossing SegmentWhich 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 management billing?????
101 Summary of R128BP page 13INCIDENT TO SERVICESThe 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
103 If your carrier is forcing you to use this method, you should protest NIBThis 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 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
104 Summary of R128BP page 13INCIDENT TO SERVICESIf 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
107 RADIATION THERAPY DRG There are 523 DRG Codes 45There are 523 DRG CodesCode 409 is the only DRG with radiation therapy409 is defined as concomitant chemotherapy and radiation therapy during the admissionDRG codes do not include additional reimbursement for radiation therapyThis is why you are discouraged from starting therapy while a hospital inpatient
108 2Clinical Treatment Management does not cease for nights, holidays, week ends, or any other time of non active treatment deliveryThe physician remains responsible for clinical management as long as the patient is under your direct care.
109 Historical Background 2The 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.
110 Historical Background 3In 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 AMA-CPT adopt the new code 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.
111 Historical Background 3As a key part of the negotiations to achieve , it was agreed thatall the items of weekly care and management will be performed on a regular basis and documented by regular under beam progress notes
112 Availability of Physician During Treatment Management, HOPPS 11Availability of Physician During Treatment Management, HOPPSMedicare 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
113 THIS IS OUR BEST INTERPRETATION OF THE EXISTING REGULATIONS NIBTHIS IS OUR BEST INTERPRETATION OF THE EXISTING REGULATIONSCheck your local carrier if in doubt about coverage, especially in rural areas of limited medical accessibility
114 12General supervision means the procedure is furnished 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, DOSIMETRYDirect 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 DELIVERYPersonal supervision means a physician must be in attendance in the room during the performance of the procedure. SIMULATION, PATIENT EXAMINATION
115 The Radiation Oncologist (CMS 2010) 12There 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
116 The Responsible Physician 13It is not in accordance with the law for a Non Physician practitioner to provide physician services supervision.
117 Summary of R128BP page 13INCIDENT TO SERVICESThe 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 providesThe 15 minute exclusion is not mentioned, as this was only a concession to ACR many years ago and never became part of CMS policy
118 Coverage under –Q5 -Q5 Services provided by a substitute physician 14A 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
119 14If 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.
120 e-RX Prescribe for Narcotics Covered in section 3 page 8e-RX Prescribe for NarcoticsThis is the token, a random number generator used to verify electronic narcotic prescribing.
121 New DEA controlled drug requirements NIBNew DEA controlled drug requirementsDEA 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.
122 IMRT, Electron or Kilovoltage treatment may not produce port films. 31The 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
123 45BILLING INPATIENT CARE FROM A FREESTANDING CENTER OR HOSPITAL BASED PROGRAMBy law, Medicare stipulates that the technical component of inpatient radiation therapy must be included as part of the DRG of the admission94/104
124 Skilled Nursing Facility This may not apply to private insurance 46Skilled Nursing FacilityPatients 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 insuranceSP98/104
126 Notice, the weekly management is being billed on the 1st date of each five-day treatment interval NIBThe progress notes are occurring regularly on Monday regardless of the elapsed number of treatments
127 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).
128 Verbatim Cut and PasteNIBThis is from HHS and DOJ