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May 2013 Radiation Oncology Coding Tip (View More Coding Tips and News Alerts)

When is the Appropriate Time for Financial Counseling?
By Scott Plemmons, RT(R)(T)

Financial counseling is a vital component of the patient care process as studies have shown patients worry as much about their financial health as their physical health.  It is also necessary to comply with the Patient Protection and Affordable Care Act (PPACA), commonly called the Affordable Care Act, which is a United States federal statute signed into law by President Barack Obama on March 23, 2010.  Included in the act is verbiage for healthcare companies and healthcare providers to ensure all patients are apprised of their financial obligation:

• Allow consumers to make informed healthcare choices
• Periodic financial disclosures
• Educate consumers on their rights and responsibilities

With the implementation of an effective financial counseling program, assistance can be provided to the patient in the form of options for a payment plan and an understanding of insurance coverage, as well as peace of mind regarding their financial responsibilities.  Additional benefits may be seen in the form of improved communication between clinicians and financial counselors, along with process improvements in the event of changes or adjustments to the treatment course by the physician. 

Many departments fail to perform financial counseling or provide the service at an inappropriate time in the patient’s course of treatment.  The appropriate time is following the initial consultation or new patient visit with the physician but prior to the initiation of any treatment related services.  Once the patient has been treated or associated services rendered, the patient would not have the proper financial information to understand monetary obligations they may incur.  Prior to the initial consult visit with the patient, the financial counselor will:

• Register the patient
• Verify basic coverage
• Obtain the primary referral
• Discuss the practice billing policy
• Provide contact information

Upon completion of consult visit, prior to the treatment initiation, the financial counselor will:

• Provide a cost estimate based on the physician’s intent for treatment
• Obtain knowledge of specific insurance coverage policies relating to treatment ordered
• Assess the patient’s ability to pay prior to treatment
• Communicate ability and payment options to the patient and physician
• Identify financial assistance resources for the patient
• Establish a payment methodology or an amicable payment arrangement

As a reminder, ensuring specific payor guidelines are applied is an important step within a financial counseling program.  Through staff education, proper communication and checks and balances, financial counseling goals can be achieved.  Revenue Cycle Inc. can assist with implementing processes toward attaining an effective financial counseling program.  For more information regarding Revenue Cycle Inc.’s services, please contact our consulting team at 512-583-2000.

April 2013 Radiation Oncology Coding Tip (View More Coding Tips and News Alerts)

Is IMRT QA Necessary and Can You Bill For It?
By Brandi Orlando, RT (T)

The complexities of radiation treatments are increasing with the implementation of new technology.  With these advances, validation of accuracy is vital and evidence of this process is required by Medicare.  In recent years, numerous instances of treatment errors occurred, bringing attention to the necessity of performing QA for all IMRT treatment plans.  Within many Medicare policies, documentation requirements have been established detailing the requirement for IMRT QA, including the independent secondary verification of the monitor units derived from the planning system.  An example of these Medicare requirements is provided in the Novitas Solutions, Inc. Intensity Modulated Radiation Therapy (IMRT) LCD:  

“Documentation in the patient’s medical records must include:

• The reasonable and necessary requirements as outlined under the “Indications and Limitations of Coverage and/or Medical Necessity” section of this LCD and must be available to Medicare for review upon request. 
  
• The prescription must define the goals and requirements of the treatment plan, including the specific dose constraints for the target(s) and nearby critical structures. 
  
• A statement by the treating physician documenting the special need for performing IMRT on the patient in question, rather than performing conventional or 3-D treatment planning and delivery. 
  
• A signed and dated IMRT inverse plan that meets prescribed dose constraints for the PTV and surrounding normal tissue using either Dynamic Multi-Leaf Collimator (DMLC) or Segmented Multi-Leaf Collimator (SMLC) (average number of “steps” required to meet IMRT delivery is five), or inverse planned IMRT solid compensators to achieve intensity modulation radiation delivery.
  
• The target verification methodology that includes the following:
  
  • Documentation of the Clinical Treatment Volume (CTV) and the PTV.
    
  • Documentation of immobilization and patient positioning.
    
  • Means of dose verification and secondary means of verification.
    
• The MUs generated by the IMRT treatment plan must be independently checked before the patient’s first treatment.
  
• Documentation of fluence distributions recomputed in a phantom is required, or an equivalent methodology consistent with patient-specific IMRT treatment verification described above.”

These components are considered an integral component of the IMRT planning process and documentation of this work also supports the associated billable services.  For instance, several Medicare payors, including the American Medical Association (AMA), have addressed the basic dosimetry calculation (CPT® 77300) service for IMRT planning.  The information included within the CPT Assistant November 2009 published by the AMA states:

“After the plan is complete, in a separate process, the physicist must perform basic dose calculations on each of the modulated beams. This evaluation is reported with code 77300, Basic radiation dosimetry calculation, central axis depth dose calculation, TDF, NSD, gap calculation, off axis factor, tissue inhomogeneity factors, calculation of non-ionizing radiation surface and depth dose, as required during course of treatment, only when prescribed by the treating physician. These patient-specific monitor unit computations verify through a second (independent of treatment planning computer) dose-calculation method that the computer has correctly performed the treatment planning calculations.”

As a result of these instructions, the basic dosimetry calculations, CPT® 77300, are reportable and supported by an independent, secondary calculation of the monitor unit calculations derived as part of the IMRT plan.  In addition, this documentation requires a physician signature supporting the professional and technical services billed. 

Similar processes are also recommended for the IMRT MLC device, CPT® 77338, which represents the treatment device modulating the treatment beam(s).  Per the provided Medicare guidelines, the fluence distribution is required to be recomputed in a phantom as a means of verification; therefore, it is recommended that this documentation be utilized to support the 77338 code, as this provides evidence of completion of the required QA and representation of the treatment device modulating the treatment beam(s). 

In order to confirm Medicare and payor guidelines are met, review of internal processes is recommended to ensure the required QA is completed and documented prior to initiation of treatment delivery.  In addition, evaluation of charge capture is suggested in order to validate that the corresponding CPT® codes are applied per payor guidelines and fully supported within the medical record.  Revenue Cycle Inc. provides education and validation of supporting documentation to ensure billing and documentation compliance with regard to radiation oncology and the IMRT-based treatment technique.

For more information regarding the consulting services offered by Revenue Cycle Inc., please email us at info@revenuecycleinc.com.