December 2018 Radiation Oncology News

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Industry News, December 2018

The summary of events and newsworthy items for the month of December is provided on the following pages.  In most instances, the link to the full document of information is provided for you.  Any of the contents may be further discussed by reaching out to Revenue Cycle Inc.  

OIG Releases Report of Improper Payments by NGS for Radiation Therapy Services

The Office of Inspector General (OIG) released a report of findings under both National Government Services (NGS) Jurisdictions (6 and K) of improper payments for services which they considered not separately billable and part of the IMRT plan (77301).  In review of report released by the OIG, the services were reviewed during CYs 2013 - 2015 resulting in approximately $5.7 million in overpayments.  During this time NGS did not have any specific IMRT LCDs covering their respective jurisdictions. 

As identified in the OIG report,, the auditors extended the language from CMS and in place prior to CY 2016 to account for all services 30 days prior to the billed IMRT plan (77301).  The following language is taken from Medicare Claims Processing Manual, Chapter 4 in 2015, "Payment for services identified by CPT codes 77014, 77280-77295, 77305-77321, 77331, 77336, and 77370 is included in the bundled payment when they are performed as part of developing an IMRT plan that is reported using CPT code 77301. Under these circumstances, these codes should not be billed in addition to CPT code 77301."

Per the OIG report the following is stated, "Specifically, we identified claims with individual IMRT services provided up to 30 days prior to the date of service for a bundled payment for the development of an IMRT treatment plan and provided to the same beneficiary by the same hospital. Generally, claims contained several line items for IMRT services." The guidelines in the previous paragraph by CMS for hospitals do not indicate the timeline the services are considered part of the IMRT planning process.  It has always been understood once the initial simulation is completed the dosimetry planning process begins and any simulations, other dosimetry plans or direct physics services performed as part of the IMRT plan itself are not separately billable.  The application of a timeline by the auditors for any services 30 days prior to the IMRT plan is not in the language by CMS is concerning.

Other concerns and feedback from providers about letters received in response to this review and the recent one under the Novitas Jurisdictions also indicate that code 77336 was indicated as improperly paid when a new IMRT plan was billed mid-course.  The auditors indicated the previous billings of code 77336 when 30 days prior to the IMRT planning code were not separately billable.  By applying a timeline to the audit, which is not stated in the guidelines, is creating greater issues for those providers who use and bill for IMRT as intended or without circumvention of the edits or guidelines to increase revenue. 

When there was significant change to the tumor volume and/or surrounding anatomy and a new IMRT plan from a new data set was medically necessary, there could have been charges such as 77336 or 77014 which were billable codes and also supported apart from the IMRT planning process.  The lack of acknowledgement of this process reflects the need for education and further discussion with the auditors responsible for these findings.

CMS Files Correction Notice for OPPS and ASC CY 2019 Final Rule

CMS identified several errors in the CY 2019 OPPS Final Rule and released a correction notice.  In a 30-page summary of errors,, here are the most pertinent items to be aware of:

  • Correcting the section "Payment of Drugs, Biologicals, and Radiopharmaceuticals If Average Sales Price (ASP) Data Are Not Available" to remove the language that suggests that drugs with pass-through status with partial quarter WAC-based pricing are not paid at WAC + 3, which is incorrect. This correction is necessary to conform the introductory language regarding OPPS payment policy for drugs, biologicals, and radiopharmaceuticals with WAC-based pricing with the policy adopted in the final rule to pay for these drugs, biologicals, and radiopharmaceuticals, including those with pass-through status, at WAC + 3 percent.
  • Table 38.-Drugs and Biologicals With Pass-through Payment Status in CY 2019," we included an incorrect Pass-Through Payment Effective Date for HCPCS code J7328. The correct Pass-Through Payment Effective Date for HCPCS code J7328 is 04/01/2017, not 01/01/16.
  • "We also are finalizing our proposal to retain our established policy to assign new skin substitute products with pricing information to the low cost group." We are correcting the word "with" to read "without" to clarify that skin substitutes without pricing information are assigned to the low cost group, consistent with our established policy which is described on page 58967.
  • The ASC payment system uses the same APC classification groupings as the OPPS; however, ASC payment indicators and OPPS status indicators are not compatible across the two payment systems. In our final rule ratesetting for CY 2019, we inadvertently carried over OPPS C-APC status indicators in our ASC ratesetting process. This error impacted the application of our multiple procedure discounting rules and the calculation of the ASC weight scalar, which led to the calculation of incorrect ASC payment rates. Accordingly, on page 59079, in our response to a comment regarding our process of applying a weight scalar in calculation of ASC payment rates, and on page 59169, we are correcting our weight scalar in ASC payment rate calculations of "0.8792" to "0.8800."
  • Additionally, on pages 59079, 59080 and 59169, we inadvertently excluded certain core-based statistical areas (CBSAs) and, therefore, incorrectly calculated the wage index budget neutrality factor that we applied to the 2018 ASC conversion factor. We previously calculated a wage index adjustment of 1.0004. We have recalculated the wage index adjustment taking into account the appropriate CBSAs, resulting in a corrected wage index adjustment of "1.0000."
  • ...for both tables, the National Quality Forum (NQF)status for OP-8: MRI Lumbar Spine for Low Back Pain and OP-33: External Beam Radiotherapy for Bone Metastases is updated to indicate that the NQF endorsement for these measures was removed.

CMS Releases FAQs from November 19th Webinar Understanding 3 Key Topics

On November 19, 2018 CMS held an Understanding 3 Key Topics Call in response to the MPFS CY 2019 Final Rule changes.  One of the three key items discussed with the evaluation and management (E/M) changes for CYs 2019 and 2021.  CMS at the time of the call indicated they would be releasing a comprehensive FAQ document in response to the many questions they have received about the CY 2019 final rules.  The following is the additional information provided by CMS in response to the call.

What parts of the history can be documented by ancillary staff or the beneficiary starting in CY 2019? View the response

The response per the CMS attachment:

1.    What parts of the history can be documented by ancillary staff or the beneficiary starting in CY 2019?

The CY 2019 PFS final rule expanded current policy for office/outpatient E/M visits starting January 1, 2019 to provide that any part of the chief complaint (CC) or history that is recorded in the medical record by ancillary staff or the beneficiary does not need to be re-documented by the billing practitioner. Instead, when the information is already documented, the billing practitioner can review the information, update or supplement it as necessary, and indicate in the medical record that she or she has done so. This is an optional approach for the billing practitioner, and applies to the chief complaint (CC) and any other part of the history (History of Present Illness (HPI), Past Family Social History (PFSH), or Review of Systems (ROS)) for new and established office/outpatient E/M visits. To clarify terminology, we are using the term "history" broadly in the same way that the 1995 and 1997 E/M documentation guidelines use this term in describing the CC, ROS and PFSH as "components of history that can be listed separately or included in the description of HPI." This policy does not address (and we believe never has addressed) who can independently take/perform histories or what part(s) of history they can take, but rather addresses who can document information included in a history and what supplemental documentation should be provided by the billing practitioner if someone else has already recorded the information in the medical record.

How does the MIPS payment adjustment apply to clinicians, especially those who may switch practices during the performance year?

A. Below are the general rules on how the payment adjustment is applied, which is different than the legacy programs.

1.    A MIPS eligible clinician (NPI) who bills to the same TIN in the payment year as they did during the performance period will be assessed the payment adjustment under that TIN/NPI combination according to the final score earned from data submitted/collected under that TIN

2.    A MIPS eligible clinician (NPI) who bills to a (new) TIN in the payment year that they did NOT bill to during the performance period will be assessed the payment adjustment under that (new) TIN/NPI combination based on the most advantageous final score attributed to that NPI under any TIN/NPI combination for the performance period

Additionally, we have a fact sheet that provides additional information and scenarios on the MIPS payment adjustments.

Are there any changes to the data completeness requirements for the MIPS Quality performance category in 2019?

A. No, the data completeness requirements are the same as in Year 2 (2018) even with the update to the submission terminology. Individual clinicians or groups submitting quality measure data on QCDR measures, MIPS CQMs, and eCQMs must submit data on at least 60% of the clinician or group's patients that meet the measure's denominator criteria, regardless of payer. Individual clinicians or groups submitting quality measure data on the Medicare Part B claims measures must submit data on at least 60% of the applicable Medicare Part B patients seen during the performance period.

Call Materials

Audio Recording


Slide Presentation


LCD PDFs to be removed from First Coast website

Effective January 4, 2019 First Coast will be removing LCDs (Local Coverage Determinations) from their website.  Providers will still be able to use the lookup tool for LCDs on the website, but any links for will take providers to the Medicare coverage database (MCD) located on the Centers for Medicare & Medicaid Services' (CMS) website.  The search function on the website will no longer be able to be used to search for LCDs once this change takes place.

December Coding Corner

Within this section, current topics will be the focus.  In some cases, the Q&A could reflect common questions received by Revenue Cycle Inc. and in other cases, represent current issues encountered by Revenue Cycle Inc. professionals.

Question:  Do we use modifier 53 for partial/discontinued treatment and do we have to bill either the Z53.09 or Z53.8 dx code? If we do have to use the Z53.xx dx, would it be the primary dx code for this date?

Advice: When a partial treatment is delivered, it is not billed with modifier 53. The treatment code is billed one of two ways as outlined and ordered by the physician. If the remaining dose is distributed over the remaining fractions, new calculations, the treatment is considered complete and billed as delivered on that date. If the remaining dose must be delivered as planned, it is billed on the date of the completion, there are no partial treatments in the manner of other non-completed procedures.  Since a partial treatment is not billed with a modifier, the Z code is not applied because treatment was carried out to some extent and will depend on the physician how it is handled.

Question:  Can 77290 be charged same day as 77280? There is an edit with rationale of "1" listed with this code pairing.

Advice:  Billing for a simple and complex simulation on same date of service is only allowed for BID brachytherapy as outlined in the NCCI Policy Manual.  The edit, which may allow for a simple simulation to be billed on same date as a complex simulation does not apply to external beam courses.