Draft Article - Billing and Coding: Radiation Therapies (DA59350)

CMS National Coverage PolicyTitle XVIII of the Social Security Act, 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 13, 70.5 Radiation Physics Services (CPT Codes 77300  77399)CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 4, 200.3 Billing Codes for Intensity Modulated Radiation Therapy (IMRT) and Stereotactic Radiosurgery (SRS), 200.3.1 Billing Instructions for IMRT Planning and Delivery, 200.3.2 Billing for Multi-Source Photon (Cobalt 60-Based) Stereotactic Radiosurgery (SRS) Planning and DeliveryMLN Matters Number: SE18013. Intensity-Modulated Radiation Therapy (IMRT) Planning Services Editing. September 11, 2018.CR9658, July 2016 Update of the Hospital Outpatient Prospective Payment System (OPPS)OIG Report, Audit (A-09-16-02033), 08-15-2018Article TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Radiation Therapies DL39553.Documentation RequirementsAll documentation must be maintained in the patient's medical record. The documentation must support the medical necessity of the services as specified in this article and it must be made available to the contractor upon request.Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature and credentials of the physician, non-physician practitioner, dosimetrist, physicist or radiation therapist responsible for and providing the described care for the patient.The submitted medical record must support the use of the selected ICD-10-CM diagnosis code(s). The submitted CPT/HCPCS code(s) must describe the service performed. It is the providers responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM and CPTcode books appropriate to the year in which the service is rendered for the claim(s) submitted.For all radiation therapy, the medical record must include the patients primary diagnosis for which the prescribed radiation therapy is needed, the patients history for this illness as well as active co-morbid medical conditions, the patients performance status when applicable and as required by the LCD, any relevant imaging reports, the proposed treatment plan, the number and location and size of tumors that are present, the stage of disease, and the anatomic site of the radiation delivery.For any type of radiation therapy for non-cancer diagnosis coverage (such as, but not limited to epilepsy, trigeminal/facial nerve applications, movement disorders, Parkinsons disease, tremor conditions), it is important to clearly and very specifically document to the prior therapies tried and failed. Names of therapies and durations given and whether improvement or worsening occurred is crucial to support a decision to proceed with aggressive radiation therapy. Failure to document with specificity and precision related to the past diagnostic and attempted treatment for a condition as it relates to a unique beneficiary may well result in a non-coverage decision due to lack of reasonable and necessary standards having been met.For Stereotactic Body Radiation Therapy (SBRT) and Stereotactic Radiosurgery (SRS), the patients record must support the medical necessity of treatment. Supporting clinical records must include not only the patients medical history and physical examination findings, but also the patients current functional status, as described by an overall performance status score (e.g., Karnofsky Performance Status (KPS) or Eastern Cooperative Oncology Group (ECOG) Performance Status score). A radiation oncologist must evaluate the clinical and technical aspects of the treatment and document this evaluation as well as the resulting management decision. Justification for aggressive local therapy to 1 or more deposits of metastatic cancer for either total disease clearance in the setting of oligometastatic disease or to reduce overall burden of systemic disease for a specifically defined clinical benefit must be documented. In the case of recurrent disease requiring palliation or when tumor cannot be treated as effectively or safely by other radiotherapy methods due to proximity of previously irradiated volumes, documentation to those beneficiary unique facts must be documented in the medical record.Medical record documentation maintained by the provider must indicate the medical necessity for radiation oncology procedure as outlined in the LCD DL39553 and must include ALL of the following for a radiation oncology procedure which employs inverse planning:The type of radiation therapy that will be delivered must be precisely documented and cannot be inferred from the equipment or technology or computerized optimization being utilized.The type of radiation therapy planning that was ultimately used must be precisely documented and cannot be inferred from the equipment or technology or computerized optimization being utilized.A treatment plan/prescription must be present and must define the goals and requirements of the treatment, including the specific dose constraints for the target(s) and nearby critical structures.A statement by the treating physician documenting the special advantages and genuine need for performing the specified radiation therapy delivery type and planning type on the patient in question, especially in comparison to conventional forward treatment planning and/or delivery. With IMRT planning and delivery documentation, the physician must address the other organs at risk (OAR) or adjacent critical structures.Review by the radiation oncologist of the radiologic images of the target and all critical structures with representative isodose distributions that characterize the three-dimensional (3D) dose. The document containing this review must be signed with credentials and dated.Radiation oncologist review of dose-volume histograms for all targets and critical structures specifically documented as reviewed or authenticated via signature with credentials and date.Description of the number and location of each treatment step/rotation or portal to accomplish the treatment plan.Documentation of dosimetric verification of treatment setup and delivery, signed by both the radiation oncologist and the medical physicist with a legible signature and credentials and date.For compensator-based radiation therapy delivery, the unique compensator design should be documented for each step or portal.Documentation of fluence distributions recomputed in a phantom, or an equivalent methodology consistent with patient specific treatment verification.Target verification methodology documentation to include documentation of the clinical treatment volume (CTV) and the planning target volume (PTV); documentation of immobilization/patient positioning, and means of dose verification and secondary means of verification.Other procedures performed during the episode of care must have documentation that supports the professional and technical components by identifying the place of service, the date of service, the supervising physician, and proof of work provided.If applicable, when billing for respiratory management simulation, documentation must be present that identifies structures that move between high- and low-dose regions due to respiration. The documentation must include the medical necessity of this service. This is more extensive documentation than what would occur with just a simulation note since it is part of the isodose planning process. Since the work occurs over several days and involves the therapists, the dosimetrist, the physicist and the physician, the narrative supporting this service would and should appear in several documents. The simulation note should document the physician review of respiratory motion management set-up and use at the time of simulation. The treatment plan document must indicate that the physician created and intended to cover the target volume in all phases of respiratory motion.Coding GuidanceNotice:It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.CPT/HCPCS code(s) may be subject to National Correct Coding Initiative (NCCI) edits. This information does not supersede NCCI edits. Please refer to NCCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.IMRT planning is paid by Medicare under the OPPS as a bundled payment. The bundled payment covers a range of services that may be performed as part of developing an IMRT treatment plan. The bundled payment covers these services regardless of when they are billed.CT guidance with CPTcode 77014 should not be separately reported with simulation service codes 77280-77290 and code 77295 (Therapeutic radiology simulation-aided field setting; 3-dimensional). The use of CT guidance is integral to the simulation procedure and the value of the professional and technical components of CT guidance is now captured within the simulation service. This guidance applies to the freestanding and hospital-based settings.CPTcode 77301 is used for development of an IMRT plan. Per CMS, payment for CPTcodes 77014, 77280, 77285, 77290, 77295, 77306, 77307, 77321, and 77331 are included in the payment for CPTcode 77301. These codes should not be reported in addition to 77301 even if provided prior to or as part of the IMRT plan. They can be reported as needed during the course of IMRT treatment delivery (with CPTcodes 77385, 77386). This guidance applies to CPTcode 77301 in both the hospital and in a freestanding facility.77370 cannot be used for quality assurance or development of the treatment plan. There may be certain clinical scenarios where the radiation oncologist will need a special physics consult after the development of the plan. That circumstance and rationale would need to be documented in the medical record by the radiation oncologist.Special dosimetry (77331), for example TLD or microdosimetry, would only be reported and potentially covered if the medical record demonstrates a specific prescription for this service by the treating physician and an explanation of medical necessity for it exists. As noted above, it is not covered before or during an IMRT plan.77372 is never to be used for the first fraction or any other fraction of a fractionated SRS treatment. It is only to be used for single session cranial linac-based SRS.For SRS and SBRT with forward planning, it is appropriate to bill CPTcodes 77290 (simulation), 77295 (planning), and CPTeither 77371/77372 (single fraction delivery) or 77373 (multifraction delivery). For SRS and SBRT with inverse planning, it is appropriate to bill CPTcodes 77301 (both simulation and planning) and either 77371/77372 (single fraction delivery) or 77373 (multifraction delivery).CPTcode 77373 (SBRT treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions) includes the possibility of treating multiple sites of disease in 1 treatment course. Therefore, if the sum of the treatment days for all of the sites treated during a single course of therapy exceeds 5; it is not appropriate to charge CPTcode 77373 for SBRT delivery.For all spinal radiosurgery (1 to 5 fractions), use CPTcode 77435 once for the entire course of treatment. CPTcode 77432 and 77435 cannot be billed for the same patient for the same episode of care. It is not appropriate to bill CPTcode 77432 with CPTcode 77470, 77427, 77431, and 77435 on the same date of service.A prolonged (4 to 6 weeks) course of cranial radiation therapy should be billed using appropriate codes for conventionally fractionated radiotherapy. Fractionated stereotactic cranial and body radiotherapy codes apply only to hypofractionated (1 to 5 fractions) radiosurgery using large doses per fraction.Usually, a radiation oncologist will work with a neurosurgeon to perform SRS. Radiation oncologists and neurosurgeons have separate CPTcodes for SRS. CPTcodes 61796  61800 are reported for the work attributed to the neurosurgeon. These codes are mutually exclusive with the radiation oncology CPTcodes 77432 and 77435; therefore, the same physician should not bill for both these codes.CPTcodes 77280-77290 Simulation aided field settings should not be reported for verification of the treatment field during the course of IMRT.The respiratory motion management simulation CPTcode 77293 is an add-on code and cannot be billed on its own. This code describes the physician work and resources involved in acquiring a respiratory correlated or 4D CT simulation study for conformal planning. It should be billed, as applicable, with either CPTcode 77295 or 77301 on the same date of service, even though the work may take place over many days. The work involved in +77293 includes physicians, therapists, dosimetrists and physicists and has both a professional and a technical component. The work is performed both in the simulator and in dosimetry. The add-on code +77293 is part of the simulation and isodose planning process, not part of treatment delivery. This code is only charged once per 3D or IMRT plan. Medicare does not provide separate technical payment for this service in the hospital outpatient environment.