Draft Article - Billing and Coding: Superficial Radiation Therapy (SRT) for the Treatment of Nonmelanoma Skin Cancers (NMSC) (DA59693)

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.Title XVIII of the Social Security Act, 1848(b)(11) Payment rules for certain radiation therapy services under the Medicare physician fee schedule.CMS Internet-Only Manual,Pub. 100-04, Medicare Claims Processing Manual, Chapter 13,70 Radiation Oncology (Therapeutic Radiology) and70.2Services Bundled Into Treatment Management CodesArticle TextThe information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Superficial Radiation Therapy (SRT) for the Treatment of Nonmelanoma Skin Cancers (NMSC) DL39808.Please refer to the LCD for reasonable and necessary requirements.Coding GuidanceIt 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. For Part B, use the GY or GZ modifier.Per the Current Procedural Terminology (CPT) codebook definition, the use of the correct CPT codes for the simulation of radiation, SRTs, delivery of radiation treatments and uses of image guidance (IG) requires consistency with ASTRO and CMS guidelines for radiation services.For purposes of this LCD, SRT is only payable in a non-facility setting. As defined by Section 3(b) of the Patient Access and Medicare Protection Act (PAMPA), the following settings would be allowable: The term non-facility settings refers to freestanding radiation therapy centers, which are treated like physicians offices for Medicare payment and billing purposes and are paid under the Medicare Physician Fee Schedule (MPFS). In contrast, the term facility settings refers to hospitals, which provide radiation therapy (RT) in their hospital outpatient departments. Physician offices if allowed by their local state requirements as meeting these requirements would also fall under the rubric of a freestanding RT center for Medicare payment and billing purposes for the delivery of SRT.A course of RT usually includes a clearly defined set of services such as RT consultation, treatment planning, certain technical preparation and special services (e.g., medical radiation physics, dosimetry, treatment devices, treatment delivery, and treatment management).Pre-Treatment Documentation RequirementsDocumentation must support medical necessity for the use of SRT over other conventional treatment modalities and include the following:A statement by the provider why the patient is a nonsurgical candidate ANDAppropriate documentation of the discussion with the patient why SRT with or withouthigh resolution ultrasound (HRUS) is preferred for the treatment of their NMSC(s) and include a discussion of present and future risks of RT treatment(s).General Documentation RequirementsDocumentation must support medical necessity for the simulation, fractionation regimen, dosing, dosimetry, medical physics evaluation and any needed changes in ongoing treatment regimens including the possible need for HRUS.All 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 RT, the medical record must include the patients primary diagnosis for which the prescribed RT 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, location and size of tumor(s) that are present, the stage of disease, and the anatomic site of the radiation delivery.Medical record documentation maintained by the provider must indicate the medical necessity as outlined in the LCD and must include ALL of the following for a radiation oncology procedure which employs radiation treatment planning:The type of SRT planning that was ultimately used must be precisely documented and cannot be inferred from the equipment or technology or computerized optimization being utilized.The type of SRT that will be delivered 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 SRT delivery type and planning type on the patient in question, especially in comparison to conventional forward treatment planning and/or delivery; the physician must address the other organs at risk (OAR) or adjacent critical structures.Review by the radiation oncologist or other qualified physician of the radiologic images of the target, if necessary, 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 or other qualified physician 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, credentials and date.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.Required IGSRT DocumentationThe use of HRUS is limited to the initial planning of NMSC, when medically indicated, for the localization of target volume and for the suitability for SRT.For high risk NMSCs, the continued change of HRUS may be reasonable and necessary if there is determined to be significant clinical change in the status of the tumor during the ongoing SRT treatments and imaging is required to adjust treatment dosing. Medical documentation should support the rationale for the additional use of HRUS.Provider Qualifications and Supervision of ServicesDiagnostic x-ray tests provided by freestanding RT centers to assist in the accurate placement of radiation fields are a covered Medicare benefit. Regulatory guidance pertinent to physician supervision of these services is provided under of the Code of Federal Regulations. Diagnostic x-ray tests may only be furnished under the supervision of a physician. Services furnished without the required level of physician supervision are not covered under Medicare.General Supervision: The procedure is furnished under the physicians overall direction and control, but the physicians presence is not required during the performance of the procedure (76950 or G6001 - Ultrasonic guidance for placement of RT fields).Direct Supervision: The use of diagnostic x-ray tests including HRUS in the freestanding center requires a physician be physically present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. Nonphysician practitioners cannot function as supervisors of diagnostic tests performed in conjunction with radiation therapy (77401- Radiation treatment delivery, superficial, per day).