At CMS, ASTRO Leaders Advocate for Stable Payments, Better Incentives

By Constantine Mantz, MD, ASTRO Health Policy Council Vice-chair

In the last two weeks, I’ve joined fellow ASTRO advocacy leaders in critical meetings with senior officials at the Centers for Medicare and Medicaid Services (CMS) on a variety of pressing payment issues facing the specialty.

The Radiation Oncology Model (RO Model), of course, continues to be the focus of ASTRO’s attention, as we continue pressing the Trump administration on necessary reforms. However, with the RO Model final rule going through the last stages of administration clearance, federal rules restrict agency staff from discussing the model. ASTRO continues to expect the model to be released in 2020. Contrary to rumors, there is no delay and practices should be preparing.

The key issues on our agenda for these meetings were those keeping me, ASTRO leaders and the membership up at night: How can recent payment stability be maintained? How can new medical oncology-focused payment models ensure appropriate radiation therapy utilization?

Given that the Agency is pursuing formal rulemaking on all of these issues, the ASTRO team did not expect to hear any final answers to these key questions from the high-level staff at the CMS’ Hospital and Ambulatory Payment Group (HAPG), which oversees physician fee schedule and hospital outpatient payments, nor the senior team at the Center for Medicare and Medicaid Innovation (CMMI), which is responsible for oncology alternative payment models, including the RO Model and the next iteration of the Oncology Care Model (OCM), known as Oncology Care First. Instead, these meetings provided an opportunity for ASTRO to press our case face-to-face with decision makers, enhancing our numerous letters with real-world illustrations of how Medicare payment policy impacts clinical and business decisions on the ground in radiation oncology.

On February 4, the ASTRO team met in Baltimore with CMS HAPG senior staff to urge the agency to again extend the G codes and payment rates for treatment delivery, IMRT and image guidance delivered in freestanding centers under the physician fee schedule until the end of 2021. ASTRO initiated and extended this payment freeze through legislation, and successfully advocated for CMS to continue the freeze through its regulatory authority in 2020. As the radiation oncology community transitions to the RO Model, which has numerous components that are linked with the physician fee schedule, we argued that continued payment stability in the fee schedule is essential to ensure successful adoption of value-based radiation oncology payments.

In addition, ASTRO again discussed the need for the agency to increase reimbursement for hospital-based brachytherapy payments, most notably for cervical cancer, where there is a gap in covering the costs of the standard of care due to CMS’ approach to packaging payments. ASTRO appreciated the HAPG attention to our issues, and we look forward to seeing the direction CMS takes when the Agency releases proposed payment rules for hospitals and freestanding centers this summer.

On February 18, our team returned to Baltimore to meet with CMMI to discuss concerns that radiation therapy utilization may be shrinking inappropriately under the OCM. We focused on ASTRO’s longstanding concerns about the perverse incentives to reduce radiation therapy utilization under the OCM. Our goal was to convince CMMI to avoid replicating the problem in the next iteration of the model, and we left with a better understanding of the Agency’s goals and agreement to explore some potential fixes that ensure radiation oncologists are better positioned under the model to be equal partners in multidisciplinary cancer care with other cancer specialists.

Each time I travel to CMS offices, I’m struck by the candid and constructive discussions we have with policymakers as we work to solve the complex radiation oncology health policy problems to the benefit of our patients. While we may not always agree with the Agency, ASTRO has established itself as a credible voice with key officials, and the data and ideas we provide are treated with respect.

When the RO Model final rule and other Medicare payment rules are released in coming months, ASTRO will be ready with a strong response that protects cancer patients’ access to radiation therapy.

Posted: February 25, 2020 | 0 comments

Reimbursement Coding Tips

2020 Radiation Oncology Reimbursement Reminders (RORR)

By Jessica Adams, CCA, ASTRO Health Policy Analyst

To assist in correct coding for radiation oncology, ASTRO has a number of resources for coding and billing professionals seeking advice on the proper application of Current Procedural Terminology (CPT) codes. In addition to coding FAQs, coding guidance articles and coding updates, which provide information on a variety of coding topics, ASTRO also circulates reimbursement reminders, called Radiation Oncology Reimbursement Reminders (RORR), to help practices address common coding and coverage issues. The reminders below address common coding questions received by ASTRO from both members and payer entities.

  1. Submit all codes, including treatment delivery, special services and image guidance codes with every claim.

    Payers report that some practices bill for all services delivered in a course of treatment on every claim that are not necessarily performed during each individual treatment session. Claims are submitted containing codes for treatment delivery, special dosimetry, special teletherapy port plan, special medical radiation physics consultation and image guidance radiation therapy each time.

    Not all parameters of treatment are completed each week because the clinical course of care may differ due to variation in treatment modality and individual patient requirements. Thus, practices should not bill for all services delivered during a course of treatment at each treatment visit, but rather bill for the services delivered during the specific visit. ASTRO’s 2020 Radiation Oncology Coding Resource states: “Supporting documentation, including ICD-10-CM codes, is needed to justify the distinctions between codes that represent apparently similar activity but different levels of effort and complexity. Each time a procedure is reported, its level of effort and complexity should be appropriately documented. Many of the procedures within each phase of care will be carried to completion before the patient’s care is taken to the next phase.” For more information, see page 28 of the 2020 ASTRO Radiation Oncology Coding Resource

  2. Use 77014 for CT simulations instead of CT image guidance.

    Some practices appear to confuse the services described by CPT codes 77280-77290 Therapeutic radiology simulation-aided field setting; simple-complex and CPT code 77014 Computed tomography guidance for placement of radiation therapy fields. Payers shared that they receive claims that include CT image guidance when the service delivered was actually CT simulation.

    This issue may stem from an ASTRO CPT update in 2014. ASTRO’s 77014 Coding Guidance explains: “Since the development of the simulation codes, there have been significant changes in the process of care for physician and other qualified health care professionals, as well as the nature of the equipment utilized. For example, fluoroscopic simulators have largely been replaced with dedicated CT scanners and related workstations. As a result, CPT code 77014 is now included in the simulation codes (CPT codes 77280-77290).”

    Though 77014 is grouped with the simulation codes, it still represents image guidance services. Practices should be sure that the documentation submitted with each claim supports the code being billed.

  3. How to code for two treated with Stereotactic Body Radiation Therapy (SBRT).

    Payers and practices alike frequently request clarification regarding billing for SBRT when two sites are being treated. ASTRO’s SBRT guidance states that the CPT instructions for CPT code 77373 SBRT treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions include the possibility of treating multiple sites of disease in one treatment course. If the sum of the treatment days for all sites treated during a single course of SBRT exceeds five, CPT code 77373 should not be reported.

  4. When to use unlisted procedure CPT code 77399.

    Payers describe claims that include CPT code 77399 Unlisted procedure, medical radiation physics, dosimetry and treatment devices, and special services, when other codes would be more appropriate. Practices should only report this code if no other code adequately describes the procedure or service that the physician provided. When billing this code, practices should be certain of the individual payer’s requirements for unlisted procedures.

    For example, the Centers for Medicare and Medicaid Services Medicare Claims Processing Manual states that when reporting an unlisted procedure, practices should “include a description in item 19 if a coherent description can be given within the confines of that box.  Otherwise, an attachment shall be submitted with the claim.” (Chapter 26, page 16.)

We hope this guidance helps radiation oncology practices as they navigate potential billing issues. If you have billing questions or any other common billing pitfalls, let us know in the comment section, below.

To purchase the 2020 ASTRO Coding Resource, which includes information on updated CPT codes effective January 1, 2020, please visit our website. Or, if you’ve already purchased the Resource, you may access it by logging in to your MyASTRO account and clicking on Virtual Meetings/Products under “My Resources.”

Posted: February 18, 2020 | 0 comments

The SECURE Act and Its Impact on You and Your Future

By the ROI Development Committee

The Setting Every Community Up for Retirement Enhancement (SECURE) Act was enacted in December 2019 and was effective as of January 1, 2020. This legislation marks the most significant changes to retirement security since the Pension Protection Act of 2006.

The SECURE Act has three major components. First, you can now contribute to your Individual Retirement Account (IRA) past the age of 70½. Second, you do not have to take the required minimum distribution (RMD) until the age of 72. And third, most non-spouse IRA and other retirement account beneficiaries must withdraw the entire amount within 10 years.

Prior to the SECURE Act, you could not contribute to your IRA past the age of 70½. This age limit has been repealed. Thus, you can save for retirement for a longer period of time to build up your retirement account. The SECURE Act changed the age at which you must start taking RMDs from your retirement account from 70½ to 72. This change gives your account additional time to grow. Notably, for those born before July 1, 1949, the previous rules apply. Contributors who turned 70½ in 2019 or earlier will have to continue to take required minimum distributions.

But you do not need to wait until you are 72 to make contributions to those causes you care about. If you are 70½ or older, you can still transfer any amount up to $100,000 per year directly from your IRA to a qualified nonprofit, tax-free. The gift does not count as income, so you benefit whether you itemize on your tax returns or not. The Radiation Oncology Institute (ROI), ASTRO’s research foundation, is a qualified nonprofit and can assist you in making this gift. The ROI will provide a sample letter for you to customize and use to communicate with your IRA administrator. By making a gift to the ROI now, you can see the impact of that gift on research in radiation oncology.

Making a gift from your IRA is an opportunity to leverage your most highly taxed assets. When IRAs are passed to loved ones, distributions from these accounts are subject to income taxes at the beneficiary’s ordinary income tax rate, which can be as high as 37% plus state income tax, depending on where they live. Rather than leaving these heavily taxed assets to family, consider giving from these accounts now and letting the value of other assets grow and eventually pass to loved ones.

Spouses can continue to stretch payments from inherited IRAs and other retirement accounts over their lifetimes. However, most non-spousal beneficiaries (such as grown children) must withdraw the entire IRA balance by the end of 10 years. If you do not want your non-spousal beneficiaries to receive their entire IRA proceeds by the end of 10 years because it creates tax issues for your loved ones, you may want to consider creating a Charitable Remainder Trust (CRT). You can stretch your inheritance by naming a CRT as a beneficiary of an IRA, and the IRA funds the trust after your death. The trust is designed to pay one or more beneficiaries’ income for life (or a term of up to 20 years) and at the end pay a remainder benefit to a charity of your choice. This will allow the beneficiaries to receive payments past the 10 years.

With the SECURE Act, some provisions of retirement plans change, but many aspects remain the same. You can name the ROI as a beneficiary of your IRA. You are encouraged to notify the ROI of your designation so that the ROI can thank you and can ensure that your gift is used exactly as you intended.

If you have questions about the impact of the SECURE Act, we encourage you to make an appointment with your financial advisor. The advisor can answer other questions you have and can review your plans (including your beneficiary designation) and ensure that your wishes are documented.

The information in this article is not intended as legal or tax advice. For such advice, please consult an attorney or tax advisor. References to tax rates include federal taxes only and are subject to change.

2020 ROI Development Committee:

J. Frank Wilson, MD, FASTRO, co-chair, Medical College of Wisconsin; Timothy R. Williams, MD, FASTRO, co-chair, Boca Radiation Oncology Associates; Shauna Campbell, DO, Cleveland Clinic; Drew Moghanaki, MD, MPH, Atlanta VA Health Care System; Jason Efstathiou, MD, PhD, Massachusetts General Hospital; Daniel Moore, Radiation Business Solutions; Charles Enke, MD, University of Nebraska Medical Center; Arul Mahadevan, MD, Wentworth-Douglass Hospital, Seacoast Cancer Center; Jenna Kahn, MD, VCU Medical Center; Douglas Martin, MD, The Ohio State University Wexner Medical Center; Join Y. Luh, MD, Dr. Russel Pardoe Radiation Oncology Center, St. Joseph Hospital; Malika Siker, MD, Medical College of Wisconsin

Posted: February 11, 2020 | 0 comments

ASTRO Highlights its Commitment to Sexual and Gender Minority Health Equity at the 2019 Annual Meeting

By Malika Siker, MD, Ross Zeitlin, MD, and Danielle Bitterman, MD

In June 2017, the ASTRO Board of Directors named diversity and inclusion a core value in its Strategic Plan. As diversity, equity and inclusion advocates, we are thrilled to see reaffirmation of these values and eager to participate in expanded initiatives. To highlight ASTRO work in this area, ASTRONews featured stories on diversity and inclusion in its 2018 issues. Margaret Barnes, MD, penned a thoughtful Letter to the Editor that expressed disappointment in the lack of inclusion of the lesbian, gay, bisexual, transgender and queer or questioning (LGBTQ+) community in these efforts and discussed a need for ASTRO to be intentional about considering LGBTQ+ voices as we advocate for diversity and inclusion. To Dr. Barnes and anyone else who has felt excluded by this omission, we emphatically agree with this suggestion and believe that addressing this issue will strengthen our field.

In 2017, the American Society of Clinical Oncology (ASCO) issued recommendations for reducing cancer disparities among sexual and gender minority (SGM) populations. This article defined known SGM cancer disparities and suggested ways to address these challenges. In addition to focusing on our SGM patients, we see a need to ensure that our SGM colleagues feel safe and included in our field. ASTRO’s Committee for Health Equity, Diversity and Inclusion (CHEDI) has been working behind the scenes on initiatives to advocate for SGM health equity from both a patient and provider perspective.

The 2019 ASTRO Annual Meeting showcased the results of collaborative efforts focused on elevating SGM equity in the field of radiation oncology during three educational sessions. All of these sessions were held on Tuesday, September 17, and were well attended with engaged audiences eager to learn more.

  • The NCI/ASTRO Diversity Breakfast, held from 6:45 a.m. to 8:00 a.m., highlighted a panel on recruitment and retention of women and minorities in the radiation oncology workforce. Dr. Raymond Mailhot of the University of Florida was featured on this panel and discussed the additional obstacles he faced as a gay Latino man navigating medical education, the residency application trail and beyond. His story illustrated the courage and resiliency our SGM colleagues need to develop as they navigate their careers in an environment that has traditionally not been inclusive of SGM population issues. Our field and the care we provide to patients will be enriched by addressing barriers faced by LGBTQ+ individuals throughout their career to ensure they are supported in achieving their personal and professional aims.
  • CHEDI sponsored a panel on the treatment of vulnerable communities in radiation oncology from 2:45 p.m. to 4:00 p.m. Dr. Ross Zeitlin of the Medical College of Wisconsin was included on this panel and examined cancer disparities in the SGM community with a specific focus on the impact these have in radiation oncology. His presentation included an evidence-based review of the current data, clinical challenges and future directions. Raising awareness and educating health care providers about SGM community cancer disparities is essential so we can improve health equity in this vulnerable community.
  • From 4:45 p.m. to 6:00 p.m., a multi-institutional and multidisciplinary panel entitled “Is there a Standard of Practice in Oncologic Care for Transgender Patients?” featured Dr. Daphne Haas-Kogan, Dr. Anthony Zietman, Dr. Stephanie Terezakis, Paula Neira, MSN, RN, JD, Dr. Danielle Bitterman and Dr. Zackory Burns. During this session, they discussed fundamentals of transgender care, the need for workforce education, cultural sensitivity and legal issues in an engaging format. As radiation oncologists, we need to understand the best practices in caring for transgender patients to ensure we are meeting the needs of this population.

As a reminder, these sessions are available on the ASTRO Annual Meeting Virtual Meeting platform. If you attended the Annual Meeting, you have access to the Virtual Meeting; if not, the Virtual Meeting is available for purchase through the catalogue.

We are pleased to see that ASTRO and its members are interested in advocating for SGM health equity and inclusion through the events featured at the 2019 Annual Meeting and see a need to continue to build on these efforts. Recently, a new initiative for radiation oncology residents identifying as or allied with LGBTQ+ individuals was announced within the ARRO network. This initiative is in the building stages, and we are eager to extend an invitation to the radiation oncology community at large as we build this idea from the ground up. For further details, please email Dr. Ross Zeitlin.

With diversity and inclusion listed as a core value in ASTRO’s Strategic Plan, we know that these values remain part of the DNA of our organization, even starting with the first interaction one may have with ASTRO: the membership application. ASTRO recently updated the gender options on the membership application form to now include non-binary.

We must remain vigilant, transparent and responsive to the needs of our diverse members to ensure that all our colleagues feel included. Through CHEDI, ARRO and other collaborating groups, we must continue to work together to make sure we embody these values as an organization. Having a diverse and inclusive workforce ready to care for our diverse society will translate to improved health equity. We value our SGM patients and colleagues and will continue to advocate to ensure all voices are heard.

Malika Siker, MD, is an associate professor of radiation oncology and associate dean for Student Inclusion and Diversity at Medical College of Wisconsin in Milwaukee, Wisconsin. Her professional areas of interest include health equity, diversity and inclusion as well as hematologic and CNS malignancies.

Ross Zeitlin, MD, is a radiation oncology resident at the Medical College of Wisconsin. His academic interests include gynecologic malignancies and oncologic health disparities in the sexual and gender minorities.

Danielle Bitterman, MD, is a PGY-4 resident at the Harvard Radiation Oncology Program.

Posted: January 21, 2020 | 0 comments

At NRC, Advocating for Radiation Oncologist Leadership in Radiopharms

By Theodore DeWeese, MD, FASTRO, ASTRO Board Chair

On Wednesday, November 20, I met with Nuclear Regulatory Commission (NRC) Chairman Kristine Svinicki and commissioners Jeff Baran and Annie Caputo, as well as with NRC staff, to preserve strong training and experience (T&E) requirements for radiopharmaceuticals.

Over the past several years, in response to external pressure, the NRC staff has been reviewing the current requirements found in 10 CFR § 35.300 and 10 CFR § 35.390 to determine whether changes should be made. Part of this review has included outreach to stakeholders, including ASTRO, for their opinion and analysis of possible changes. As ASTRO chair, one of my priorities is to ensure that radiation oncologists play a leading role in the administration of radiopharmaceuticals. Fending off potential ill-advised changes to training and experience requirements will help achieve that goal.

Current regulations require that an authorized user (AU) be either board certified or complete 700 hours of training. The relevant sections of the regulations can be found here: Training for the use of unsealed byproduct material for which a written directive is required and Training for the parenteral administration of unsealed byproduct material requiring a written directive.

On the surface, reviewing current requirements to ensure their relevance is important and necessary. However, we are concerned that this review could initiate rulemaking to loosen the current 700-hour requirement – something that ASTRO, and partner organizations, oppose because the current requirements are appropriate, protect the safety of patients, the public, and practitioners, and should not be changed.

The NRC staff has concluded its review and is preparing a report to the commissioners. This report will outline policy options, as well as a recommendation for commission action. A version of the report was made public in October, so we were able to see the options the staff laid out; however, it did not include the staff’s final recommendation.

In the draft paper, the staff outlines two different approaches, each with several options, as follows:

Approach 1: Revise the T&E regulatory framework to remove prescriptive requirements, and the NRC and Agreement States would no longer review and approve T&E for AUs.

  • Option 1a: Specialty Board Credentialing– Physicians must be certified by any medical specialty board.
  • Option 1b: Licensee Credentialing– Licensees develop their own policies and procedures for credentialing their physicians.
  • Option 1c: NRC-recognized Specialty Board Credentialing – Physicians must be certified by a medical specialty board that has been recognized by the NRC as meeting high-level board certification criteria.

Approach 2: Maintain or enhance the existing T&E regulatory framework.

  • Option 2a: Status Quo– No changes.
  • Option 2b: Tailored Requirements– T&E would be tailored and reduced for use of individual or categories of radiopharmaceuticals.
  • Option 2c: Emerging Radiopharmaceuticals– Individual reviews of each emerging radiopharmaceutical to determine drug specific T&E and other requirements.
  • Option 2d: Team-based Requirements– T&E would be reduced based on pairing AUs with other individuals with radiation safety training.

The staff paper also states: “The NRC regulates medical uses of byproduct material to ensure the safety of workers and the general public, and while patient access concerns were considered by the staff, the NRC cannot regulate T&E with a primary goal of increasing patient access to radiopharmaceuticals or improving geographic distribution of AUs.”

In response, the NRC’s Advisory Committee on the Medical Use of Isotopes (ACMUI), made the following ASTRO-supported recommendations:

  1. The Subcommittee recommends maintaining the status quo under 10 CFR § 35.390. While strongly affirming the structural superiority of the status quo over the other options proposed in the draft paper, we acknowledge there is room for a comprehensive review of the specific requirements in § 35.390 such as the seemingly arbitrary requirement of 700 hours. The Subcommittee (and likely, ACMUI) would welcome the opportunity to critically assess these details.
  2. If the NRC proceeds to grant AU status by NRC-recognized specialty boards, the T&E should be equivalent to § 35.390.
  3. The Subcommittee recognizes the value of an alternate pathway and is willing to review and evaluate the requisite knowledge, preceptor-reviewed experience and competency assessments.

ASTRO and I believe maintaining the status quo (Option 2a) for training and experience for radiopharmaceuticals is appropriate, protects the safety of patients, the public, and practitioners, and should not be changed. The NRC’s focus on patient safety and the safety of the general public as it develops training and experience requirements is appropriate. The classroom and clinical experiences encompassed by radiation oncology and nuclear medicine training programs provide appropriate levels of knowledge and skill for any current and future radioactive agents.

Reporting data also supports maintaining the status quo. While non-expert AUs would introduce significant radiation risks, radiopharmaceuticals — when administered under the supervision of comprehensively trained and experienced AUs — have an exemplary safety record, and the current regulations ensure that safety. In both 2017 and 2018, there was one event reported to the NRC using Ra-223. Between January 2014 and May 2019, only 16 out of 9,848 total events entered into RO-ILS: Radiation Oncology Incident Learning System® were related to radiopharmaceuticals. As indicated in the self-reported data, none of these events have been reported to either the NRC or an Agreement State.

Weakening AU T&E requirements would not create an influx of new licensed health care facilities providing these therapies in remote geographical areas. Rather, there are other considerations guiding facilities’ decisions, such as:

  • availability/preference for alternative therapies,
  • the high cost of these drugs,
  • complexity of the patient cases, and
  • financial and staff resources required (radiation safety officer services, technologists/therapists with appropriate licensure, license fees, etc.). 

I was very pleased with the meetings, and I came away hopeful that ultimately the NRC will keep the status quo and will not initiate new rulemaking to lessen the current T&E requirements.  ASTRO will keep up the pressure and continue reporting on developments.

ASTRO is interested in receiving your feedback regarding the T&E requirements for radiopharmaceuticals. Use the comments below to share your thoughts.


Posted: January 3, 2020 | 0 comments