By Jessica Adams, ASTRO Health Policy Analyst
In late May 2019, the Office of Inspector General (OIG) released the Health Care Fraud and Abuse Control Program Report for fiscal year 2018. The OIG continues to focus its attention on intensity-modulated radiation therapy (IMRT) treatment planning services, this time reviewing calendar years 2016 and 2017. In the two years after the initial 2013-2015 audit period, the OIG found $3.7 million in potential overpayments for complex simulations and $1.7 million for other IMRT treatment planning services.
ASTRO has raised concerns with the OIG and the Center for Medicare and Medicaid Services (CMS) several times in recent years, first to highlight the confusion during the 2013-2015 time period regarding this code combination and, second, to explain the complexity of IMRT services. It was not until the 2016 Hospital Outpatient Prospective Payment System (OPPS) Final Rule that CMS explicitly stated that providers cannot bill simulation prior to or during IMRT planning. Because of the confusion the regulatory ambiguity caused, ASTRO urged the OIG not to recoup any payments prior to the 2016 Final Rule.
In January 2017, CMS updated the CPT codes that may not be reported with the development of an IMRT treatment plan. CPT codes 77014, 77280, 77285, 77290, 77295, 77306, 77307, 77321 and 77331, are included in the payment for IMRT treatment planning and should not be reported when provided prior to or as part of developing the IMRT treatment plan. ASTRO released coding guidance to help practices ensure proper billing, and this issue was also covered in the February 2018 Radiation Oncology Reimbursement Reminders (RORRs).
Additionally, CMS has issued resources to clarify billing for IMRT treatment planning services. In a May Medicare Learning Network (MLN) Connects transmittal, CMS reiterated existing coding restrictions associated with CPT code 77301. Members should review these resources and ensure that their practices are billing for IMRT treatment planning services correctly. If your practice is struggling with questions related to IMRT treatment planning services, you may wish to purchase ASTRO’s Radiation Oncology Coding Resource, available in print or as an ebook. The Coding Resource includes information on updated CPT codes effective January 1, 2019, and is available for purchase on the ASTRO website. If you have already purchased the Coding Resource, access it by logging in to your MyASTRO account and clicking on Virtual Meetings/Products under My Resources.
For any questions, contact the ASTRO Health Policy department.
By Caroline Patton, Manager of Quality Improvement, and Lisa Bradfield, Senior Manager of Quality Improvement
If you work in the field of radiation oncology, you may have used ASTRO guidelines in your practice, but do you know how these guidelines are developed? To share the process, ASTRO recently developed a methodology guide to offer a high-level overview of the many steps involved in bringing a guideline from topic selection through publication and implementation.
Why did ASTRO write a methodology guide?
One goal of the guide is to communicate the process to various groups, including the general ASTRO membership; new members of the Guidelines Subcommittee and guideline task forces; guideline reviewers; and other societies, especially those who may be interested in collaboration or endorsement of our documents.
The guide is also designed to spotlight recent changes to the guideline development process. ASTRO first began writing guidelines more than a decade ago and the process has evolved over time to align with rigorous standards set by the National Academy of Medicine (formerly, Institute of Medicine) and the Council of Medical Specialty Societies. ASTRO has also incorporated improvements based on member feedback to make guidelines more user-friendly.
What are the key areas of the process?
- Collaboration – Other societies with an interest in the topic of an ASTRO guideline may participate by partnering on the topic, collaborating by naming representatives and reviewers to the ASTRO project, and/or endorsing the finished guideline.
- Conflict of interest – ASTRO has a rigorous process for assessing relationships between guideline task force members and companies that may be impacted by the guideline’s recommendations to avoid a real or perceived conflict of interest.
- Systematic review – Each guideline is supported by a systematic review of the literature. After refinement of the results, selected studies are abstracted into detailed evidence tables, which are published with the guideline for complete transparency.
- Clinical recommendations – The task force develops recommendations based on the data from the evidence tables and rates the strength of the recommendation and the quality of the evidence for each one. The recommendations also undergo formal evaluation of consensus.
- Peer review and public comment – All guidelines are formally peer reviewed by topic experts identified by ASTRO and collaborating societies. They are also posted online for public comment during which anyone can provide input. The feedback from both phases of review is used to revise the guideline with the final version approved by ASTRO’s Board of Directors.
- Post-publication monitoring and updating – Guidelines are reviewed for currency annually beginning two years after publication or at the request of an ASTRO member or participating society, with the goal of revising or reaffirming guidelines about every five years.
What’s changed in the guidelines format?
Readers will see a number of changes in our upcoming guidelines that we hope will make the guidelines easier to use and more valuable for treating patients. These include:
- Reduced length due to less narrative. Those who want more detail on the studies can consult the evidence tables published with the guideline.
- Presentation of recommendations in a table format to enhance readability.
- Revised definitions for quality of evidence that quantify the number and types of studies needed for each quality rating and add an “expert opinion” category for recommendations based on consensus rather than data. References that support the quality rating are also included with the recommendation for greater transparency.
- Inclusion of a preamble outlining several important elements of the development process to standardize and shorten the introductory sections while making the methods section more focused and specific to each guideline.
You can see all the steps in the process in ASTRO’s guideline development process overview.
What’s coming in the future?
- ASTRO will begin to focus more on patient involvement and developing supplemental materials to share the guideline content with patients and improve clinician to patient interaction.
- ASTRO is also in the very early stages of researching options to promote and disseminate guideline content to physicians, including implementation materials or tools.
Under the leadership of a Guideline Methodology Workgroup, ASTRO is continually evaluating and enhancing how guidelines are developed. If there are other elements of the guideline process or format that ASTRO could improve upon to make them more useful, we would welcome your feedback!