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.