By Anne Hubbard, Director, Health Policy, and Bryan Hull, Assistant Director, Health Policy
Proposed Medicare payment policies set to start January 1, represent significant financial challenges for radiation oncology practices as they enter the new year, regardless of whether or not your practice is participating in the Radiation Oncology Alternative Payment Model (RO Model). Despite many practices experiencing revenue declines of 20-30% in 2020, the Centers for Medicare and Medicaid Services (CMS) is pushing ahead with massive cuts for radiation oncology and other specialties.
In August 2020, CMS issued the 2021 Medicare Physician Fee Schedule (MPFS) proposed rule effective January 1, 2021. The MPFS proposed rule includes significant cuts that will be implemented broadly across the field of medicine. Subsequently, on September 18, 2020, the Center for Medicare and Medicaid Innovation (CMMI) issued a final rule establishing a Radiation Oncology Alternative Payment Model (RO Model), effective January 1, 2021. The RO Model also includes significant payment cuts due to the payment methodology that involves discounts and withholds.
ASTRO is fighting hard to reverse these pending cuts, which are unwarranted and will potentially lead to serious access to care issues across the country. We have engaged ASTRO’s congressional champions and have contacted the highest levels of leadership within the Department of Health and Human Services to intervene. That said, ASTRO members must be aware of just how dire the consequences are for the field. Below is an overview of what practices can expect in 2021. Be forewarned, the outlook is grim.
Medicare Fee-for-Service Payments
Under fee-for-service payments, which will continue to apply to the professional component payments of those practices not participating in the RO Model, providers are paid according to patient care delivered based on the provisions of the MPFS. The Impact Table below (Table 90 of the 2021 MPFS proposed rule) shows the estimated impact on total allowed charges for radiation oncology based on the relative value unit (RVU) changes contained within the proposed rule.
The expected impact on radiation oncology is a combined reduction of 6% on payment rates for 2021. These reductions are specifically related to modifications of the Evaluation and Management (E/M) codes that create a shift in payments across all specialties resulting in a reduction to the Conversion Factor (CF) of more than 10% to comply with the statutorily mandated budget neutrality requirement.
Table 90: CY 2021 PFS Estimated Impact on Total Allowed Charges by Specialty
||Allowed Charges (mil)
||Impact of Work RVU Changes
||Impact of PE RVU Changes
||Impact of MP RVU Changes
|Radiation Oncology and Radiation Therapy Centers
Upon closer analysis, the budget neutrality adjustment results in even greater variation across radiation oncology services. For instance, CPT code 77014, Computed tomography guidance for placement of radiation therapy fields, is expected to see an 11% reduction in payment under fee-for-service billing in 2021. In addition, CPT code 77301, IMRT plan, including dose-volume histograms for target and critical structure partial tolerance specifications, is expected to see a 7% ($129.76) reimbursement cut for 2021. Of note, CMS proposed RVU increases for several key radiation oncology codes; however, the budget neutrality adjustment largely offset those increases. The table below demonstrates the impact of the CF reduction on key radiation oncology services.
||2020 National Rate
||2021 Estimated National Rate
||CT scan for therapy guide
||Radiation therapy dose plan
||Radiotherapy dose plan IMRT
||Radiation treatment aid(s)
||CT scan for therapy guide
||Radiation therapy planning
||Set radiation therapy field
||Radiation therapy dose plan
||Radiotherapy dose plan IMRT
||Radiation physics consult
||Design MLC device for IMRT
||Radiation tx management x5
||Stereoscopic x-ray guidance
||Radiation treatment delivery
||Radiation treatment delivery
||Radiation tx delivery IMRT
ASTRO is engaged in a comprehensive advocacy campaign to mitigate or postpone the expected cuts for 2021. In collaboration with a broad coalition of physician and non-physician health care provider organizations, ASTRO has urged Congress in a letter to waive the budget neutrality requirement for 2021 in any forthcoming health-related legislative package to provide relief from the reimbursement cuts associated with the MPFS updates. ASTRO’s congressional allies have also been contacted and are aware of the significant impact these cuts have on the profession. In addition to congressional action, ASTRO provided CMS with substantial comments in response to the 2021 MPFS proposed rule addressing how the budget neutrality adjustment poses a significant threat to the profession, which is already suffering significant losses as a result of the COVID-19 public health emergency (PHE). ASTRO urged CMS to use its authority under the PHE to waive the budget neutrality requirement for at least another year, allowing practices time to recuperate from significant losses already suffered in 2020.
RO Model Payment Rates for 2021
For those practices required to participate in the RO Model, it’s bad news as well. ASTRO has documented and is advocating for significant changes to the RO Model payment methodology, which layers a series of deep cuts on participants. But one aspect of the RO Model payment methodology, a “Trend Factor,” is influenced by the MPFS and Hospital Outpatient Prospective Payment System (HOPPS) and deserves greater scrutiny in light of the PFS cuts discussed above.
The Trend Factor serves as an annual update to the payment methodology by reflecting utilization and payment changes outside the Model, i.e., the MPFS and HOPPS. For 2021, the Trend Factor will use 2018 utilization data and 2021 MPFS and HOPPS data to establish an update to the RO Model payment methodology. Due to the anticipated reduction in the 2021 MPFS rates, the Trend Factor is likely to put additional undue financial strain on radiation oncology practices participating in the Model.
Practices participating in the RO Model are already subject to discount factors of 3.75% off the Professional component payment and 4.75% off the Technical component rates, as well as payment withholds for quality measures performance and incorrect payments. These reductions will be compounded by a low or potentially negative Trend Factor. This “double whammy” rate reduction is a disservice to practices that are compelled to participate in the Model, which is particularly disappointing given that the purpose of the RO Model was to establish rate stability over time. By establishing a Trend Factor that fluctuates based on the whims of the MFPS and HOPPS, CMS has effectively eroded the stability that practices thought they might be able to secure under the RO Model.
ASTRO has raised concerns regarding the RO Model’s aggressive implementation timeline and cuts with our congressional champions, as well as those at the highest levels of the Department of Health and Human Services (HHS). We are urgently seeking a delay in the RO Model’s implementation date of January 1, 2021, so that practices have more time to prepare for implementation. This will also allow for additional time to address the flaws in the payment methodology, which, as they currently stand, equate to a series of cuts on radiation oncology services.
As we enter the last quarter of 2020, a year that has been fraught with tragedy, we are bracing ourselves for further struggles in 2021, with serious potential for more financial instability. Whether your practice is in or out of the RO Model, Congress needs to hear your voice about the direct impact of these flawed policies. Go to https://www.astro.org/Advocacy/Become-an-Advocate and join the fight for the future of radiation oncology.
Posted: October 19, 2020
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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
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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.
- 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
- 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.
- 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.
- 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
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By Corbin Johnson, MD, CUAC chair, and Nikhil Thaker, MD, CUAC vice-chair
As radiation oncology heads into 2020, are you worried about whether your practice has its coding compliance in order and is up to speed on new coding rules? ASTRO, the authority on radiation oncology coding, is rolling out an updated ASTRO Radiation Oncology Coding Resource and hosting a Coding and Coverage Seminar to help practices get off to the right start in the new year.
ASTRO’s Code Utilization and Application Committee (CUAC) works throughout the year to ensure that the radiation oncology (RO) community has access to comprehensive tools that assist with consistent application and interpretation of the Current Procedural Terminology (CPT®) code set most commonly used in RO. The CPT system, developed by the American Medical Association (AMA), is a highly technical process. New codes are developed, redefined and revalued every year for physicians and other qualified health care providers to report services provided in a universal manner to institutions, private and government payers, researchers and other interested parties. ASTRO actively provides input to the AMA and other groups that update the CPT coding system to ensure that CPT coding accurately reflects the clinical logic and level of effort that is required in RO.
Annual Coding and Coverage Seminar and Resource
CUAC’s primary responsibility is to understand the impact of these changes on coding for radiation oncology services. This includes providing membership with educational programs and materials that include the most recent and up-to-date coding guidance. One of the most popular educational programs that ASTRO offers to the RO community is the annual Coding and Coverage Seminar. This two-day seminar held at ASTRO headquarters provides a comprehensive overview of the many factors that affect the complex and ever-changing aspects of coding in clinical practice. The seminar is geared to make clinical coding easier to understand and applicable to those new to coding as well as for those with experience who are looking to hone their skills. This year’s seminar will take place on December 6 and 7 in Arlington, Virginia. Registration is currently open on the ASTRO website.
In addition to the seminar, CUAC also produces the ASTRO Radiation Oncology Coding Resource. The Coding Resource is designed as an orientation and reference document to assist physicians, their practice administrators and their staff to develop accurate coding and documentation procedures to support billing for RO services. The ASTRO Radiation Oncology Coding Resource is an essential coding reference for all radiation oncology practices, and ASTRO strongly encourages all coding/billing professionals to utilize this resource in their daily practice. This resource is updated twice a year to ensure that it reflects the most up-to-date information on CPT coding, rules and regulations related to radiation therapy. Coding and Coverage Seminar attendees will receive a copy of the updated Coding Resource as part of their registration.
Additional ASTRO coding resources
In addition to the comprehensive ASTRO Coding Resource and annual Coding and Coverage Seminar, ASTRO provides the RO community with coding education through regularly updated coding FAQs, Coding Guidance Articles and Coding Updates on the ASTRO website. If ASTRO members have coding questions that are not answered through these various resources, or if further clarification on a nuanced topic is needed, they are encouraged to submit the question through the ASTRO Coding Question submission form. The questions submitted through the Coding Question submission form are processed through CUAC during their monthly meeting, and members are provided an answer to their questions via email. While providing individualized coding guidance to members, this question form also enables CUAC to keep track of frequently asked questions and topics that may have significant importance to the membership at large.
It's important to remember that correct coding encourages efficiency, reduces audit risk and claim rejections and facilitates efficient reimbursement. Additionally, accurate coding and proper supporting documentation demonstrate an understanding of the process and delivery of patient care. While correct coding reflects the process of care, it is vital to acknowledge that coding does not drive the process of care. Selection of codes should not be based on reimbursement but rather on the services provided by the physician that are considered medically necessary while caring for the patient. The physician of record is held responsible not only for all aspects of patient care but also for all codes and documentation submitted in his or her name. Arming yourself with a thorough understanding of these key elements and taking advantage of ASTRO’s educational resources can lead to successful practice management.
Corbin Johnson, MD is a radiation oncologist at Vanderbilt University Medical Center. Dr. Johnson currently serves as chair of ASTRO’s Code Utilization and Application Subcommittee in addition to playing a vital role as a member of ASTRO’s Code Development and Valuation Subcommittee.
Nikhil Thaker, MD, is a radiation oncologist with The Arizona Oncology Associates of Tucson and currently serves as vice-chair of ASTRO’s Code Utilization and Application Subcommittee, as well as serving on the Code Development and Valuation Subcommittee.
Posted: November 13, 2019
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By Vivek Kavadi, MD
"Honestly, why do you need prior authorization for my cancer treatment? It is not elective!" This comment from one of our radiation patients represents the frustrations of many patients across the country. As vice-chair of the Payer Relations Subcommittee (PRC), I frequently receive complaints from ASTRO members about the negative effects that the prior authorization process has on their practice and their patients. In the recent ASTRO Prior Authorization Survey, an overwhelming majority of respondents reported that their patients experience delays in care. Nearly three quarters of these radiation oncologists also said that their patients regularly express concern over these delays.
I work in a cancer center where the radiation treatment area is in the same location as chemotherapy infusion. This provides for seamless coordination and patient convenience. However, when prior authorization for radiation is delayed, treatment with chemotherapy is also delayed. Combined modality treatment requires a lot of coordination. Radiation is daily and many infusions last several days. We often like to start both treatments on a Monday or Tuesday. Recently, treatment starts have become very unpredictable. It is not a rare circumstance where delays of one to two weeks occur due to prior authorization issues.
This issue remains at the forefront for radiation oncologists and the entire house of medicine, which led to ASTRO signing on to the Consensus Statement on Improving the Prior Authorization Process. The Consensus Statement outlines five areas for improvement for prior authorization programs. One area, the message of Transparency and Communication Regarding Prior Authorization, is extremely resonant in our current environment. Prior authorization requirements and rationale must be easily accessible to providers and patients. Perhaps most important, is the area discussing Continuity of Patient Care that emphasizes that prior authorization should not interrupt appropriate medical services, potentially causing harm and distress to patients.
My experiences are not unique; this issue affects us all. Last fall, more than 500 ASTRO members urged their members of Congress to sign the Roe-Bera Prior Authorization Letter, which called on the Centers for Medicare and Medicaid (CMS) to regulate Medicare Advantage plans’ use of prior authorization and ensure these requirements do not create barriers to care. PRC continues to engage with the American Medical Association and other stakeholders to reform prior authorization practices. ASTRO’s Government Relations team is working with our Hill champions to address prior authorization issues. We frequently provide updates in ASTROgrams and What’s Happening in Washington, so be sure to read those publications.
How has prior authorization impacted the way you practice? Let us know in the comments, or email email@example.com.
Posted: April 24, 2019
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