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 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
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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
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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:
- 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.
- If the NRC proceeds to grant AU status by NRC-recognized specialty boards, the T&E should be equivalent to § 35.390.
- 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
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By Lisa Braverman, Journals Managing Editor
The ASTRO portfolio of journals has had a productive year, with Practical Radiation Oncology’s first-ever impact factor (IF) of 2.794 and a soaring 6.203 IF for the Red Journal. The journals saw special sections about payment policy and gender in radiation oncology, along with groundbreaking podcasts covering topics as wide-ranging as end of life care and machine learning. Looking ahead to 2020, there is another innovation on the horizon: the inclusion of data availability statements in published ASTRO journal articles.
The Journals team invites readers to learn about the new data sharing policy, which goes into effect for articles submitted January 1 and later, by reading the recent Advances in Radiation Oncology article. Readers may also wish to complete the accompanying CME activity.
ASTRO journals are committed to enhancing research transparency through the inclusion of data availability statements in published works. Importantly, data sharing is not required. While there are many benefits to sharing data — including the potential for faster scientific advancement — we understand not all data can or should be shared. Rather, we are requiring a statement about data availability for all scientific articles. Data availability statements are short descriptions included with scientific publications that provide readers with the conditions surrounding access to data underlying the research being reported. These statements will appear alongside funding and disclosure statements.
In order to better understand how other societies have implemented data sharing policies, we spoke with Ken Kornfield, director of Editorial and Publishing at the American Society for Clinical Oncology (ASCO) and Annie Hill, associate publisher, Community Initiatives at the American Psychological Association (APA). Abridged interviews are below.
What is your data sharing policy?
Ken Kornfield, ASCO (KK): We are putting the finishing touches on a new policy which will include a data sharing statement requirement beginning January 1, 2020. Our current guidelines refer to data sets relevant to the development of predictive or prognostic markers, as well as those relevant to risk assessment. For such data, JCO requires that it be submitted along with the original work as a supplemental file. Whether submitted as a supplemental file, table or figure, the data must be anonymized so as to protect the identities of subjects involved in the research. The same requirement applies to all text, tables and figures submitted as part of the manuscript itself. These data will be published as supporting supplemental material if the manuscript is accepted for publication.
Prior to publication, data sets or sequences relevant to the research must be provided in full, including gene expression profiling data with clinical correlative information. Such data must be anonymized and may be provided either as a supplementary file or by depositing the data in a public database such as GenBank, Gene Expression Omnibus or Array Express, with the accession number provided in the text of the final manuscript. As a condition of publication, it is expected that authors will share all data relevant to the manuscript with readers who may wish to replicate the results.
Annie Hill, APA (AH): APA Journals is committed to openness and transparency and encourages authors to share data when possible (recognizing that it may not always be possible per confidentiality agreements or funder requirements). APA’s Ethics Code does require authors to share data with other professionals for reanalysis after publication (as long as participant confidentiality is protected and the data are not proprietary). Several APA-published journals offer open-science badges to authors who make their data and materials open, and some now require authors to provide data availability statements (indicating whether they will or will not make their data available, along with links to them or explanations as to why they are not available).
When did you implement your policy, and why?
KK: This policy has been in place for at least four years. The reason we did this was for biomarker studies; we wanted others to have access to the data behind the study.
AH: We entered a partnership with the Center for Open Science to offer open science badges to authors and create an APA data repository to ease sharing in 2017. We are also committed to providing resources for authors who are able to share data or materials – making data available can help with replication and facilitate collaboration among researchers, so it’s really a benefit to the field to make it easier to do. Some editors are now requiring data availability statements to further encourage sharing and to get researchers thinking about how to make data available as they plan their studies.
Has anything surprised you about your society’s data sharing policy implementation? If so, what?
KK: We haven’t had any surprises or complaints.
AH: We knew early on that building understanding and consensus would be key, especially for a society publisher with different constituents. What we didn’t anticipate was the depth of knowledge and experience so many constituents would provide! We have a real opportunity to collect this knowledge for the benefit of researchers at every stage of their careers.
ASTRO is committed to research integrity and transparency. Our goals in requiring data availability statements are to facilitate quick identification of relevant data in a study, to promote transparency in instances of access or restriction, and to increase awareness of data availability statement structures. We welcome questions and comments about data availability statements in the comments below or email email@example.com.
Posted: December 18, 2019
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