83

Radiation Radiation Therapy Therapy Clinical Clinical Treatment Treatment ManagementManagement

Covered by pages 1-49

Modified For 04-11-14

03111410:15 -10:45 AM

Section Section 1111

Carl Bogardus, Jr, MD

TOTAL CARE OF THERADIATION ONCOLOGY PATIENT

CLINICAL TREATMENT MANAGEMENT

The total care of the radiation oncology The total care of the radiation oncology patient mandates patient mandates direct clinical direct clinical managementmanagement by the radiation oncologist by the radiation oncologist throughout the course of therapy.throughout the course of therapy.

It is the radiation oncologist’s It is the radiation oncologist’s role and responsibility to role and responsibility to provide provide dailydaily supervision of supervision of treatment and hands-on, face-treatment and hands-on, face-to-face patient care.to-face patient care.

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Clinical Treatment ManagementClinical Treatment Management

Clinical Treatment Management starts with the acceptance of the patient for treatment.

Clinical Treatment Management ends with the

Clinical End of Treatment report.

Clinical Treatment Management is tied to 5 days of treatment delivery only as a convenient means of tracking time for billing purposes.

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CPT Radiation Therapy CPT Radiation Therapy Treatment Management CodesTreatment Management Codes

7742777427 - - Weekly Radiation Therapy Weekly Radiation Therapy Management, 5 fractionsManagement, 5 fractions

77431 -77431 - Radiation Therapy Management; Short Radiation Therapy Management; Short course, 1 or 2 fractionscourse, 1 or 2 fractions

77432 -77432 - Radiation Therapy Management; Radiation Therapy Management;

Stereotactic, (SRS) 1 fractionStereotactic, (SRS) 1 fraction

77435 –77435 – Radiation Therapy Management; Radiation Therapy Management; SBRT, SRS, full course of therapy, up to a SBRT, SRS, full course of therapy, up to a max of 5 fractions, (2007)max of 5 fractions, (2007)

7746977469- Radiation Therapy Management; - Radiation Therapy Management; Intraoperative.Intraoperative.

4

Professional billing 77427Professional billing 77427

Professional billing relates to 5 fractions of therapy delivered, regardless of the number of elapsed calendar days and must be billed as 77427 X 1 per 5 FX block of treatments.

The billing date for weekly management , 77427, is usually the first day of each of the 5 day blocks.

4

Most of the Carriers want you to report this way

5 fractions equal one Week, bill first date of week

NIB

Historical BackgroundHistorical Background

• It is imperative that each physician It is imperative that each physician document their direct involvement in document their direct involvement in all of the procedures related to a week all of the procedures related to a week of treatment management.of treatment management.

• It is expected that each patient It is expected that each patient will have as many regularly will have as many regularly spaced progress notes as there spaced progress notes as there are weeks of treatments.are weeks of treatments.

• The complexity and completeness of The complexity and completeness of the note must reflect the complexity the note must reflect the complexity of care for the patient.of care for the patient.

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The physician will be expected to have reviewed as many of these elements as are applicable to the current course of treatment management

It is extremely important that It is extremely important that these five critical elements be these five critical elements be covered in each note.covered in each note.

I Chart and dosimetry review II Treatment setup and delivery review III Port film or electronic image review IV Under beam evaluation of the patient V Recommendation of therapy

WEEKLY UNDER BEAM PROGRESS NOTES Five Required Review Elements

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• The weekly progress note does not

necessarily have to occur on the same day of each week, but for a course of therapy there should be

an equal or greater number of progress

notes than the weeks of management being

billed.

8

Mon Tues Wed Thurs FriWeek TX TX TX TX TX TX TX TX TX TX 1 NO PROGRESS NOTE WEEK 1NO PROGRESS NOTE WEEK 1 This causes problems with This causes problems with 7742777427

Week TX TX TX TX TX TX TX TX TX TX 2 PNPN 77427

Week TX TX TX TX TX TX TX TX TX TX 3 PNPN 77427

Week TX TX TX TX TX TX TX TX TX TX 4 PNPN 77427

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A weekly note must occur sometime during each 5 day intervalA weekly note must occur sometime during each 5 day interval

Mon Tues Wed Thurs FriWeek TX TX TX TX TX TX TX TX TXTX 1 PN PN Having a note on week 1 is Having a note on week 1 is crucialcrucial 77427

Week TX TX TX TX TX TX TX TX TXTX 2 PNPN 77427

Week TX TX TX TX TX TX TX TX TXTX 3 PNPN 77427

Week TX TX TX TX TX TX TX TX TXTX 4 PNPN 77427

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A weekly note must occur sometime during each 5 day intervalA weekly note must occur sometime during each 5 day interval

PN77427EOT

Having a note on the last TX date is very important

WEEKLY PROGRESS NOTEWEEKLY PROGRESS NOTE

There is no written directive stating which day during the treatment week that the physician/patient encounter must occur.

There is no stipulation of the manner of interaction, only that it be “face to face”

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Which is a valid location for patient/physician encounter?Exam room

Waiting room Parking garage

Treatment console Treatment room

Hall way

9

ALL OF THEMALL OF THEM At each encounter this patient had the opportunity ask At each encounter this patient had the opportunity ask

question related to her course of treatment.question related to her course of treatment. At each encounter the patient acknowledges her At each encounter the patient acknowledges her

interaction with the physician.interaction with the physician. At each encounter the physician has the opportunity to At each encounter the physician has the opportunity to

evaluate the patient’s general condition.evaluate the patient’s general condition. At each encounter the physician will use his best At each encounter the physician will use his best

judgment to determine what is needed to evaluate judgment to determine what is needed to evaluate response to treatment and radiation reactionsresponse to treatment and radiation reactions

There is no written requirement related to length of time There is no written requirement related to length of time or location of the patient/physician encounteror location of the patient/physician encounter

As long as privacy concerns are metAs long as privacy concerns are met to the to the satisfaction of both the physician and satisfaction of both the physician and the patient.the patient.

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WEEKLY PROGRESS NOTEWEEKLY PROGRESS NOTE

The patient /physician encounter is only The patient /physician encounter is only one of the 5 required elements of weekly one of the 5 required elements of weekly managementmanagement

The weekly progress note is a document The weekly progress note is a document covering all aspects of patient care and covering all aspects of patient care and management.management.

Each of the 5 basic elements is further Each of the 5 basic elements is further subdivided into many sub routines that subdivided into many sub routines that require individual documentationrequire individual documentation

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WEEKLY PROGRESS NOTEWEEKLY PROGRESS NOTE

The production of this The production of this supporting document does not supporting document does not need to coincide with the need to coincide with the physical examination of the physical examination of the patient.patient.

It is customary done this way It is customary done this way only as a general convenience, only as a general convenience, not a requirementnot a requirement

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INITIAL EVALUATION DOSIMETRY TREATMENT IMAGING EXAMINATIONINITIAL EVALUATION DOSIMETRY TREATMENT IMAGING EXAMINATION

UNDER BEAM PROGRESS NOTESUNDER BEAM PROGRESS NOTES

CLINICAL END OF TREATMENT SUMMARYCLINICAL END OF TREATMENT SUMMARY

FOLLOW UP NOTESFOLLOW UP NOTES

Using the cascading Using the cascading Information format, Information format, vital clinical and vital clinical and technical data may technical data may be transferred, be transferred, discarded, or added discarded, or added to each new weekly to each new weekly document as it is document as it is createdcreated

The under beam The under beam progress note is a progress note is a clinical weekly summary clinical weekly summary

documentingdocumenting the the physician’s involvement physician’s involvement in the weekly in the weekly management of the management of the patientpatient

NIB Narrative on page 6NIB Narrative on page 6

Compliance and audits. These are two words that most physicians and administrators really don't like to hear.

With cascading, elements of an E/M document will copy verbatim into subsequent documents. Verbatim copying will cause cascading of old information into new encounter forms without any change.

Medicare considers that an identically copied note indicates that the physician was not actively involved in the creation of the new note. Templating has HCFA  considering severe penalties when they find large sections of notes that are 100% copies in subsequent workups.  

NIB

All physicians and users should be very much aware of this potential problem. They are well advised to carefully read any areas of their notes that are likely to change such as;

Chief Complaint, HPI, Physical Exam Review of Systems Medical decision-making Other areas may also change. Do not always use exactly the same time for every patient or type of encounter.

NIB

NIB

Compliance Warning, Cascaded Information

Original work up Six week follow-up

NIB

All that is really required is a quick review of the areas of a document where you know some changes have probably occurred based upon the patient's clinical findings and treatment parameters.

Document those changes in the record. If no changes have occurred, indicate that you have reviewed that section and it is truly unchanged from the previous work up. EMRs make compliance very easy, but they also make auditing very easy.

NIB

We Recommend

Any cascaded topic that has not been Any cascaded topic that has not been reviewed on a new document will reviewed on a new document will clear upon save and record.clear upon save and record.

If the topic has been opened and any If the topic has been opened and any change has been made, then the change has been made, then the changed topic and its questions and changed topic and its questions and answers will be saved.answers will be saved.

You may indicate “reviewed and save, You may indicate “reviewed and save, no change needed”.no change needed”.

NIB

• Verification of correctVerification of correct summation of summation of dosedose

• Verify thatVerify that time and/or monitor unitstime and/or monitor units are correctare correct..

• Stop or re-evaluation pointsStop or re-evaluation points are clearly are clearly indicatedindicated..

• The correctThe correct modalities modalities of treatment are of treatment are indicatedindicated..

• The correct beamThe correct beam energy energy is indicated.is indicated.• Proper beamProper beam modifiersmodifiers are in place.are in place.• Tumor dose is compared to theTumor dose is compared to the

tolerance dosetolerance dose ofof critical tissues.critical tissues.• Critical tissueCritical tissue dose pointsdose points are carriedare carried • The number ofThe number of treatment volumestreatment volumes is is

correctcorrect..• The numberThe number of of ports ports is correct.is correct.

# 1--Chart & Dosimetry Review

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Document of the first day of treatment with the first under beam note

It is understood that it is impossible for the physician to be physically present during each

and every setup, but the the physician should be physician should be readily available for readily available for corrective action should corrective action should the need arise.the need arise.

#2 Treatment Setup & Positioning Evaluation

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Document of the first day of treatment with the first under beam note

Radiographic films or electronic or portal imaging studies are taken at regular intervals of all of the portals being treated.

Port film review must be Port film review must be documented each week documented each week

in the under beam in the under beam progress note, if progress note, if

imaging is performed.imaging is performed.

# 3--Portal Film Review for Imaging

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Examination of the patient Examination of the patient consists of clinical evaluation, consists of clinical evaluation, assessment of tumor assessment of tumor response, and case response, and case management.management.

The radiation oncologist The radiation oncologist should physically examine the should physically examine the patient each week for patient each week for treatment related side effects, treatment related side effects, and tumor response.and tumor response.

# 4--UNDER BEAM EVALUATION PROGRESS

NOTE

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Under Beam Examination

- Every patient under Every patient under treatment, without exception, treatment, without exception, should be seen and examined should be seen and examined at least once per week at least once per week by by the physicianthe physician. .

This is a key element of the This is a key element of the weekly note. The PA can do weekly note. The PA can do much of the work, but the much of the work, but the physician must be involvedphysician must be involved

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For under beam visits, these components are the same as for other E/M services.

E/M services are included in weekly management and cannot be charged separate.

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Many factors make up a weekly progress note, the use of multiple choice questions

with many choices of answers, makes each note unique and reduces the appearance of “macro copying”

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Pages 17 to 20 give a short summary of the needed elements to make up a compliant progress note.

You should follow these guide lines to format the content of your notes.

NIB

Every progress note should have the basic demographic information about

the patient.

21UNDER BEAM PROGRESS NOTE

History of Present Illness

A very short version of the patient's present illness

should be presented limited to only a few sentences

summarizing the case to-date.

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Current Treatment

Parameters Area(s) under treatmentEnergy/modeEvaluation of appropriateness and accuracy of all Treatment DevicesCurrent dosagePlanned dosageCritical structure dosageMicrodosimetry as doneAny corrective action as required

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22A weekly review of technical factors is required, once entered, this component usually will not vary week to week, if any factors change, then the note must reflect the changes

23Physical Examination

ConstitutionalGeneral appearanceExamination of area under treatment must always be includedExamination of other areas as needed

Current Status of anyTreatment Reactions

Skin reactionsGI reactionsOral cavity reactionsHematologic profilePresent weight as related to previous weight

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24Tumor Response

Indicate any changes from previous work-up

Significant or subtle changes in tumor size

Expected response at current dose level

• Full assessment of pain• Medications and corrective actions

• Order and document medications

• Print prescriptions • Maintain a compliant list Maintain a compliant list

of all medications and of all medications and prescriptions.prescriptions.

Pain Assessment and Management

ONCOCHART

See Section 3 See Section 3 Page 8Page 8

• Patient to continuecontinue therapy• Patient placed on holdhold – state the

reason• Treatment requires modificationmodification• Patient has completedcompleted the course

of treatment

• THIS MUST BE COMPLETED BY THIS MUST BE COMPLETED BY THE PHYSICIAN EACH WEEK, THE PHYSICIAN EACH WEEK, NO OTHER PERSON CAN MAKE NO OTHER PERSON CAN MAKE THIS DECISION.THIS DECISION.

#5 Recommendation of Treatment

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Physician orders (CPO)Physician orders (CPO)

With electronic records, Clinical With electronic records, Clinical Physician Orders have been Physician Orders have been made much easier to deal with.made much easier to deal with.

Multiple paper forms are Multiple paper forms are eliminatedeliminated

Orders can be tailored to fit the Orders can be tailored to fit the case case

Orders can be sent electronicallyOrders can be sent electronically

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Physician work page has all the common procedures that require orders. This can be initiated by any authorized person in the department

A narrative is produced which can be sent electronically, faxed, or printed

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ONCOCHART

THIS IS A MEANINGFUL USE REQUIREMENTTHIS IS A MEANINGFUL USE REQUIREMENT

Drug Orders in Dept.

Electronic record of physician order for medication dispensed by nursing staff and signed off by physician. Compliant with JCAHO and Meaningful Use.

• This is a brief narrative summary of a review of any of the preceding elements that show significant change, or new developments of importance to the care of the patient.

Clinical comment regarding Current Status

ONCOCHART

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26Coordination of Care•Routine progress notes should be sent to the patient’s other physicians to keep them informed of the case under treatment.

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Physician Demographics

• Every progress note should conclude with a signature of the physician of record and indication of copies to other physicians or charts.

• Electronic signature is acceptable if original signature is on file.

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Check-off and fill-in weekly summaries are marginally acceptable, but they must be legible and complete.

They must show that the physician has documented his/her direct involvement in the production of the weekly assessment.

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NIB

This check off note just barely will suffice as a valid progress note. Demographics, vitals, dose,

and some recommendation of therapy are noted, but the rest is almost unintelligible, and far too brief, with many key elements missing,

such as a legible signature and physician name.

THIS NOTE DOES NOT MEET MEANINGFUL USE, WHICH IS NOW REQUIRED

This weekly under beam note is also marginal in terms of useful data, and does not meet compliance requirements.

NIB

NIB

Electronically Generated Progress Notes are Preferable

NIB

Clinical end of treatment summary.

The clinical end of treatment summary is a non reimbursable procedure, but is absolutely necessary to indicate the termination of the course of radiation treatment.

This document should contain sufficient information to allow the requesting physician, or any other physician involved in the care of the case to fully understand the course of treatment that was just completed.

Transition of care

If you are attesting for meaningful use a transition of care record is required, but it is also very good clinical practice.

The transition of care record, combined with an end of treatment summary allows you to transfer a great deal of meaningful information to the referring physician for their continued care of the patient.

Transition of Care Document

Weekly Treatment Management Weekly Treatment Management 7742777427

What’s it for?What’s it for?The physician’s ongoing clinical care during a course of therapy.The physician’s ongoing clinical care during a course of therapy.

Who normally documents/bills/captures this code?Who normally documents/bills/captures this code?The physician.The physician.

What Documentation is suggested for this code?What Documentation is suggested for this code?A weekly progress note (every 5 fractions) by the physician A weekly progress note (every 5 fractions) by the physician

What are the common documentation errors with this code?What are the common documentation errors with this code?Inadequate amount of information in the weekly notes.Inadequate amount of information in the weekly notes.Missing progress notes for the given number of fractions.Missing progress notes for the given number of fractions.

What are the common billing errors identified?What are the common billing errors identified?Billing this code based only on the number of fractions without Billing this code based only on the number of fractions without adequate documentation (progress notes) existing in the record.adequate documentation (progress notes) existing in the record.

BID therapy requires a progress note every 5 fractions (2 ½ BID therapy requires a progress note every 5 fractions (2 ½ calendar days)calendar days)

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FIBEROPTIC ENDOSCOPYPROCEDURE CPT 31575

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Typical format of endoscopy report

FIBEROPTIC ENDOSCOPY

This patient is currently being treated for a T1, N0, M0, squamous cell carcinoma of the right true vocal cord. The patient has just completed his third week of radiation therapy. He is currently being treated at 180 cGy per day and is currently at 2700 cGy

Procedure: Utilizing a premedication of Pontocaine and Epinephrine applied through nasal atomizer into the right nares, the fiberoptic endoscope was inserted without difficulty. The nasal vestibule and nasal passages were carefully evaluated and found to be unchanged from the previous examination of two weeks ago. The endoscope was advanced further and the nasopharynx was clearly visualized. Both eustachian orifices were clear. A mild amount of dried secretion was noted along the posterior pharyngeal wall. None of this appears to be significant. There is a mild injection of the mucosa of the nasopharynx but no abnormalities were noted.

The endoscope was then advanced further and the hypopharynx and base of the tongue area were carefully evaluated and found to be unchanged from previous evaluations. The endoscope was then advanced into the region of the larynx. The epiglottis was noted to be symmetrical and without lesions. A moderate amount of mucositis is beginning to develop in the area of the larynx. This is most noticeable along the base of the epiglottis. Laryngeal ventricles are completely within normal limits. Pyriform sinuses are within normal limits. The false cords are beginning to show a very light edema. There is a moderate amount of mucositis throughout the perilaryngeal area.

The vocal cords move well and oppose midline. The lesion that was previously noted along the anterior aspect of the right cord is beginning to decrease in size. There is a white membrane that has formed along the area of the right anterior cord primarily in the region of the tumor. There is no membrane formation on the left cord.

The procedure was terminated without difficulty.

Impression: Expected response at three weeks of therapy with beginning resolution of tumor.

Recommendation: The patient will continue on the planed course of radiation therapy without modification.

C.R. Bogardus, Jr., M.D./nz

ONCOCHART

MAY BE REPORTED DURING AN ACTIVE COURSE OF TREATMENT

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77417 Therapeutic radiology port Film(s)

Port films are taken on the treatment machine using the treatment beam to ensure that the treatment setup is as prescribed by the simulation and dosimetry.

Any changes indicated by the port films must be corrected or incorporated into the treatment plan. For coding purposes, real-time or on-line portal imaging is the same as obtaining port films.

The technical component (i.e. the costs The technical component (i.e. the costs associated with generating port films) is associated with generating port films) is reportable using code 77417reportable using code 77417..

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Conformal Treatment Conformal Treatment ManagementManagement

• Conformal radiation therapy Conformal radiation therapy treatment management (3-D treatment management (3-D designed) consists of clinical designed) consists of clinical

management of custom management of custom designed and blocked treatment designed and blocked treatment portals, directed to a treatment portals, directed to a treatment

volume of interest.volume of interest.

• 3-D Conformal 3-D Conformal management management (not SRS, or (not SRS, or SBRT)SBRT) is to be reported is to be reported

using code 77427using code 77427

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77469 Intraoperative treatment management, single session

• This code is to be utilized when This code is to be utilized when only 1 fraction makes up the only 1 fraction makes up the entire course of treatment entire course of treatment management.management.

• All management codes are All management codes are mutually exclusive per course of mutually exclusive per course of therapytherapy

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77431 Short Course of Short Course of ClinicalClinical

Treatment Treatment ManagementManagement • This code is to be utilized when

only 1 or 2 fractions make up the entire course of treatment management.

• Note: This code may not be used to be reimbursed for the remaining one or two treatments at the end of a long course of therapy (ACR, 2001).

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Prevention of Heterotrophic Prevention of Heterotrophic Bone formationBone formation

Most commonly done following Most commonly done following major bone traumamajor bone trauma

Single treatment of 6 to 8 GySingle treatment of 6 to 8 Gy All procedures done on one day.All procedures done on one day. Consult, treatment planning, Consult, treatment planning,

simulation, blocks, dosimetry, and simulation, blocks, dosimetry, and treatmenttreatment

ICD-9 code 728.13 or V-07.8ICD-9 code 728.13 or V-07.8

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HETROTROPHIC BONE PREVENTIONPOST OPERATIVE

36

Short Course of Clinical Short Course of Clinical Treatment Management 77431Treatment Management 77431

What is this code for?What is this code for?The physician’s clinical care during a short course of only 1 or 2 fractions.The physician’s clinical care during a short course of only 1 or 2 fractions.

Who normally documents this code?Who normally documents this code?The physician.The physician.

When is this code normally billed?When is this code normally billed?The last day of the short course.The last day of the short course.

What Documentation is needed for this code?What Documentation is needed for this code?A progress note outlining the short course of therapy.A progress note outlining the short course of therapy.

What are the common documentation errors identified with this What are the common documentation errors identified with this code?code?No physician’s note being documented.No physician’s note being documented.

What are the common billing errors identified?What are the common billing errors identified?Billing this code with Brachytherapy, this is only for external beam Billing this code with Brachytherapy, this is only for external beam patients.patients.Do not report for 1 or 2 leftover fractions of at the end of a long course of Do not report for 1 or 2 leftover fractions of at the end of a long course of therapy.therapy.

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Chemotherapy with Radiation Treatments

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Chemotherapy with Radiation Treatments

• Chemotherapy, or the use of drugs to Chemotherapy, or the use of drugs to treat cancer, is a concept that has been treat cancer, is a concept that has been with us for over 40 years.with us for over 40 years.

• In the beginning, the drugs were In the beginning, the drugs were extremely toxic, and relatively ineffective.extremely toxic, and relatively ineffective.

• New drugs have been perfected which are New drugs have been perfected which are highly disease selective.highly disease selective.

• There are many drugs in use today that There are many drugs in use today that target specific cell lines of malignancy.target specific cell lines of malignancy.

• Some of these drugs are used alone, Some of these drugs are used alone, others are used in combination, and others are used in combination, and others are used in conjunction with others are used in conjunction with radiation therapy.radiation therapy.

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• Almost all of the Almost all of the chemotherapeutic agents are chemotherapeutic agents are highly toxic and create various highly toxic and create various medical problems for the patient medical problems for the patient in addition to their beneficial in addition to their beneficial effects against the malignancy.effects against the malignancy.

• The beneficial effects of these The beneficial effects of these drugs usually will out weigh the drugs usually will out weigh the toxic side effects, and for this toxic side effects, and for this reason chemotherapy plays a reason chemotherapy plays a very important role in the overall very important role in the overall management scheme of patients management scheme of patients with malignancy.with malignancy.

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• When chemotherapy is used, the acute When chemotherapy is used, the acute and long-term effects, must be taken and long-term effects, must be taken into account by the radiation into account by the radiation oncologist.oncologist.

• Patients receiving chemotherapy tend Patients receiving chemotherapy tend to be sicker and require closer and to be sicker and require closer and more careful attentionmore careful attention

• The treatment planning and The treatment planning and treatment management of the treatment management of the course of therapy will always be course of therapy will always be complex. This will be true even in complex. This will be true even in what otherwise, would have been what otherwise, would have been a simple case. a simple case.

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7747077470 Special treatment procedure Special treatment procedure (e.g. total body irradiation, (e.g. total body irradiation, hemibody hemibody irradiation, per oral endo-cavitary or irradiation, per oral endo-cavitary or intra-operative cone irradiation)intra-operative cone irradiation)

This code covers the additional This code covers the additional physician effort and work required for the physician effort and work required for the special procedures of, total body special procedures of, total body irradiation, hemibody irradiation, irradiation, hemibody irradiation, intracavitary cone use, Brachytherapy, intracavitary cone use, Brachytherapy, hyperthermia, hyperthermia, concurrent chemotherapyconcurrent chemotherapy, , radiation response modifiers, stereotactic radiation response modifiers, stereotactic radiosurgery (single fraction or radiosurgery (single fraction or fractionated), fractionated), intra-operative radiation intra-operative radiation therapy, therapy, 3-D CRT, IMRT3-D CRT, IMRT (removed 2012(removed 2012)), , heavy particles (e.g. protons/neutrons),heavy particles (e.g. protons/neutrons), and any and any other special time-consuming and other special time-consuming and complex treatment procedure. complex treatment procedure.

))

Special Treatment Procedure Special Treatment Procedure 7747077470

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The code 77470, is designated The code 77470, is designated to cover the additional time and to cover the additional time and effort required effort required of the physician of the physician and the hospital technical staffand the hospital technical staff while performing and/or while performing and/or managing special treatment managing special treatment situationssituations.

This code may be reported only This code may be reported only one time per course of therapy.one time per course of therapy.

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77470 IS A GLOBAL BILLLING CODE77470 IS A GLOBAL BILLLING CODE

SPECIAL TREATMENT PROCEDURE WORKPAGESPECIAL TREATMENT PROCEDURE WORKPAGE

Note the Note the many many

different different indications indications

for reporting for reporting the special the special treatment treatment procedure, procedure,

7747077470

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ONCOCHART

Can anything better exemplify special treatment procedure than pediatric anesthesia?

NIB

A narrative note is absolutely necessary as the backup documentation for 77470. Simply including a line in a weekly progress note is not sufficient documentation to justify the billing of this code. The reasons are all here, just make certain that they are verbalized.

Special Procedure NoteThis patient has just completed three months of multi-drug chemotherapy by Dr.

Ishmael. We have been watching the patient over the last few weeks as the counts have slowly risen to a respectable level. The patient now has 4500 WBC's and 217,000 platelets. Patient still has marked alopecia from the chemotherapy.

Considerable time was spent this morning with the patient and the patient's family explaining the possibility of continued, severe, interactions between the radiation and the just completed course of chemotherapy. It is anticipated that the patient will be experiencing a marked increase in skin reactions because of the course of Adriamycin. The treatment portals will be close to the heart, but every effort will be made to avoid treating any of the myocardium. The patient and the patient's family do understand the possibility of severe reactions and difficulties that will probably be experienced during the forthcoming course of radiation treatments.

The course of radiation therapy over the next six weeks will be carefully coordinated with Dr. Ishmael. Dr. Ishmael will be available to handle any medical problems that may arise during this period of time. We will be observing the patient on a daily basis during the first part of the course of treatment to make certain that reactions are not excessive.

The patient and the patient's family fully understand that the treatments are absolutely necessary but that the patient will experience considerable discomfort and other interrelated problems during the next few weeks.

Carl R. Bogardus, Jr., M.D.ONCOCHART

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Multiple reasons for 77470

Special Treatment ProceduresSpecial Treatment Procedures7747077470What’s it for?What’s it for?

The additional effort involved in caring for patients under highly complex The additional effort involved in caring for patients under highly complex circumstances.circumstances.

Who normally documents this code?Who normally documents this code?Varies widely, but usually the physician. Varies widely, but usually the physician.

When is this code normally billed?When is this code normally billed?Upfront at the same time as the physician’s clinical treatment planning. Upfront at the same time as the physician’s clinical treatment planning.

What Documentation is suggested for this code?What Documentation is suggested for this code?A physician narrative explaining medical necessity.A physician narrative explaining medical necessity.

What is the common documentation error identified with this code?What is the common documentation error identified with this code?Not documenting the code with a separate written document.Not documenting the code with a separate written document.

What are the common billing errors identified?What are the common billing errors identified?Missing the code due to inadequate documentation of the procedure.Missing the code due to inadequate documentation of the procedure.There is no “physical” event to trigger billing, it must be recognized by There is no “physical” event to trigger billing, it must be recognized by circumstances.circumstances.

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SP89/104

If the patient is a Medicare If the patient is a Medicare recipient and becomes recipient and becomes hospitalized as an inpatient, but hospitalized as an inpatient, but being transported to a being transported to a freestanding center each day for freestanding center each day for treatment, then the patient must treatment, then the patient must be billed as an inpatient, not as be billed as an inpatient, not as an outpatientan outpatient. .

Most freestanding centers have Most freestanding centers have contracts with hospitals to cover these contracts with hospitals to cover these situations. situations. Hospital owned departments make Hospital owned departments make these corrections internally.these corrections internally.

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HYPERTHERMIAHYPERTHERMIA

Covered by codes 77600 to Covered by codes 77600 to 7762077620

Payment value of coverage Payment value of coverage of treatment by negotiation of treatment by negotiation with local insurance carrierswith local insurance carriers

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77600 – 77620 ARE GLOBAL BILLING CODES77600 – 77620 ARE GLOBAL BILLING CODES99/104

BSD Phased Array hyperthermia unit

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HYPERTHERMIA ISOTHERMIC PLAN

NIB

AVAILABLE CODESAVAILABLE CODES Only the Hyperthermia delivery codes are Only the Hyperthermia delivery codes are

specific to Hyperthermia.specific to Hyperthermia. 77600 Superficial up to 4 cm depth77600 Superficial up to 4 cm depth 77605 Deep over 4 cm in depth77605 Deep over 4 cm in depth 77610 Probes (interstitial) 5 or less probes77610 Probes (interstitial) 5 or less probes 77615 Probes (interstitial) 6 or more 77615 Probes (interstitial) 6 or more

probesprobes 77620 Probes ( intracavitary) any number77620 Probes ( intracavitary) any number New codes were planned for 2009New codes were planned for 2009

49

CODES THAT CAN BE USEDCODES THAT CAN BE USED 77263 Complex treatment planning77263 Complex treatment planning 77470 Special treatment procedure77470 Special treatment procedure 77290 Initial set up simulation77290 Initial set up simulation 77280 Subsequent simulations same area77280 Subsequent simulations same area 77305 Isothermic plan, superficial77305 Isothermic plan, superficial 77310 Isothermic plan deep one port77310 Isothermic plan deep one port 77315 Isothermic plan deep, multiple ports77315 Isothermic plan deep, multiple ports 77295 Isothermic plan, 3-D planning77295 Isothermic plan, 3-D planning 77326 Isothermic plan interstitial up to 4 probes77326 Isothermic plan interstitial up to 4 probes 77327 Isothermic plan interstitial, 5-10 probes77327 Isothermic plan interstitial, 5-10 probes 77328 Isothermic plan interstitial, over 10 probes77328 Isothermic plan interstitial, over 10 probes 77328 Isothermic plan intracavitary77328 Isothermic plan intracavitary 77300 Basic Dosimetry for heating time 77300 Basic Dosimetry for heating time

calculationscalculations 77300 Calculation of areas of maximal or minimal 77300 Calculation of areas of maximal or minimal

heatingheating

49

PRINCIPLES OF BILLING, CODING

AND COMPLIANCE IN RADIATION ONCOLOGY

BMSi 2014

END 11

END OF SECTION 11

MEDICARE (CMS), 2010, REQUIRESMEDICARE (CMS), 2010, REQUIRES There shall be a full-time There shall be a full-time

physician, preferably a radiation physician, preferably a radiation oncologist, per facility, physically oncologist, per facility, physically available on a daily basis for direct available on a daily basis for direct supervision of daily treatment, and supervision of daily treatment, and management of any patient management of any patient related treatment problems.related treatment problems.

The 5 elements of weekly The 5 elements of weekly management must be documented management must be documented by this physician for each week of by this physician for each week of treatment.treatment.

7

Trail Blazer opinion June 2010Trail Blazer opinion June 2010For billing radiation treatment For billing radiation treatment

management, 77427, Medicare management, 77427, Medicare expects the radiation oncologist to expects the radiation oncologist to bill the weekly management code bill the weekly management code for the management related to for the management related to five consecutive treatment five consecutive treatment delivery sessions and to have seen delivery sessions and to have seen the patient at least once during the patient at least once during that time period. that time period. The actual The actual visit could occur anytime visit could occur anytime during that time period.during that time period.

11

R128BP page 13

23

PainAmbulationSocial interactionsMemoryPsycho-social adjustmentNutritional status should always be mentioned as related to present weightPhysician/patient self assessment of Q of L

Assessment of Quality of Life

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Generally done by the nursing staff but must be reviewed by the physician

• Review of current portal films or images• Comparison with previous portal films or images• Comparison with simulation films or images• Comparison with appropriate diagnostic imaging• Corrective action if necessary• Review of corrected portal films or images•Indicate if films not required (electrons, superficial)

Review of Portal Images

ONCOCHART

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Total Body or Hemi body Radiation Therapy

Total or hemi body therapy is an Total or hemi body therapy is an extremely complex procedure extremely complex procedure requiring a great deal of physician requiring a great deal of physician input, often requiring special testing, input, often requiring special testing, consultations, and physics consultations, and physics evaluations.evaluations.

When only one or two treatments are When only one or two treatments are given for the entire course of therapy, given for the entire course of therapy, you should bill short course of you should bill short course of treatment management 77431.treatment management 77431.

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992XX High Complexity Evaluation77263 Therapeutic Radiology Treatment Planning; Complex77290 Therapeutic Radiology Simulation; Complex

Simulation may be repeated on different days during the initial setup procedures.77300 Basic Radiation Dosimetry Calculation

This may be calculated on many occasions. This may be reported as many times as performed and Documented.77321 Special Teletherapy Port Plan (Electrons, if used)77336 Continuing Medical Physics Support, 1 charged for 1 to 5 fractions.77370 Special Medical Radiation Physics Consultation

As Requested By the radiation oncologist.Usually only 1 of these would be required

for a total body course of treatment.

Valid charges for total body radiation therapy 38

77331 Special Dosimetry (TLD or Diode Microdosimetry)

This may be billed as often as requested to cover all measured dose points.77334 Special Shields Special shields for the lungs may be constructed.77427 Weekly Megavoltage Treatment Management –22,

If over 2 treatments given, Modifier –22 is used to increase the billed value.77431 Short Course Clinical Treatment Management -22

Modifier –22 may be used to increase the value of this code.77417 Port Films, 1 charge is allowed per week (5 fractions) of treatment.77470 Special Treatment Procedure -22 Modifier –22 may be used for a one-time charge for the special treatment procedure.

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Review of Laboratory Data Review of Laboratory Data (page 18-19)(page 18-19)

Laboratory tests, should be discussed Laboratory tests, should be discussed andand summarizedsummarized Comparison to previous laboratory Comparison to previous laboratory workwork Indicate corrective actions if Indicate corrective actions if necessarynecessary Ordering of any new testing as Ordering of any new testing as requiredrequired

Review of Diagnostic Imaging Review of Diagnostic Imaging Studies ( page 19)Studies ( page 19)

Compare with previous imaging Compare with previous imaging studiesstudiesCompare with current portal films Compare with current portal films if indicatedif indicatedOrdering of any new testing or Ordering of any new testing or imaging as requiredimaging as required

Look at errors on note

Rework incident toRework incident to

Decrease number of slidesDecrease number of slides Clean up wordingClean up wording

Month End CrossingMonth End CrossingOn March 2009 the National Government Services,  a CMS contracting agent "clarified" the proper reporting of 77427. This is reported  in the Medicare Claims processing manual (100-04), Chapter 13, Section.1.In the event that five fractions occur in two different calendar months or years, the billing "from and to" dates should reflect the month in which the most fractions were performed.

NIB

“Clarified” method of Billing

3 Fractions make up this week

Bill first date of “clarified” week

Week MgmtOrphaned

dateOrphaned date

This makes the billing more difficult

Orphaned dateOrphaned dateWeek Mgmt

We then return to a conventional 5 day week but what do we do with the 2

orphaned dates?

NIB

Even More Difficult with 2 days in each Crossing Segment

Which set has the week of management billed, and if only 2 fractions make up the end of a course, you cannot bill a week of

management, so do we loose the last week of 77427 management billing?????

NIB

INCIDENT TO SERVICESINCIDENT TO SERVICES The Physician direct supervision The Physician direct supervision

requirements are required if the requirements are required if the services are performed within a services are performed within a hospital, the physician must be hospital, the physician must be within the hospital,within the hospital, but not but not necessarily in the radiation therapy necessarily in the radiation therapy department,department, this has been clearly this has been clearly stated by CMS in the ruling of April stated by CMS in the ruling of April 7, 20007, 2000

Summary of R128BP page 13

ASTRO Comments, 04-30-12NIB

This illogical scheme of reporting will This illogical scheme of reporting will make billing and auditing very difficult make billing and auditing very difficult for no rational  purpose. I recall this for no rational  purpose. I recall this same proposal about the year 1991 as same proposal about the year 1991 as the code 77427 was brought into use. the code 77427 was brought into use. This was soon changed to ignore the This was soon changed to ignore the monthly crossing recommendation as monthly crossing recommendation as being far too difficult to bill and audit. being far too difficult to bill and audit.

If your carrier is forcing you to use this If your carrier is forcing you to use this method, you should protestmethod, you should protest

NIB

INCIDENT TO SERVICESINCIDENT TO SERVICES If the hospital owned radiation therapyIf the hospital owned radiation therapy

department isdepartment is not physically locatednot physically located within, or connected to, the hospital, i.e., within, or connected to, the hospital, i.e., a free standing center thena free standing center then the the physician physician must be “Interruptible” and able to must be “Interruptible” and able to intervene “right away” when Medicare intervene “right away” when Medicare patients are being treatedpatients are being treated.. Free standing, non hospital owned Free standing, non hospital owned

centers are subject to this centers are subject to this requirementrequirement

Summary of R128BP page 13

PORTAL-VISION IMAGES (ARIA-VARIAN)

BLENDED IMAGES

DRR

PORTAL IMAGE

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RULE OF 5 ROUND OFFRULE OF 5 ROUND OFF5

RADIATION THERAPY DRGRADIATION THERAPY DRG There are 523 DRG CodesThere are 523 DRG Codes Code 409 is the only DRG with radiation Code 409 is the only DRG with radiation

therapytherapy 409 is defined as concomitant 409 is defined as concomitant

chemotherapy and radiation therapy chemotherapy and radiation therapy during the admissionduring the admission

DRG codes do not include additional DRG codes do not include additional reimbursement for radiation therapyreimbursement for radiation therapy

This is why you are discouraged from This is why you are discouraged from starting therapy while a hospital inpatientstarting therapy while a hospital inpatient

45

Clinical Treatment Management Clinical Treatment Management does not cease for nights, does not cease for nights, holidays, week ends, or any holidays, week ends, or any other time of non active other time of non active treatment deliverytreatment delivery

The physician remains The physician remains responsible for clinical responsible for clinical management as long as the management as long as the patient is under your direct patient is under your direct care.care.

2

Historical BackgroundHistorical Background

• The original three levels of complexity descriptors for treatment management were formulated in the early 1970’s..

• The term “treatment The term “treatment management” was used to management” was used to describe both the supervision of describe both the supervision of treatment delivery and the treatment delivery and the clinical management of the clinical management of the patient.patient.

2

Historical BackgroundHistorical Background

• In the Fall of 1990, AMA-CPT requested that In the Fall of 1990, AMA-CPT requested that the ACR and ASTRO CPT Committees work to the ACR and ASTRO CPT Committees work to devise a weekly treatment management devise a weekly treatment management system system that could identify physician that could identify physician procedures performed, and their procedures performed, and their complex interactions.complex interactions.

• The ACR recommended that the The ACR recommended that the AMA-CPT adopt the new code AMA-CPT adopt the new code 77427 weekly treatment 77427 weekly treatment management, effective Jan 1, management, effective Jan 1, 1991,1991, we have had this code for we have had this code for 21 years, and many physicians 21 years, and many physicians still have problems documenting still have problems documenting it’s use. it’s use.

3

Historical BackgroundHistorical Background

•As a key part of the negotiations to achieve

77427, it was agreed that• all the items of weekly all the items of weekly

care and management care and management will be performed on a will be performed on a

regular basis and regular basis and documented by regular documented by regular under beam progress under beam progress

notesnotes

3

Medicare is tightening the Medicare is tightening the availability rules as part of the availability rules as part of the “Revised Incident To” ruling of Jan “Revised Incident To” ruling of Jan 1, 2009, April 7, 2009, April 1, 1, 2009, April 7, 2009, April 1, 2010.2010.

Commercial carriers are also Commercial carriers are also beginning to pay very close beginning to pay very close attention to physician attention to physician availabilityavailability.

Availability of Physician During Treatment Management, HOPPS

11

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THIS IS OUR BEST THIS IS OUR BEST INTERPRETATION OF INTERPRETATION OF

THE EXISTING THE EXISTING REGULATIONSREGULATIONS

Check your local carrier if Check your local carrier if in doubt about coverage, in doubt about coverage, especially in rural areas of especially in rural areas of limited medical limited medical accessibilityaccessibility

NIB

•General supervisionGeneral supervision means the procedure is means the procedure is furnished under the physician’s overall direction furnished under the physician’s overall direction

and control, but the and control, but the physician’s physician’s presence is presence is not requirednot required during the performance of the during the performance of the procedure. ISODOSE PLAN, BLOCKS, DOSIMETRYprocedure. ISODOSE PLAN, BLOCKS, DOSIMETRY

•Direct supervisionDirect supervision in the office setting in the office setting

means the physician means the physician must be presentmust be present in the in the office suite and immediately available to furnish office suite and immediately available to furnish assistance and direction throughout the assistance and direction throughout the performance of the procedure. It does not mean performance of the procedure. It does not mean that that the physician must be presentthe physician must be present in the in the room when the procedure is performed. room when the procedure is performed. TREATMENT DELIVERYTREATMENT DELIVERY

•Personal supervisionPersonal supervision means a means a physician physician must be inmust be in attendanceattendance in the room during the in the room during the performance of the procedure. SIMULATION, performance of the procedure. SIMULATION, PATIENT EXAMINATIONPATIENT EXAMINATION

12

There shall be a full-time radiation oncologist per facility (Hospital out patient or Free standing center) immediately available, interruptible, and able to furnish assistance and direction throughout the procedure.

The attending physician or a responsible physician (Ideally THIS PHYSICIAN SHOULD

BE A RADIATION ONCOLOGIST) must be either in direct attendance or reasonably accessible during the time that radiation treatments are being delivered.

The Radiation Oncologist (CMS 2010) 12

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The Responsible PhysicianThe Responsible Physician

It is not in accordance It is not in accordance with the law for a Non with the law for a Non Physician practitioner Physician practitioner to provide physician to provide physician services supervision.services supervision.

13

INCIDENT TO SERVICESINCIDENT TO SERVICES The CMS requirements clearly state that if The CMS requirements clearly state that if

the responsible physician leaves a free the responsible physician leaves a free standing center, even to go to the hospital, standing center, even to go to the hospital, then all Medicare related services must then all Medicare related services must stop unless coverage is providesstop unless coverage is provides

The 15 minute exclusion is not mentioned, The 15 minute exclusion is not mentioned, as this was only a concession to ACR many as this was only a concession to ACR many years ago and never became part of CMS years ago and never became part of CMS policypolicy

Summary of R128BP page 13

Coverage under –Q5Coverage under –Q5 A Medical Oncologist who has

been credentialed to cover daily treatment delivery patient care,

Who is working in the same clinic,

Who is interruptible and able to respond “Right away”

-Q5 Services provided by a -Q5 Services provided by a substitute physiciansubstitute physician

14

If a physician is unavailable for one If a physician is unavailable for one week (5 treatments) then week (5 treatments) then the physician the physician who is covering will be the Physician of who is covering will be the Physician of RecordRecord and the Week of Management and the Week of Management

must be billed under his name. must be billed under his name.

The only exception is for locum tenens The only exception is for locum tenens coverage where the billing remains in coverage where the billing remains in

the original physician’s name.the original physician’s name.

14

e-RX Prescribe for Narcoticse-RX Prescribe for NarcoticsCovered in section 3 page 8

This is the token, a random number generator used to verify electronic narcotic prescribing.

New DEA controlled drug requirements

DEA regulations require a pharmacy to receive a new valid signed prescription.

DEA has further stated that a pharmacy may not provide a partially or fully pre-populated form for the prescribing practitioner.

The physician may either fax narcotic prescriptions or send electronically if pharmacy has the capability.

NIB

• The review and interpretation of port films is considered as part of the weekly clinical treatment management by the physician.

• IMRT, Electron or Kilovoltage treatment may not produce port films.

• Weekly orthogonal images for IMRT setup may be billed as port films

31

BILLING INPATIENT CARE BILLING INPATIENT CARE FROM A FREESTANDING FROM A FREESTANDING

CENTER OR HOSPITAL BASED CENTER OR HOSPITAL BASED PROGRAMPROGRAM

By law, Medicare stipulates By law, Medicare stipulates that the technical component that the technical component of inpatient radiation therapy of inpatient radiation therapy must be included as part of must be included as part of the DRG of the admission the DRG of the admission

45

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Skilled Nursing FacilityPatients admitted to a skilled Patients admitted to a skilled

nursing facility (SNF) nursing facility (SNF) under the under the part A benefit or a Medicare part A part A benefit or a Medicare part A stay are considered to be hospital stay are considered to be hospital

inpatients,inpatients, and as such are and as such are covered under a specific DRG of covered under a specific DRG of

admission. admission. Treatment of these patients Treatment of these patients

requires the technical component requires the technical component of treatment to be billed to the of treatment to be billed to the

SNF, not Part B. SNF, not Part B. This may not apply to private This may not apply to private

insuranceinsurance

46

SP98/104

Clinical exampleClinical example

Notice, the weekly management is being billed on the 1st date of each five-day treatment interval

The progress notes are occurring regularly on Monday regardless of the elapsed number of treatments

NIB

Port Films 77417Port Films 77417What’s is this code for?What’s is this code for?

Weekly Port Film or Electronic Portal Imaging.Weekly Port Film or Electronic Portal Imaging.Who normally documents/bills/captures this code?Who normally documents/bills/captures this code?

Treatment Therapist.Treatment Therapist.When is this code normally billed?When is this code normally billed?

One time per five fractions, regardless of how many images are taken.One time per five fractions, regardless of how many images are taken. What Documentation is suggested for this code?What Documentation is suggested for this code?

A notation in the chart that portal images were taken, and if any A notation in the chart that portal images were taken, and if any corrective action corrective action was needed.was needed.

What are the common documentation errors identified.What are the common documentation errors identified.The lack of physician participation in the documentation.The lack of physician participation in the documentation.

What are the common billing errors identified?What are the common billing errors identified?Billing an incorrect number of units.Billing an incorrect number of units.Billing these images professionally (they are technical only).Billing these images professionally (they are technical only).

33

Verbatim Cut and Paste NIB

This is from HHS and DOJ

They Really Mean ItNIB