Oncology & Hematology Coding Alert

You can mark one in the win column for matching physician supervision requirements to radiation oncology reality. CMS recently announced changes to 77421's technical component requirements. Here's the scoop.

The relevant supervision levels for technical 77421 (Stereoscopic x-ray guidance for localization of target volume for the delivery of radiation therapy) include:

• (02) Direct supervision: When your physician is present and immediately available to furnish direction and assistance throughout the procedure, consider it "direct supervision." Remember, however, that "direct supervision" doesn't mean your physician must be present in the room during the procedure -- just that he's in the vicinity and immediately available in person if needed.

• (03) Personal supervision: "Personal supervision does not mean the doctor has to perform the procedure; he just has to be there in person supervising the procedure," explains Erin Goodwin, CPC, CMC, reimbursement and coding professional with South Carolina Oncology Associates.

In other words, the physician must be in the room for services requiring personal supervision.

Resource: The "National Physician Fee Schedule Relative Value File Calendar Year 2009," available with the fee schedule files on the CMS Web site, lists the definitions for the supervision indicators.

CMS announced the supervision level changes for 77421 in transmittal 1748, released May 29.

The implementation date, when carriers must be prepared to execute the change, is July 6. But the effective date is Jan. 1, meaning that the new supervision levels actually apply to services performed as far back as Jan. 1 (www.cms.hhs.gov/Transmittals/downloads/R1748CP.pdf).

Old way: Before the switch the physician supervision level for 77421 (TC) was personal supervision (03).

New way: The July update changes the TC supervision requirements to direct supervision (02).

By changing the technical component from personal to direct supervision, CMS has changed from requiring the oncologist's presence in the room to requiring the oncologist to be immediately available, which is helpful for those coding the technical side.

ASTRO and other societies advocated this change, contending direct supervision was more appropriate for 77421 than personal supervision because the oncologist's contribution typically requires looking at real-time images on a computer screen and alerting the therapist if changes are required, which can be done remotely (based on patient condition).

Personal supervision -- requiring the oncologist's presence in the room -- "limits other things the doctor can be doing in the clinic," Goodwin says. The oncologist "could be doing a consult, working on planning, etc., instead of personally supervising IGRT [image guided radiation therapy]," she says.

Remember: Your documentation needs to support the supervision level for the code you choose, or CMS will demand a refund during audit, Goodwin warns.