Outpatient Facility Coding Alert

Published on Mon Oct 17, 2016 PDF

Know what is covered by IMRT planning code 77301.

The OIG has decided to review Medicare outpatient payments for intensity-modulated radiation therapy (IMRT), to analyze whether CMS paid for these services according to the Federal guidelines. Could there be any specific reason behind OIG choosing this particular therapy for post-payment audits now? Read on to find out.

Background: IMRT is an advanced process that uses computer-driven technology to impart accurate radiation doses to precise areas within a tumor, malignant or otherwise. Prior OIG reviews have identified hospitals that have incorrectly billed for IMRT services. Furthermore, the service is provided in two phases: planning and delivery. CMS requires the provider not to bill certain services if you performed them in the process of developing an IMRT plan. (CMS’s Medicare Claims Processing Manual, Pub. No. 100-04, Ch. 4, § 200.3.2.)

“The codes have been confusing and not well understood,” says Sarah L. Goodman, MBA, CHCAF, COC, CCP, FCS, President, CEO, and principal consultant for SLG, Inc, in Raleigh, N.C. “A lot is included in code 77301 that may have been inadvertently unbundled.”

The all-in-one code: According to the CMS Change Request 9486, chapter 4, section 200.3.1/Billing Instructions for IMRT Planning (Rev.3425, Issued: 12-18-15, Effective: 01-01-16, Implementation: 01-04-16), payment for the services identified by the following CPT^® codes is included in the APC payment for CPT^® code for IMRT planning (77301, Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specifications):

• 77014 (Computed tomography guidance for placement of radiation therapy fields),
• 77280 (Therapeutic radiology simulation-aided field setting; simple) through 77295 (3-dimensional radiotherapy plan, including dose-volume histograms),
• 77306 (Teletherapy isodose plan; simple (1 or 2 unmodified ports directed to a single area of interest), includes basic dosimetry calculation(s)) through 77321 (Special teletherapy port plan, particles, hemibody, total body),
• 77331 (Special dosimetry (eg, TLD, microdosimetry) (specify), only when prescribed by the treating physician), and
• 77370 (Special medical radiation physics consultation).

Remember: Do not report these codes in addition to CPT^® code 77301 (on either the same or a different date of service) unless you perform these services as a part of a separate and distinct non-IMRT radiation therapy for a different tumor.

Ref: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3425CP.pdf.