Part B Insider (Multispecialty) Coding Alert

Published on Fri Jul 16, 2004 PDF

Doctors trapped by Medicare reimbursement limits

Physicians providing stereotactic radiosurgery have run smack into a Medicare restriction that prevents them from billing for these procedures in the freestanding settings.

Until recently, Medicare's ban on SRS in a freestanding surgery center or radiation oncology center didn't bother physicians, because most patients receiving stereotactic procedures had brain tumors and were non-Medicare patients, according to Jim Hugh, vice president of American Medical Accounting & Consulting in Atlanta.

But recently, SRS has become more common for liver, spleen, brain stem and spine patients, and these are all Medicare patients. Medicare won't allow physicians to use its G-codes to bill for the technical components of SRS outside of the outpatient setting.

CMS Cannot Change Current Policy

In a recent meeting at CMS headquarters, representatives of the American Society forTherapeutic Radiation Oncology met with CMS officials and raised this issue, according to radiation oncologist Michael Steinberg. Currently, the technical components of SRS procedures are only payable through G-codes, which are only billable in a hospital outpatient setting and not a freestanding center.

Unfortunately, CMS officials told ASTRO they were unable to change the reimbursement status for SRS themselves. It's up to the American Medical Association to create new CPT Codes.

"Sometimes the AMA with the CPT editorial will ask, 'Are there G codes that need CPT analogues?'" notes Steinberg. There's a fairly rigorous process of creating new CPT codes, involving literature review and a survey of at least 30 physicians who are performing a particular procedure.

It's already too late to obtain new CPT codes for SRS in 2005, but ASTRO is "exploring all options" in terms of new CPT codes for 2006, says Steinberg. Currently, physicians receive a practice expense reimbursement but no technical component for the SRS CPT codes, and the only freestanding radiation oncology centers that can bill for SRS are billing under a hospital license.