Wiki Pending OIG 2019 Work Plan for Outpatient 3-D Radiation Therapy Planning

[deirdre]

Hello,

I have read and re-read this and feel more confused each time I read it:

"3-Dimensional Conformal Radiation Therapy (3D-CRT) is a radiation therapy technique that allows doctors to sculpt radiation beams to the shape of a patient's tumor. 3D-CRT is provided in two treatment phases: planning and delivery. Hospitals bill Medicare for developing a 3D-CRT treatment plan using Current Procedural Terminology code 77295. Automated prepayment edits prevent additional payments for separately billed radiation planning services if they are billed on the same date of service as the 3D-CRT treatment plan. However, Medicare allows additional payments if they are billed on a different date of service (e.g., 1 day before). For a form of radiation similar to 3D-CRT, Medicare requirements prohibit payments for separately billed radiation planning services when they are billed on a different date of service. We will determine the extent of potential savings to Medicare if it had implemented the same requirements for 3D-CRT planning services." (OIG 2019 Work Plan).

What I am interpreting the work plan is add a prepay edit to also not allow 77295 (3D-CRT) the day before example: 77280, 77285, 77290, 77306, 77307

https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000305.asp

Thoughts?
Thank you

 

[thomas7331]

As I read this, I take it to mean that they are only looking at planning services that are billed over multiple dates of service, so I gather just targeting 77295 when billed and paid on successive dates. It would not impact the delivery/therapeutic codes. It sounds to me also as this is just exploratory to identify potential savings and they are not recommending an edit at this time. It also sounds to be just targeting hospital claims and not physician.

 

[deirdre]

Thank you Thomas, I appreciate your insight.

 

[CANDERSON]

77295 charging

I am questioning if we should be billing a second 77295 for boosts/ cone downs using the same CT as the original plan? If not, then what do we charge?

 

[ggoode66]

I am questioning if we should be billing a second 77295 for boosts/ cone downs using the same CT as the original plan? If not, then what do we charge?

You would treat that second 3Dplan just like the original. Meaning there would be a new order, medical necessity for the plan. If the medical necessity is for tumor shrinking or anything that has changed and is different than originally it would also be expected to have a new simulation, 77290, to show those changes for planning, with all the needed documentation for that 2nd simulation.

As far as the original question on the pending OIG plan for 3D. Things are heading towards a set payment plan for radiation, similar to hips/knees if my memory of how those are now done is correct. So if you have a pt for xrt for prostate. it will be one fee for everything that will be done during that course of treatment. When the OIG put that out, it seemed more of a way to explore that way. Similar to IMRT (77301) where certain services are no longer billed even though the are still needed to be done to create the plan.