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Radiation OncologyReimbursement andCodingdi BasicsiDavid C. Beyer M.D., FACR, FACRO, FASTROArizona Oncology ServicesPhoenix, ArizonaAll Rights Reserved11.2.3.4.Explain the importance of correct coding in billing andreimbursement for a physician office.Provide an overview of the basics of correct radiation oncologycoding practicespractices.Give examples of tools used by Medicare to ensure correct coding.Describe and discuss the Medicare formula for calculatingphysician payment.1
Agenda Importance of correct coding Radiation oncology coding basics Correct coding tools (modifiers, CCI edits,MUEs, and RAC audits) Medicare physician payment overview Resources/More information3Importance of Correct Coding What is correct coding? Detailed description of level of service performed that is submitted tocarrier/payer Documentation is a key component Justifies provision of service Physicians are responsible for providing clear and accurate documentation Physicians and coding staff should work collaboratively to ensure propercoding and documentation is being reported to carrier/payerWhy is correct coding important?y to appropriatepp p Keyreimbursement Limits audit risk Decreases claim rejections Speeds reimbursement Interfaces with quality reporting measures42
Correct Coding Does NOT MeanCorrect Payment Inaccurate claims paymentSignificantproblemSi ifibl andd gettingi worseSample of 2.4M claims Compare remittance to expected contracted fee 7 commercial insurers 17.3% in 2010 19.3% in 2011 Medicare 3.8%American Medical News 54(13):1-4, July 11, 2011Coding BasicsCommon Procedural TerminologyCPT Code CategoriesCategoryDescriptionCriteriaRO ExampleIDescribesprocedures andservices Widely accepted andperformed FDA approval granted Proven clinical efficacy77261, Therapeutic radiology treatmentplanning; simpleIISupplementaltracking codes usedfor data collectionabout quality of care Performance measurementcodes Alphanumeric designation No payment assigned4165F, 3-dimensional conformal radiotherapy(3D-CRT) or intensity modulated radiationtherapy (IMRT) receivedIIITemporary codesused for datacollection onassessment of newprocedure/service New emerging technology Used to track utilization Typically payment andcoverage determined by localcarrier for Medicare0073T, Compensator-based beam modulationtreatment delivery of inverse plannedtreatment using 3 or more high resolution(milled or cast) compensator convergent beammodulated fields, per treatment session63
Radiation Oncology Coding Basics Healthcare Common Procedure Coding System (HCPCS) Level I Used to describe medical, surgical, and diagnostic procedures CPT codes which are maintained by the AMA Ex: 77427, Radiation treatment management, 5 treatments Level II Used to identify products, supplies and services which are notincluded in CPT codes 55-digitdigit alphanumeric code Maintained by CMS Ex: A4648, Tissue marker, implantable, any type, each7Radiation Oncology Coding Basics Framework of RO coding – Process ofCare123456 Consultation Preparing for treatment Medical radiation physics, dosimetry, treatment devices, and specialservices Radiation treatment delivery Radiation treatment management Follow-up care management84
Radiation Oncology Coding Basics1 ConsultationAn evaluationrequeste al ation or managementmana ement providedpro ided byb a physicianph si ian at the reqest of anotherphysician or appropriate source to either recommend care for a specific conditionor problem to determine whether to accept responsibility for ongoingmanagement of the patient’s care or for the care of a specific condition.Consultation CodesOffice or other outpatient visits, new patient99201-99205Office or other outpatient visits, established patient99211-99215Office or other outpatient consultations, new or establishedpatient99241-99245Inpatient consultations, new or established patient99251-99255Initial hospital care, new or established patient99221-99223Subsequent hospital care99231-992339Levels of E/M Key components HiHistoryt Examination Medical decision making Contributory factors Counseling Coordination of care Nature of presenting problem Time5
Complexity of Medical Decision Number of: Possible diagnoses Management options considered Amount/Complexity of records, tests, etc. Risk of complications, morbidity, mortalityCbidi not consideredid d unlessl Comorbiditysignificantly increases complexityComplexity TableDx, TxOptionsRisk ofComp. tforward6
Complexity of Decision Making Not clinical treatment planning (7726x) Decisions regarding field configuration,energy, modality, fractionation, etc. is notE/M and must be performed and documentedelsewhere.“ time may be controlling ” “Counseling and/or coordination more than50%” Face time – office Unit/Floor time – inpatient Must be documented in the medical record7
New ght10 aight20 min.Low30 min.ComprehensiveComp.Comp.Moderate45 min.Comp.High60 min.992039920499205Established PatientHistoryExamDecisionTime99211 /- PhysicianMinimal5 min.99212FocusFocusStraight10 min.99213ExpandExpandLow30 min.99214DetailedDetailedModerate45 min.99215Comp.Comp.High60 min.8
Radiation Oncology Coding Basics1 Consultation Elimination of consultation codes by Medicare(99241 As of 1/1/2010 Medicare eliminated payment for office consultation (99241‐99245) and inpatient consultation (99251‐99255) codes, except for telehealth. Providers should report new and established visit codes that best describe theservice being provided. Private payers may still accept; check individual payer policies. Typical reasons ROs report E/M codes Counseling Coordinating care Other aspects of cancer (i.e. pain or nutrition management) Diagnostic testing for staging Exclusion – E/M services cannot be reported when billing the following codes: Treatment management codes 77427, 77431, 77432, 77435, 77470 Intracavitary radiation source application codes 77761 ‐ 77763 Interstitial radiation source application codes (LDR) 77776 ‐ 7777817Radiation Oncology Coding Basics2 Preparing for treatmentCodes Related to Preparing for TreatmentClinical treatment planning codes (simple,intermediate, complex)77261 - 77263Simulation (simple, intermediate, complex, 3dimensional)77280 - 77295189
Radiation Oncology Coding Basics2 Preparing for treatment Clinicalli i l treatment planningli – initiali i i l step,cognitive process Determine disease bearing areas. Identify type and method of radiationtreatment delivery. Specify areas to be treated.treated Select radiation treatment techniques. Specify dose and duration of therapy.19Clinical Treatment Planning Treatment planning definitions Simple (77261) – planning requires a singletreatment area of interest encompassed in a single portor simple parallel opposed ports with simple or noblocking. Intermediate (77262) – planning requires 3 or moreconverging ports, 2 separate treatment areas, multipleblocks, or special time dose constraints.g y Complex (77263) – planningg requires highlycomplex blocking, custom shielding blocks, tangentialports, special wedges or compensators, 3 or moreseparate treatment areas, rotational or special beamconsiderations, combination of therapeutic modalities.10
Radiation Oncology Coding Basics2 Preparing for treatment Therapeutic radiology simulation – process toestablish radiation treatment portals Documentation requirements for simulation Written record of procedure Hard copy or electronically archived images Evidence of image review by physician(signature and date of review)21Simulation Simulation definitions Simple (77280) – simulation of a single treatment area witheither a single port or parallel opposed ports; simple or noblocking. Intermediate (77285) – simulation of 3 or more convergingports, 2 separate treatment areas, multiple blocks. Complex (77290) – simulation of tangential portals, 3 or moretreatment areas, rotation or arc therapy, complex blocking,custom shielding blocks, brachytherapy source verification,hyperthermiahhi probeb verification,ifi i any use off contrast materialsi l Three dimensional (77295) – computer-generated 3Dreconstruction of tumor volume and surrounding critical normaltissue structures from direct CT scans and/or MRI data inpreparation for non-coplanar or coplanar therapy.11
Radiation Oncology Coding Basics Medical radiation physics, dosimetry,treatment devices, and special services3Codes for medical radiation physics, dosimetry, treatment devices and special services togetherencompass the phase of care in which the radiation oncology team develops dosimetry, buildstreatment devices to modify and refine treatment delivery, and performs other special servicesfor the measurement of precision and dose delivery.Codes Related to Medical Radiation Physics, Dosimetry, Treatment Devices, andSpecial ServicesBasic radiation dosimetry calculation andspecial dosimetry77300 and 77331Isodose plans77305-77315, 77326-77328Special teletherapy port plan77321Treatment devices77332-77334 and 77338Medical radiation physics77336 and 7737023Documentation Requirements3 Medical radiation physics, dosimetry, treatment devices,and special servicesBasic dosimetry (77300) Course of therapy for standard external beam would involve 1–6dosimetry calculations. All calcs. must be checked, reviewed, and approved by a physician. Special dosimetry (77331) Uses special radiation monitoring and measuring devices Physician order for the procedure and physician‐dated signatureshowing the work product was reviewed Teletherapy and brachytherapy isodose plans (77305‐77315, 77326‐77328) A printed or electronic treatment plan and evidence that thephysician has reviewed and approved the work product with asignature and date by the physician and physicist2412
Documentation3 Medical radiation physics, dosimetry,treatment devices, and special services Special teletherapy port plan (77321) The special teletherapy port plan should be reviewed, signed,and dated by the radiation oncologist and physicist. Treatment devices (77332‐77334 and 77338) Physician signature and date on simulation and port images Medical radiation physics (77336 and 77370) Physician request for the consultation and physics report andevidence that the physics report was reviewed by the physician25Radiation Oncology Coding Basics4 Radiation treatment deliveryRadiation Treatment Delivery CodesExternal beam therapy77401-77416Port films774172613
Radiation Delivery Factors that determine which treatment deliverycode to choose: Energy level used in treatment, in megavolts (MV) The complexity of treatment (i.e. number of treatmentsites, ports, and devices) Technical-only codes (no physician work associated withcodes) Documentation requirements: Documentation of treatment delivery and port filmreview should appear on the daily treatment log. Documentation of port films must be maintained as anX-ray film or electronically stored image.Radiation Oncology Coding Basics5 Radiation treatment managementRadiation treatment management represents theradiation oncologist’s professional contribution topatient management during a course of external beamradiation.Radiation Treatment Management CodesRadiationdi i treatment management77427, 77431Special radiation treatment774702814
Radiation Oncology Coding Basics5 Radiation treatment management Radiationdi i treatment management typicallyi llinvolves 4 elements Medical E/M of the patient Review of port films Review of dosimetry, dose delivery, andtreatment parameters Review of patient treatment set up May be charged once per 5 fractions(min. of 3 fractions for a partial week))29Radiation Oncology Coding Basics Special Treatment Procedure, 77470 CPT code 77470, Special treatment procedure(eg, total body irradiation, hemibody radiation,per oral, or endocavitary irradiation) Captures the additional physician effortand work required for special radiationtreatment procedures Ex:E CConcomitantit t chemoradiotherapyhdi th Appropriate documentation must bereported. Procedure is performed once per courseof therapy.3015
Radiation Oncology Coding Basics6 Follow-up Care ManagementFollow‐up care management is the last phase of care inradiation therapy management. Continued follow‐up care ofpatients who have completed radiation therapy isappropriately provided by the radiation oncologist to manageany acute or chronic morbidity resulting from treatment aswell as to monitor the patient for tumor recurrence.FFollow‐upllcare managementt isi typicallyt i ll includedi l d d ini thethwork of CPT code 77427, radiation treatmentmanagement.Medicare will not pay for routine follow‐up care during thethree months after completion of external beam therapy.31Radiation Oncology Coding Basics Specialized Techniques Intensity Modulated Radiation Therapy (IMRT) Image Guided Radiation Therapy (IGRT) Stereotactic Radiosurgery (SRS) Stereotactic Body Radiation Therapy (SBRT) Particle Beam Therapy Brachytherapy3216
Radiation Oncology Coding Basics Intensity Modulated Radiation Therapy (IMRT)IMRT CodesIMRT is a technology for delivering highly conformalbeam radiation to solid tumors.IMRT radiation dose planning77301t tt deliveryd liIMRT treatmentCompensator-based IMRTDesign MLC device for IMRT77418 0073T77418,773347733833Radiation Oncology Coding Basics Intensity Modulated Radiation Therapy (IMRT) IMRT Coding Guidance The need for IMRT will always justify a complex level ofclinical treatment planning . CPT code 77263 Distinct from radiation dose planning, IMRT, asdescribed by 77301 Initial simulation (may be required) Localize the area of interest prior to IMRT planning. Place fiducial markers on the skin. CPT code 77290 IGRT is used in conjunction with IMRT in patients whosetumors are located near or within critical structures and/ortissue with inherent setup variation (76950, 77014, 77421). Reported separately, when performed3417
Radiation Oncology Coding Basics Intensity Modulated Radiation Therapy (IMRT) IMRT Policy Issues In 2008, Medicare spent roughly 1 billion on IMRT. Largely for treatment of prostate cancer 77418: 59.80% prostate; 8% breast (2nd highest) 0073T: 60.80% prostate; 5.40% breast (3rd highest) There is now a push for comparative effectiveness datafrom payers and cost benefit comparisons with othert ttreatmentt modalities,d liti i.e.i brachytherapy.b h th Radiation oncology benefit managers have emerged. Concern by private payers of over‐utilization of IMRT35Radiation Oncology Coding Basics Image Guided Radiation Therapy (IGRT)IGRT CCodesdIGRT is a form of adaptive radiation therapy which usesimaging technology to guide action(s) that modifies thetreatment in reference to the intended target.Ultrasound76950CT77014Stereoscopic X-ray77421 For intra‐fraction localization and tracking of target orpatient motion during delivery of radiation therapy reportCPT code 0197T3618
Radiation Oncology Coding Basics Image Guided Radiation Therapy (IGRT) IGRT Coding Guidance Performed with the following services: 3D conformal therapy IMRT Particle beam therapy SRS/SBRT Code components Includes both a professional and technical component Required documentation Physician involvement and for technical aspect of thiscode Work in addition to physician work involved with77427 (weekly management)37IGRT Clinical Appropriateness Image Guided Radiation Therapy (IGRT) Clinical circumstances must reasonably warrant use of IGRT Target volume is located near or within critical structures Targets with inherent set‐up variation Examples Target volume is in close proximity to critical structures that must beprotected. Volume of interest must be covered with narrow marginsg to protectpimmediately adjacent structures adequately. An immediate adjacent area has been previously irradiated andabutting portals must be established with high precision. Dose escalation is planned to deliver radiation dose in excess of thosecommonly used for similar tumors with conventional treatment.3819
Medical Appropriateness Sitesg g modalityy can visualize targetg or Imagingsurrogate Target moves relative to isocenter High dose required relative to OAR Bone or marker? Pelvic bone poor surrogate for prostate Skull may be good surrogate for brain20
Supervision Image Guided Radiation Therapy (IGRT)ypqPhysicianSupervisionRequirementsCPT CodeDescriptionSupervision Level76950UltrasoundGeneral supervision – The procedure is furnished under the physician’soverall direction and control, but the physician’s presence is not requiredduring the performance of the procedure.77014CTsetting the physician must be present inDirect supervision – In the office setting,the office suite and immediately available to furnish assistance anddirection throughout the performance of the procedure. The physicianneed not be present in the room when the procedure is performed.77421Stereoscopic X-rayDirect supervision – Same definition as above.41Radiation Oncology Coding Basics Stereotactic Radiosurgery (SRS)SRS CodesSRS is a technique for delivering a high dose of radiation to aspecific target while delivering a minimal dose to surroundingtissues. This technique is used to treat defined target(s) in thehead and spine.Treatment delivery (freestanding)77372Treatment delivery (freestanding/hospitaloutpatient)77371, G0339,G0340Treatment delivery (hospital outpatient)G0173, G0251Radiation treatment management (singlefraction, cranial only)774324221
Coding Guidance Basis for choosing code to report Source used (cobalt vs.vs linac) Setting (freestanding vs. hospital outpatient) Fractionation scheme (single vs. fractionated) Single fraction SRS CPT code 77432 Cranial SRS is delivered in 2-5 fractions CPT coded 77435 Planning and simulation No specific SRS codesSBRT Management and Delivery 77435 SStereotactici bbodyd radiationdi i therapy,htreatmentmanagement, per treatment course, to 1 or morelesions, including image guidance, entire course notto exceed 5 fractions 77373py, treatment Stereotactic bodyy radiation therapy,delivery, per fraction to 1 or more lesions, includingimage guidance, entire course not to exceed 5fractions22
Crosswalk CPT & HCPCS Codes forSRS & SBRTG0173Linear accelerator based stereotacticradiosurgery, complete course of therapy inone session77372Radiation treatment delivery, stereotacticradiosurgery (SRS), complete course oftreatment of cerebral lesions(s) consisting of 1session; linear accelerator basedG0251LinearacceleratorbasedLilt bd stereotactictt tiradiosurgery, delivery including collimatorchanges and custom plugging, fractionatedtreatment, all lesions, per session, maximumfive sessions per course of treatment77373Stereotacticbodytherapy, treatmentStt ti bd radiationdi tithtttdelivery, per fraction to one or more lesions,including image guidance, entire course not toexceed 5 fractionsG0339Image guided robotic linear acceleratorbased stereotactic radiosurgery, completecourse of therapy in one session or firstsession of fractionated treatment77373Stereotactic body radiation therapy, treatmentdelivery, per fraction to one or more lesions,including image guidance, entire course not toexceed 5 fractionsG0340Image guided robotic linear acceleratorbased stereotactic radiosurgery, deliveryincluding collimator changes and customplugging, fractionated treatment, all lesions,per session, second through fifth sessions,maximum 5 sessions per course of treatment77373Stereotactic body radiation therapy, treatmentdelivery, per fraction to one or more lesions,including image guidance, entire course not toexceed 5 fractionsG0243Multi-source photon stereotacticradiosurgery, delivery including collimatorchanges and custom plugging, completecourse of treatment, all lesions77371Radiation treatment delivery, stereotacticradiosurgery (SRS), complete course oftreatment of cerebral lesion(s) consisting of 1session; multi-source Cobalt 60 basedIndications for SBRT:“Check with your local contractor.” Inoperablepearlyy stageg lungg cancerRecurrent lung cancerPrimary liver cancerSecondary lung or liver cancerPancreasAdrenalRetroperitoneal tumorsSpinal and paraspinous tumorsOther recurrent23
Noridian LCD effective 1/1/10 “NAS covers primary and metastaticneoplasms of the lung,lung liver,liver kidney,kidney adrenal,adrenalpancreas, CNS, brain and spinal cord ”http://www.cms.hhs.gov/mcd/viewlcd.asp?lcd id 24363&lcd version 10&show all when and only when each of thefollowing criteria are met and specificallydocumented in the medical record:” Performance status justifies aggressive treatment Other forms of XRT including IMRT cannot be as safely or effectivelyutilized Tumor can be completely targeted with acceptable risk to OAR If germ cell or lymphoma, effective chemotherapy regimens are exhaustedor not feasible Other focal therapy such as RFA or cryo cannot be as safely or lcd.asp?lcd id 24363&lcd version 10&show all24
Key Assumptions Made whenSBRT Codes Were Created SBRT is a stand alone treatment,treatment not a boost after othertherapies No specific codes for: planning, simulation, medical radiationphysics, dosimetry, treatment devices, and special services Image guidance, respiratory motion management, etc. isincludedin the body SBRT is 1-5 fractions anywhereyy For radiation oncologist SRS is 1 fraction in the brain Radiation oncologist is present and participating during eachfractionRadiation Oncology Coding Basics Stereotactic Body Radiation Therapy (SBRT)SBRT CodesSBRT describesdib theh deliveryd lioff potent dosesdoff radiationdi iusing numerous carefully directed fields to extracranialsites.Treatment delivery (freestanding) 77373Treatment deliveryy(freestanding/hospital outpatient)Treatment delivery (hospitaloutpatient)Radiation treatment managementG0339,, G0340G0251774355025
Radiation Oncology Coding Basics Particle Beam TherapyParticle Beam Therapy CodesParticletherapyisoff conformalP ti l beambthi a formffl externaltlbeam radiation treatment.Proton treatment delivery77520,77522,77523,7752577422,77423Neutron beam treatment delivery Payment Policy Codes are technical only No physician work associated with them May only be reported by the facility delivering the treatment51Radiation Oncology Coding Basics BrachytherapyProcedure 76000-76001, 76872-76873,guidance76950,76965, 77002codes77012-77014Fluoroscopy ( 1hour)TRUSUS for RT fields, USfor interstitialFluoroscopy for needleplacementCT forf needledlplacement, CT for RTfields5226
Brachytherapy Treatment based on placement of radiationsources in the ppatient near or in the cancer Coding is based on: Intracavitary vs. interstitial Low-dose rate (LDR) vs. High-dose rate (HDR) LDR requires knowing the number of sources.i kknowingi theth numberb off channels.hl HDR requires Unique codes for surgical placement ofapplicator or device to receive the sources Guidance codes may be usedLDR Delivery Codes Depends on complexity DependsDd on locationli (cavity( i vs. interstitial)ii i l)InterstitialIntracavitary # 10Complex7777877763 1027
Other LDR codesSupervision andhandling, loading ofradiation source77790Surface applicationbrachytherapy77789Delivery HDR Irrespective of location UsesU channelshl ratherh thanh sources or 7871 channel2-12 channels 12 channels28
Insertion Codes 57155“afterloading expandable catheter (single ormultichannel) into the breast”“afterloading brachytherapy catheters(multiple tube and button type) into thebreast”“uterine tandem and/or vaginal ovoids”57156“vaginalvaginal radiation afterloading apparatusapparatus”58346“Heyman capsules”1929619298Insertion Codes 5587555876“needles or catheters into prostate, with orwithout cysto”“fiducial marker into prostate”29
Insertion Codes 31643“needles or catheters into muscle and/or softtissue”“bronchoscopy”41019“needles, catheters head and neck region”49327“interstitial device(s) into abdomen/pelvis”(fid i l )(e.g.,fiducials)“Stereotactic with burr holes into brain”205556177055920“pelvic organs and/or genitalia (exceptprostate)Brachy Codes Brachytherapy 77263, therapeutic radiology treatment planning, complex 77290/77295,77290/77295 therapeutic radiology simulation‐aided fieldsetting, complex/3D 77326‐77328, brachytherapy isodose plans, simple (1‐4sources), intermediate (5‐10) or complex ( 10) 77332‐77334, treatment devices 77300, basic radiation dosimetry calculation 77470, special treatment procedure Sources: depends on the setting Use Q3001 if done in physician’s office. Carrier priced Use source‐specific C code for facility setting. Priced by HOPPS Documentation Proper documentation is needed.6030
New Codes for 2012Intraoperative Radiation Therapy IORT management 77469 Intraoperative radiation treatmentmanagement IORT delivery 77424 Intraoperative radiation treatment delivery,X-ray,y, singleg treatment session 77424 Intraoperative radiation treatment delivery,electrons, single treatment sessionDiagnosis Coding – ICD-9International Classification of Diseases (ICD) Legislative mandate Social Security Act (SSA) 1842(p)(1),1842(p)(1) all Medicare claimssubmitted by a physician or practitioner shall include theappropriate ICD-9-CM code(s) Code structure – 3, 4, or 5 digits Must report to highest level of specificity. Diagnosis must be valid at the time procedure is performed. Reporting guidance Neoplasm ICD-9 codes 140 – 239 Electronic claims – provider can report up to 8 diagnoses Paper claims – provider can report up to 4 diagnoses6231
Radiation Oncology Coding Basics Diagnosis Coding – ICD-10 Oct. 1, 2013 conversion to ICD-10 Applies to ICD-9-CM and ICD-9-PCS CPT codes not affected Rationale for conversion Code set outdated No room to add new codes More compatible with electronic health records,provides greater detail Partial freeze of new codes implemented to assist intransition63October 1, 2011October 1, 2012October 1, 2013October 1, 2014Last regular,regular annual updates to both ICDICD-9-CM9 CMand ICD-10Only limited updates to both ICD-9-CM andICD-10 to capture new technology and newdiseasesOnly limited updates to ICD-10 to capture newtechnology and new diseasesRegular updates to ICD-10 will begin32
Radiation Oncology Coding Basics ICD-9 vs. ICD-10ComparisonNumber of codesICD-917,000 (approximately)Code structure – Length 3-5 charactersICD-10150,000 (approximately)3-7 charactersCode structure – Type of Digit 1 – alpha ordigitsnumericDigits 2-5 – numericLevel of detailDigit 1 – alphaDigits 2-3 – numericDigits 4-7 – alpha orinumericLimited space for adding Space for adding new codesnew codesLacks detailVery specificLateralityLacks lateralityCapacity to add codesHas laterality (i.e. right vs.65left)Radiation Oncology Coding Basics Crosswalk from ICD-9 to ICD-10ICD-9Code ICD-9 noma of skinof eyelid,including m ofprostateC61ICD-10 DescriptorMelanomalini situi off eyelid,lid includingi l dicanthus, unspecified sideMelanoma in situ of right eyelid, includingcanthusMelanoma in situ of left eyelid, includingcanthusMalignant melanoma of eyelid, includingcanthus, unspecified sideMalignant melanoma of right eyelid,including canthusMalignant melanoma of left eyelid,including canthusMalignant neoplasm of prostate6633
Correct Coding Tools ModifiersNCCI editsMUEsRAC Audits67Correct Coding Tools Modifiers General description Two-digit suffixes appended to CPT codes to indicateprocedure/service is changed due to extenuatingcircumstances Definition of procedure/service remains the same Modifiers explain to payers why the procedure/servicehas been altered May impact payment Documentation is important6834
Correct Coding Tools Modifiers Many physician diagnostic or therapeutic services may include both atechnical and professional component. Physician must only bill for the component provided. TC – Technical component Includes the equipment and technician performing the test Should not be used if service is 100% technical PC/26 – Professional component Interpretation of the test results Modifier used when the professional component is reportedseparately Global billing – no modifier Reported when both the TC and PC are provided in aphysician’s office, a freestanding imaging or radiationoncology center, or leased hospital radiology department69Correct Coding Tools Modifiers Other common RO modifiers 58 - Staged or related procedure or service bysame physician during the postoperative period 59 - Distinct procedural service 62 – Two surgeons 66 – SurgicalS i l team 76 – Repeat procedure by same physician7035
National Correct Coding Initiative NCCI Edits History In 1996, CMS developed NCCI to minimize impropercoding by stipulating procedures that are not normallyperformed together. Description Identifies procedures that cannot be performed togetheron the same day, on the same patient, by the sameprovider Types of edits “0” modifier not allowed to override edit “1” modifier allowed to override edit Ex: CPT code 77431 (radiation therapy management)(column 1) with CPT code 99239 (hospital discharge day)(column 2) has a modifier of 071Correct Coding Tools Medically Unlikely Edits (MUEs) Developed by CMS in 2007 to detect and deny unlikelyMedicare claims on a pre-payment basis. MUEs limit the number of units o
5-digitalphanumericcodedigit alphanumeric code Maintained by CMS Ex: A4648, Tissue marker, implantable, any type, each 7 Radiation Oncology Coding Basics Framework of RO coding - Process of Care 1 Consultation 2 Preparing for treatment 3 Medical radiation physics, dosimetry, treatment devices, and special services 4
