OBJECTIVES
PROFESSIONAL SYMPOSIUM
PROFESSIONAL ECONOMICS UPDATE
James Goodwin
Lena Lamel
To understand the major reimbursement systems and
how payment rates are established
To understand the CPT®
CPT® coding system and the need
for proper documentation in the clinic
To identify authoritative sources of reimbursement and
coding information
To learn about AAPM PEC activities and how they
benefit the membership
Reimbursement Mechanisms
Physics Reimbursement
An Overview
James Goodwin, M.S.
Fletcher Allen Health Care
Burlington VT 05401
CPT®
CPT® Codes
PEC Activities
Radiation Oncology/Medical Physics
Where does the money come from?
Reimbursement Mechanisms
Centers For Medicare and Medicaid
Services (CMS)
Medicare:
Part A:
Part B:
Part C:
Part D:
Government Programs: Medicare, Medicaid,
other state programs
Private Insurers
HMO, PPO organizations
Patients
Charity
Major Payment Systems
Medicare Part A: Hospitals
Hospital Services
Physician Services, Free Standing Centers
Managed Care
Prescription Drugs
Hospital Outpatient Payment System (HOPPS)
(HOPPS)
Inpatient Prospective Payment System (IPPS)
Medicare Part B: Physicians, Free Standing
Centers
Medicare Physician Fee Schedule (MPFS)
Ambulatory Surgical Centers (ASC)
Medicare is administered through local carriers
Medicare Fiscal Intermediaries (FI) → Medicare
Administrator Contractors (MAC)
Carriers directed by:
Carrier Medical Director (CMD)
Carrier Advisory Committee (CAC)
Payment policies = Local Coverage
Determinations (LCD)
(LCD)
Two Components of Reimbursement
“Professional”
Professional” = Physician
“Technical”
Technical” = everything else
Equipment, supplies
NonNon-physician labor (physicists)
“Global”
Global” includes both components
CMS gives local carriers guidance
CMS can issue National Coverage
Determinations (NCD)
Carriers will not always be consistent.
Payment is local!
How are reimbursement levels determined?
Hospital (Hopps) ≠ Physician (MPFS)
Both: Charged Based → Cost Based
Hospital (Medicare Part A)
Inpatient: Diagnostic Related Groups (DRG)
APC values based are on hospital costs
Based on primary diagnosis
Cost = charge x (cost to charge ratio)
Outpatient (HOPPS): Ambulatory Payment
Classifications (APC)
Groupings of CPT®
CPT® codes based on financial and
resource homogeneity
costs are modified by: economic indexes,
professional society input
Problems: 2 year lag
hospital billing accuracy
limited data
Physician and Free Standing
(Medicare Part B)
Relative value system is based on actual practice
expenses
PC: RVUTOT = RVUPW + RVUPE + RVUMI
TC: RVUTOT =
PW = Physician work
RVUPE + RVUMI
PE = Practice Expense
MI = Malpractice Insurance
Practice Expense = Direct (physics) and Indirect
Payment = RVUTOT x CONVERSION FACTOR
CF includes: Deficit Reduction Act (DRA)
Sustainable Growth Rate (SGR)
Budget Neutrality
Can be modified by Congress
RVU Valuation
Relative Value Scale Update Committee (RUC)
assisted by: RUC Advisory Committee
Health Care Professional Advisory
Committee (HCPAC)
Practice Expense Advisory Committee
Reimbursement Threats
Reimbursement levels
Code bundling/packaging
Trend towards Inpatient (DRG) type system
CMS Coding Systems
Healthcare Common Procedure Coding System
(HCPCS)
Coding
Level I:
CPT®
CPT® Codes (AMA)
Level II:
Products, supplies (brachy
(brachy sources),
other services
Internal Classification of Diseases (ICD(ICD-9)
CPT® Codes
Category I:
Category II:
Category III:
procedures and services
tracking codes
new, emerging technology
Codes are maintained by CPT Editorial Board and CPT
Advisory Committee. Are updated yearly.
Process for change: SLOW!!!!!
Rad Onc CPT® Codes
77XXX codes:
Treatment planning (simulation)
Medical Physics/Dosimetry/Device/Special Services
77336 Continuing Medical Physics Consultation …
77370 Special Medical Physics Consultation
Stereotactic
Treatment Delivery
Neutron, Proton
Treatment Management
Hyperthermia
Brachytherapy
Unlisted Procedures 77X99
Coding Complications
Other CPT®
CPT® Codes:
Surgical procedure codes
Radiology imaging codes
Modifiers
Explain extenuating curcumstances
Category III CPT®
CPT® Codes:
compensator based IMRT
electronic brachytherapy
Other HCPCS Codes
stereotactic
brachytherapy sources
National Current Coding Initiative (NCCI)
(NCCI)
Stipulate codes that can’
can’t be charged together
Medically Unlikely Edits (MUE)
(MUE)
Limits on # of units
Sources of Coding Information
ASTRO/ACR Guide
CPT®
CPT® Manual and CPT®
CPT® Assistant
CMS website
Medicare info: manuals, transmittals
NCCI edits
HCPCS codes
ACR Coding Source
ACR, ASTRO coding advisory services
ASTROgrams
AAPM PEC
Private coding consultants
AAPM Professional Economics Committee
Chair: Jim Goodwin
Vice chair: Lena Lamel
Consultant: Wendy Smith Fuss
Responsibilities:
Analysis and response to CMS PRM’
PRM’s
Support of ASTRO and ACR with RUC and CMS
Review of regulatory and legislative actions
Member assistance
PEC Activities