83
Covered by pages 1-49
Carl Bogardus, Jr, MD
10:15 -10:45 AM
031114
Modified For 04-11-14

TOTAL CARE OF THE
RADIATION ONCOLOGY PATIENT
CLINICAL TREATMENT MANAGEMENT
1
The total care of the radiation oncology patient mandates direct clinical management by the radiation oncologist throughout the course of therapy.
It is the radiation oncologist’s role and responsibility to provide
supervision of treatment and handson, face-to-face patient care.

2
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Clinical Treatment Management starts with the acceptance of the patient for treatment.
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Clinical Treatment Management ends with the
Clinical End of Treatment report.
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Clinical Treatment Management is tied to 5 days of treatment delivery only as a convenient means of tracking time for billing purposes.

4
77427 Weekly Radiation Therapy Management,
5 fractions
77431 Radiation Therapy Management; Short course, 1 or
2 fractions
77432 Radiation Therapy Management; Stereotactic,
(SRS) 1 fraction
77435 – Radiation Therapy Management; SBRT, SRS, full course of therapy, up to a max of 5 fractions, (2007)
77469 - Radiation Therapy Management; Intraoperative.

4
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Professional billing relates to 5 fractions of therapy delivered, regardless of the number of elapsed calendar days and must be billed as 77427 X 1 per 5 FX block of treatments.
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The billing date for weekly management ,
77427, is usually the first day of each of the 5 day blocks.

NIB
Most of the Carriers want you to report this way
5 fractions equal one Week, bill first date of week

Historical Background
•It is imperative that each physician document their direct involvement in all of the procedures related to a week of treatment management.
•It is expected that each patient will have as many regularly spaced progress notes as there are weeks of treatments.
•The complexity and completeness of the note must reflect the complexity of care for the patient.
7

WEEKLY UNDER BEAM PROGRESS NOTES
Five Required Review Elements
The physician will be expected to have reviewed as many of these elements as are applicable to the current course of treatment management
It is extremely important that these five critical elements be covered in each note.
7
I Chart and dosimetry review
II Treatment setup and delivery review
III Port film or electronic image review
IV Under beam evaluation of the patient
V Recommendation of therapy

•The weekly progress note does not necessarily have to occur on the same day of each week, but for a course of therapy there should be an equal or greater number of progress notes than the weeks of management being billed.
8

Mon Tues Wed Thurs Fri
Week TX TX TX TX TX
1 NO PROGRESS NOTE WEEK 1
This causes problems with 77427
Week TX TX TX TX TX
2 PN
77427
Week TX TX TX TX TX
3 PN
77427
Week TX TX TX TX TX
4 PN
77427
9
A weekly note must occur sometime during each 5 day interval

Mon Tues Wed Thurs Fri
Week TX TX TX TX TX
1 PN Having a note on week 1 is crucial
77427
Week TX TX TX TX TX
2 PN
77427
9
Week
3 PN
77427
Week
TX TX TX TX TX
TX TX TX TX TX
4 PN
77427
Having a note on the last TX date is very important
PN
77427
EOT
A weekly note must occur sometime during each 5 day interval

9
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There is no written directive stating which day during the treatment week that the physician/patient encounter must occur.
There is no stipulation of the manner of interaction, only that it be “face to face”

Hall way Waiting room
Parking garage
9
Treatment console Treatment room Exam room
Which is a valid location for patient/physician encounter?

10
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At each encounter this patient had the opportunity ask question related to her course of treatment.
At each encounter the patient acknowledges her interaction with the physician.
At each encounter the physician has the opportunity to evaluate the patient’s general condition.
At each encounter the physician will use his best judgment to determine what is needed to evaluate response to treatment and radiation reactions
There is no written requirement related to length of time or location of the patient/physician encounter
As long as privacy concerns are met to the satisfaction of both the physician and the patient.
20/104

10
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The patient /physician encounter is only one of the 5 required elements of weekly management
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The weekly progress note is a document covering all aspects of patient care and management.
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Each of the 5 basic elements is further subdivided into many sub routines that require individual documentation

10
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The production of this supporting document does not need to coincide with the physical examination of the patient.
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It is customary done this way only as a general convenience, not a requirement

NIB Narrative on page 6
INITIAL EVALUATION DOSIMETRY TREATMENT IMAGING EXAMINATION
UNDER BEAM PROGRESS NOTES
CLINICAL END OF TREATMENT SUMMARY
The under beam progress note is a clinical weekly summary documenting the physician’s involvement in the weekly management of the patient
FOLLOW UP NOTES
Using the cascading
Information format, vital clinical and technical data may be transferred, discarded, or added to each new weekly document as it is created

Compliance and audits.
These are two words that most physicians and administrators really don't like to hear.
NIB
With cascading, elements of an E/M document will copy verbatim into subsequent documents .
Verbatim copying will cause cascading of old information into new encounter forms without any change.
Medicare considers that an identically copied note indicates that the physician was not actively involved in the creation of the new note.
Templating has HCFA considering severe penalties when they find large sections of notes that are 100% copies in subsequent workups.

All physicians and users should be very much aware of this potential problem.
NIB
They are well advised to carefully read any areas of their notes that are likely to change such as;
Chief Complaint,
HPI,
Physical Exam
Review of Systems
Medical decision-making
Other areas may also change.
Do not always use exactly the same time for every patient or type of encounter.

NIB
Compliance Warning, Cascaded Information

NIB
Original work up Six week follow-up

All that is really required is a quick review of the areas of a document where you
NIB know some changes have probably occurred based upon the patient's clinical findings and treatment parameters.
Document those changes in the record. If no changes have occurred, indicate that you have reviewed that section and it is truly unchanged from the previous work up.
EMRs make compliance very easy, but they also make auditing very easy.

NIB
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Any cascaded topic that has not been reviewed on a new document will clear upon save and record.
If the topic has been opened and any change has been made, then the changed topic and its questions and answers will be saved.
You may indicate “reviewed and save, no change needed”.

# 1--Chart & Dosimetry Review 15
•Verification of correct summation of dose
•Verify that time and/or monitor units are correct .
•Stop or re-evaluation points are clearly indicated .
•The correct modalities of treatment are indicated .
•The correct beam energy is indicated.
•Proper beam modifiers are in place.
•Tumor dose is compared to the tolerance dose of critical tissues.
•Critical tissue dose points are carried
•The number of treatment volumes is correct .
•The number of ports is correct.
Document of the first day of treatment with the first under beam note

#2 Treatment Setup & Positioning
Evaluation
15
It is understood that it is impossible for the physician to be physically present during each and every setup, but the physician should be readily available for corrective action should the need arise.
Document of the first day of treatment with the first under beam note

# 3--Portal Film Review for
Imaging
Radiographic films or electronic or portal imaging studies are taken at regular intervals of all of the portals being treated.
16

# 4--UNDER BEAM 16
EVALUATION PROGRESS NOTE
Examination of the patient consists of clinical evaluation, assessment of tumor response, and case management.
The radiation oncologist should physically examine the patient each week for treatment related side effects, and tumor response.

Under Beam Examination
Every patient under treatment, without exception, should be seen and examined at least once per week
.
This is a key element of the weekly note. The PA can do much of the work, but the physician must be involved
17

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17

17
Many factors make up a weekly progress note, the use of multiple choice questions with many choices of answers, makes each note unique and reduces the appearance of “macro copying”

Pages 17 to 20 give a short summary of the needed elements to make up a compliant progress note.
You should follow these guide lines to format the content of your notes.
NIB

UNDER BEAM PROGRESS NOTE 21
Every progress note should have the basic demographic information about the patient.

21
History of Present Illness
A very short version of the patient's present illness should be presented limited to only a few sentences summarizing the case to-date.

22
Current Treatment
Parameters
Area(s) under treatment
Energy/mode
Evaluation of appropriateness and accuracy of all Treatment
Devices
Current dosage
Planned dosage
Critical structure dosage
Microdosimetry as done
Any corrective action as required

A weekly review of technical factors is
22 required, once entered, this component usually will not vary week to week, if any factors change, then the note must reflect the changes

Physical Examination
Constitutional
General appearance
Examination of area under treatment must always be included
Examination of other areas as needed
23

Current Status of any
Treatment Reactions
Skin reactions
GI reactions
Oral cavity reactions
Hematologic profile
Present weight as related to previous weight
24

Tumor Response
24
Indicate any changes from previous work-up
Significant or subtle changes in tumor size
Expected response at current dose level

Pain Assessment and Management
See Section 3
Page 8
•Full assessment of pain
•Medications and corrective actions
•Order and document medications
•Print prescriptions
•Maintain a compliant list of all medications and prescriptions.
ONCOCHART

#5 Recommendation of
Treatment
• Patient to continue therapy
• Patient placed on hold – state the reason
• Treatment requires modification
• Patient has completed the course of treatment
•THIS MUST BE COMPLETED BY
THE PHYSICIAN EACH WEEK, NO
OTHER PERSON CAN MAKE THIS
DECISION.
25

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With electronic records, Clinical
Physician Orders have been made much easier to deal with.
Multiple paper forms are eliminated
Orders can be tailored to fit the case
Orders can be sent electronically
25

Physician work
25 page has all the common procedures that require orders.
This can be initiated by any authorized person in the department
A narrative is produced which can be sent electronically, faxed, or printed
ONCOCHART
THIS IS A MEANINGFUL USE REQUIREMENT

Electronic record of physician order for medication dispensed by nursing staff and signed off by physician.
Compliant with JCAHO and Meaningful Use.

Clinical comment regarding Current
Status
• This is a brief narrative summary of a review of any of the preceding elements that show significant change, or new developments of importance to the care of the patient.
26
ONCOCHART

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Coordination of Care
•Routine progress notes should be sent to the patient’s other physicians to keep them informed of the case under treatment.
26

Physician Demographics
•Every progress note should conclude with a signature of the physician of record and indication of copies to other physicians or charts.
•Electronic signature is acceptable if original signature is on file.
26

27

NIB
THIS NOTE DOES NOT MEET MEANINGFUL
USE, WHICH IS NOW REQUIRED
This check off note just barely will suffice as a valid progress note. Demographics, vitals, dose, and some recommendation of therapy are noted, but the rest is almost unintelligible, and far too brief, with many key elements missing, such as a legible signature and physician name.

NIB
This weekly under beam note is also marginal in terms of useful data, and does not meet compliance requirements.

Electronically Generated
Progress Notes are Preferable
NIB
NIB

Clinical end of treatment summary.
The clinical end of treatment summary is a non reimbursable procedure, but is absolutely necessary to indicate the termination of the course of radiation treatment.
This document should contain sufficient information to allow the requesting physician, or any other physician involved in the care of the case to fully understand the course of treatment that was just completed.

Transition of care
If you are attesting for meaningful use a transition of care record is required, but it is also very good clinical practice.
The transition of care record, combined with an end of treatment summary allows you to transfer a great deal of meaningful information to the referring physician for their continued care of the patient.

Transition of Care Document

Weekly Treatment Management
77427
27
What’s it for?
The physician’s ongoing clinical care during a course of therapy.
Who normally documents/bills/captures this code?
The physician.
What Documentation is suggested for this code?
A weekly progress note (every 5 fractions) by the physician
What are the common documentation errors with this code?
Inadequate amount of information in the weekly notes.
Missing progress notes for the given number of fractions.
What are the common billing errors identified?
Billing this code based only on the number of fractions without adequate documentation (progress notes) existing in the record.
BID therapy requires a progress note every 5 fractions (2 ½ calendar days)

FIBEROPTIC ENDOSCOPY
PROCEDURE CPT 31575
28

Typical format of endoscopy report 29
FIBEROPTIC ENDOSCOPY
This patient is currently being treated for a T1, N0, M0, squamous cell carcinoma of the right true vocal cord. The patient has just completed his third week of radiation therapy. He is currently being treated at 180 cGy per day and is currently at 2700 cGy
Procedure: Utilizing a premedication of Pontocaine and Epinephrine applied through nasal atomizer into the right nares, the fiberoptic endoscope was inserted without difficulty. The nasal vestibule and nasal passages were carefully evaluated and found to be unchanged from the previous examination of two weeks ago. The endoscope was advanced further and the nasopharynx was clearly visualized. Both eustachian orifices were clear. A mild amount of dried secretion was noted along the posterior pharyngeal wall. None of this appears to be significant. There is a mild injection of the mucosa of the nasopharynx but no abnormalities were noted.
The endoscope was then advanced further and the hypopharynx and base of the tongue area were carefully evaluated and found to be unchanged from previous evaluations. The endoscope was then advanced into the region of the larynx. The epiglottis was noted to be symmetrical and without lesions. A moderate amount of mucositis is beginning to develop in the area of the larynx. This is most noticeable along the base of the epiglottis.
Laryngeal ventricles are completely within normal limits. Pyriform sinuses are within normal limits. The false cords are beginning to show a very light edema. There is a moderate amount of mucositis throughout the perilaryngeal area.
The vocal cords move well and oppose midline. The lesion that was previously noted along the anterior aspect of the right cord is beginning to decrease in size. There is a white membrane that has formed along the area of the right anterior cord primarily in the region of the tumor. There is no membrane formation on the left cord.
The procedure was terminated without difficulty.
Impression: Expected response at three weeks of therapy with beginning resolution of tumor.
Recommendation: The patient will continue on the planed course of radiation therapy without modification.
C.R. Bogardus, Jr., M.D./nz
MAY BE REPORTED DURING AN ACTIVE COURSE OF TREATMENT
ONCOCHART

77417 Therapeutic radiology port Film(s)
30
Port films are taken on the treatment machine using the treatment beam to ensure that the treatment setup is as
prescribed by the simulation and dosimetry.
Any changes indicated by the port films must be corrected or incorporated into the treatment plan.
For coding purposes, real-time or on-line portal imaging is the same as obtaining port films.
The technical component (i.e. the costs associated with
generating port films) is reportable using code 77417.
70/104

Conformal Treatment Management
•Conformal radiation therapy treatment management (3-D designed) consists of clinical management of custom designed and blocked treatment portals, directed to a treatment volume of interest.
34
•3-D Conformal management (not
SRS, or SBRT) is to be reported using code 77427

34
• This code is to be utilized when only 1 fraction makes up the entire course of treatment management.
• All management codes are mutually exclusive per course of therapy

77431 Short Course of Clinical
Treatment Management
•This code is to be utilized when only 1 or 2 fractions make up the entire course of treatment management.
35
•Note: This code may not be used to be reimbursed for the remaining one or two treatments at the end of a long course of therapy (ACR, 2001).
77/104

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Most commonly done following major bone trauma
36
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Single treatment of 6 to 8 Gy
All procedures done on one day.
Consult, treatment planning, simulation, blocks, dosimetry, and treatment
ICD-9 code 728.13 or V-07.8

36
HETROTROPHIC BONE PREVENTION POST OPERATIVE

Short Course of Clinical
39
Treatment Management 77431
What is this code for?
The physician’s clinical care during a short course of only 1 or 2 fractions.
Who normally documents this code?
The physician.
When is this code normally billed?
The last day of the short course.
What Documentation is needed for this code?
A progress note outlining the short course of therapy.
What are the common documentation errors identified with this code?
No physician’s note being documented.
What are the common billing errors identified?
Billing this code with Brachytherapy, this is only for external beam patients.
Do not report for 1 or 2 leftover fractions of at the end of a long course of therapy.

41
85/104

Chemotherapy with Radiation Treatments
• Chemotherapy, or the use of drugs to treat cancer, is a concept that has been with us for over 40 years.
• In the beginning, the drugs were extremely toxic, and relatively ineffective.
• New drugs have been perfected which are highly disease selective.
• There are many drugs in use today that target specific cell lines of malignancy.
• Some of these drugs are used alone, others are used in combination, and others are used in conjunction with radiation therapy.
41

•Almost all of the chemotherapeutic agents are highly toxic and create various medical problems for the patient in addition to their beneficial effects against the malignancy.
41
•The beneficial effects of these drugs usually will out weigh the toxic side effects, and for this reason chemotherapy plays a very important role in the overall management scheme of patients with malignancy.

•When chemotherapy is used, the acute and long- term effects, must be taken into account by the
41 radiation oncologist.
•Patients receiving chemotherapy tend to be sicker and require closer and more careful attention
•The treatment planning and treatment management of the course of therapy will always be complex. This will be true even in what otherwise, would have been a simple case.
88/104

)
Special Treatment Procedure 77470
42
77470 Special treatment procedure (e.g. total body irradiation, hemibody irradiation, per oral endo-cavitary or intra-operative cone irradiation)
This code covers the additional physician effort and work required for the special procedures of, total body irradiation, hemibody irradiation, intracavitary cone use, Brachytherapy, hyperthermia, concurrent chemotherapy , radiation response modifiers, stereotactic radiosurgery (single fraction or fractionated), intra-operative radiation therapy, 3-
D CRT, IMRT (removed 2012 ) , heavy particles (e.g. protons/neutrons), and any other special timeconsuming and complex treatment procedure.

The code 77470, is designated to cover the additional time and effort required of the physician and the hospital technical staff while performing and/or managing special treatment
situations.
42
This code may be reported only one time per course of therapy.
77470 IS A GLOBAL BILLLING CODE

43
Note the many different indications for reporting the special treatment procedure, 77470
SPECIAL TREATMENT PROCEDURE WORKPAGE
ONCOCHART

Can anything better exemplify special treatment procedure than pediatric anesthesia?
NIB

A narrative note is absolutely necessary as the backup documentation for 77470. Simply including a line in a weekly progress note is not sufficient documentation to justify the billing of this code. The reasons are all here, just make certain that they are verbalized.

Special Procedure Note
This patient has just completed three months of multi-drug chemotherapy by Dr. Ishmael. We have been watching the patient over the last few weeks as the counts have slowly risen to a respectable level. The patient now has 4500 WBC's and 217,000 platelets. Patient still has marked alopecia from the chemotherapy.
Considerable time was spent this morning with the patient and the patient's family explaining the possibility of continued, severe, interactions between the radiation and the just completed course of chemotherapy. It is anticipated that the patient will be experiencing a marked increase in skin reactions because of the course of Adriamycin. The treatment portals will be close to the heart, but every effort will be made to avoid treating any of the myocardium. The patient and the patient's family do understand the possibility of severe reactions and difficulties that will probably be experienced during the forthcoming course of radiation treatments.
The course of radiation therapy over the next six weeks will be carefully coordinated with Dr.
Ishmael. Dr. Ishmael will be available to handle any medical problems that may arise during this period of time. We will be observing the patient on a daily basis during the first part of the course of treatment to make certain that reactions are not excessive.
The patient and the patient's family fully understand that the treatments are absolutely necessary but that the patient will experience considerable discomfort and other interrelated problems during the next few weeks.
Carl R. Bogardus, Jr., M.D.
92/104 ONCOCHART
43

Multiple reasons for 77470

44
What’s it for?
The additional effort involved in caring for patients under highly complex circumstances.
Who normally documents this code?
Varies widely, but usually the physician.
When is this code normally billed?
Upfront at the same time as the physician’s clinical treatment planning.
What Documentation is suggested for this code?
A physician narrative explaining medical necessity.
What is the common documentation error identified with this code?
Not documenting the code with a separate written document.
What are the common billing errors identified?
Missing the code due to inadequate documentation of the procedure.
There is no “physical” event to trigger billing, it must be recognized by circumstances.
SP89/104

46
If the patient is a Medicare recipient and becomes hospitalized as an inpatient, but being transported to a freestanding center each day for treatment, then the patient must be billed as an inpatient, not as an outpatient .
Most freestanding centers have contracts with hospitals to cover these situations.
Hospital owned departments make these corrections internally.

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
Covered by codes 77600 to
77620
Payment value of coverage of treatment by negotiation with local insurance carriers
46
77600 – 77620 ARE GLOBAL BILLING CODES
99/104

BSD Phased Array hyperthermia unit
48

HYPERTHERMIA ISOTHERMIC PLAN
NIB

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Only the Hyperthermia delivery codes are specific to Hyperthermia.
77600 Superficial up to 4 cm depth
77605 Deep over 4 cm in depth
77610 Probes (interstitial) 5 or less probes
77615 Probes (interstitial) 6 or more probes
77620 Probes ( intracavitary) any number
New codes were planned for 2009
49

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77263 Complex treatment planning
77470 Special treatment procedure
77290 Initial set up simulation
77280 Subsequent simulations same area
77305 Isothermic plan, superficial
77310 Isothermic plan deep one port
77315 Isothermic plan deep, multiple ports
77295 Isothermic plan, 3-D planning
49
77326 Isothermic plan interstitial up to 4 probes
77327 Isothermic plan interstitial, 5-10 probes
77328 Isothermic plan interstitial, over 10 probes
77328 Isothermic plan intracavitary
77300 Basic Dosimetry for heating time calculations
77300 Calculation of areas of maximal or minimal heating

BMSi 2014
END 11

7
MEDICARE (CMS), 2010, REQUIRES
 There shall be a full-time physician, preferably a radiation oncologist, per facility, physically available on a daily basis for direct supervision of daily treatment, and management of any patient related treatment problems.

The 5 elements of weekly management must be documented by this physician for each week of treatment.

For billing radiation treatment management, 77427, Medicare expects the radiation oncologist to bill the weekly management
11 code for the management related to five consecutive treatment delivery sessions and to have seen the patient at least once during that time period. The actual visit could occur anytime during that time period.

R128BP page 13

Assessment of Quality of Life
23
Pain
Ambulation
Social interactions
Memory
Generally done by the nursing staff but must be reviewed by the physician
Psycho-social adjustment
Nutritional status should always be mentioned as related to present weight
Physician/patient self assessment of Q of L
51/104

Review of Portal Images
• Review of current portal films or images
• Comparison with previous portal films or images
• Comparison with simulation films or images
• Comparison with appropriate diagnostic imaging
• Corrective action if necessary
• Review of corrected portal films or images
•Indicate if films not required (electrons, superficial)
31
ONCOCHART

Total Body or Hemi body
Radiation Therapy
37
Total or hemi body therapy is an extremely complex procedure requiring a great deal of physician input, often requiring special testing, consultations, and physics evaluations.
When only one or two treatments are given for the entire course of therapy, you should bill short course of treatment management 77431.
80/104

Valid charges for total body radiation therapy
992XX High Complexity Evaluation
38
77263 Therapeutic Radiology Treatment Planning; Complex
77290 Therapeutic Radiology Simulation; Complex
Simulation may be repeated on different days during the initial setup procedures.
77300 Basic Radiation Dosimetry Calculation
This may be calculated on many occasions. This may be reported as many times as performed and
Documented.
77321 Special Teletherapy Port Plan (Electrons, if used)
77336 Continuing Medical Physics Support, 1 charged for 1 to 5 fractions.
77370 Special Medical Radiation Physics Consultation
As Requested By the radiation oncologist.
Usually only 1 of these would be required for a total body course of treatment.

77331 Special Dosimetry (TLD or Diode Microdosimetry) measured dose points.
77334 Special Shields Special shields for the lungs may be
38
This may be billed as often as requested to cover all constructed.
77427 Weekly Megavoltage Treatment Management –22 ,
If over 2 treatments given, Modifier –22 is used to increase the billed value.
77431 Short Course Clinical Treatment Management -22
Modifier –22 may be used to increase the value of this code.
77417 Port Films, 1 charge is allowed per week (5 fractions) of treatment.
77470 Special Treatment Procedure -22 Modifier –22 may be used for a one-time charge for the special treatment procedure.

Review of Laboratory Data (page 18-19)
Laboratory tests, should be discussed and summarized
Comparison to previous laboratory work
Indicate corrective actions if necessary
Ordering of any new testing as required
Review of Diagnostic Imaging
Studies ( page 19)
Compare with previous imaging studies
Compare with current portal films if indicated
Ordering of any new testing or imaging as required



Decrease number of slides
Clean up wording

On March 2009 the National Government
Services, a CMS contracting agent "clarified" the proper reporting of 77427. This is reported in the Medicare Claims processing manual (100-04), Chapter 13, Section.1.
NIB
In the event that five fractions occur in two different calendar months or years, the billing "from and to" dates should reflect the month in which the most fractions were performed .

“Clarified” method of Billing
Orphaned date Orphaned date
Week Mgmt
Bill first date of “clarified” week
3 Fractions make up this week

This makes the billing more difficult NIB
Orphaned date Orphaned date Week Mgmt
We then return to a conventional 5 day week but what do we do with the 2 orphaned dates?

Even More Difficult with 2 days in each
Crossing Segment
NIB
Which set has the week of management billed, and if only 2 fractions make up the end of a course, you cannot bill a week of management, so do we loose the last week of 77427 management billing?????

Summary of R128BP page 13

The Physician direct supervision requirements are required if the services are performed within a hospital, the physician must be within the hospital, but not necessarily in the radiation therapy department, this has been clearly stated by CMS in the ruling of April 7, 2000

NIB

NIB
This illogical scheme of reporting will make billing and auditing very difficult for no rational purpose. I recall this same proposal about the year 1991 as the code 77427 was brought into use. This was soon changed to ignore the monthly crossing recommendation as being far too difficult to bill and audit.
If your carrier is forcing you to use this method, you should protest

Summary of R128BP page 13

If the hospital owned radiation therapy department is not physically located within, or connected to, the hospital, i.e., a free standing center then the physician must be
“Interruptible” and able to intervene
“right away” when Medicare patients are being treated .

Free standing, non hospital owned centers are subject to this requirement

DRR
31
PORTAL
IMAGE
BLENDED IMAGES
72/104
PORTAL-VISION IMAGES (ARIA-VARIAN)

5

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There are 523 DRG Codes
Code 409 is the only DRG with radiation therapy
409 is defined as concomitant chemotherapy and radiation therapy during the admission
DRG codes do not include additional reimbursement for radiation therapy
This is why you are discouraged from starting therapy while a hospital inpatient
45

Clinical Treatment Management does not cease for nights,
2 holidays, week ends, or any other time of non active treatment delivery
The physician remains responsible for clinical management as long as the patient is under your direct care.

•The original three levels of complexity descriptors for treatment management were formulated in the early 1970’s.
•The term “treatment management” was used to describe both the supervision of treatment delivery and the clinical management of the patient.
2

• In the Fall of 1990, AMA-CPT requested that the ACR and ASTRO CPT Committees work to devise a weekly treatment management system that could identify physician procedures performed, and their complex interactions.
•The ACR recommended that the AMA-
CPT adopt the new code 77427 weekly treatment management, effective Jan 1,
1991, we have had this code for 21 years, and many physicians still have problems documenting it’s use.
3

3

11
Medicare is tightening the availability rules as part of the “Revised Incident To” ruling of Jan 1, 2009, April 7, 2009, April 1,
2010.
Commercial carriers are also beginning to pay very close attention to physician availability.
25/104

NIB
Check your local carrier if in doubt about coverage, especially in rural areas of limited medical accessibility

•General supervision means the procedure is furnished under the physician’s overall direction and control, but the physician’s presence is not required during the performance of the procedure. ISODOSE PLAN, BLOCKS,
DOSIMETRY
12
•Direct supervision in the office setting means the physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed. TREATMENT DELIVERY
•Personal supervision means a physician must be in attendance in the room during the performance of the procedure. SIMULATION, PATIENT EXAMINATION

The Radiation Oncologist (CMS 2010
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 There shall be a full-time radiation oncologist per facility ( Hospital out patient or Free standing center) immediately available, interruptible , and able to furnish assistance and
direction throughout the procedure.
 The attending physician or a responsible physician ( Ideally
THIS PHYSICIAN SHOULD BE A
RADIATION ONCOLOGIST) attendance must be either in direct or reasonably accessible during the time that radiation treatments are being delivered.
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Summary of R128BP page 13
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The CMS requirements clearly state that if the responsible physician leaves a free standing center, even to go to the hospital, then all
Medicare related services must stop unless coverage is provides
The 15 minute exclusion is not mentioned, as this was only a concession to ACR many years ago and never became part of CMS policy

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A Medical Oncologist who has been credentialed to cover daily treatment delivery patient care,
Who is working in the same clinic,
Who is interruptible and able to respond “Right away”
-Q5 Services provided by a substitute physician

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If a physician is unavailable for one week (5 treatments) then the physician who is covering will be the Physician of
Record and the Week of Management must be billed under his name.
The only exception is for locum tenens coverage where the billing remains in the original physician’s name.

Covered in section 3 page 8
This is the token, a random number generator used to verify electronic narcotic prescribing.

NIB
New DEA controlled drug requirements
DEA regulations require a pharmacy to receive a new valid signed prescription.
DEA has further stated that a pharmacy may not provide a partially or fully pre-populated form for the prescribing practitioner.
The physician may either fax narcotic prescriptions or send electronically if pharmacy has the capability.

•The review and interpretation of port films is considered as part of the weekly clinical treatment management by the physician.
•IMRT, Electron or Kilovoltage treatment may not produce port films.
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•Weekly orthogonal images for
IMRT setup may be billed as port films

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By law, Medicare stipulates that the technical component of inpatient radiation therapy must be included as part of the DRG of the admission

Skilled Nursing Facility
Patients admitted to a skilled nursing facility (SNF) under the part A benefit or a
Medicare part A stay are considered to be hospital inpatients, and as such are covered under a specific DRG of admission.
Treatment of these patients requires the technical component of treatment to be billed to the SNF, not Part B.
This may not apply to private insurance
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SP98/104

Notice, the weekly management is being billed on the 1st date of each five-day treatment interval NIB
The progress notes are occurring regularly on
Monday regardless of the elapsed number of treatments

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What’s is this code for?
Weekly Port Film or Electronic Portal Imaging.
Who normally documents/bills/captures this code?
Treatment Therapist.
When is this code normally billed?
One time per five fractions, regardless of how many images are taken.
What Documentation is suggested for this code?
A notation in the chart that portal images were taken, and if any corrective action was needed.
What are the common documentation errors identified.
The lack of physician participation in the documentation.
What are the common billing errors identified?
Billing an incorrect number of units.
Billing these images professionally (they are technical only).

NIB

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