I recently boasted that those involved in Radiation Oncology billing are Olympians. My references were brief, so I thought it timely to provide a more in depth look at a few of the common coding situations that can be challenging to master.
Event #1: The 90-day Global period rule. For years government and commercial payers have insisted that “routine” follow up care (E and M service) provided to patients within 90 days of their radiation therapy course is considered a non-reimbursable charge.
A recent review of the CMS fee schedule shows this rule applicable to only these Rad/Onc codes: 77750, 77761-77763, 77776-77778. Does this mean, they have changed their mind and will pay E and M services within 90 days of EBRT? It might be worth contacting your local MAC, state Medicaid office and your large commercial payers for clarification. Since each patient has at least one follow up visit in this timeframe, this could add up to significant added revenue.
If your research finds that the payers are not budging on this policy, remember the rule is for routine follow up. It is quite common for a patient to return during the “global period” with a new problem that requires immediate treatment. In this instance, the documentation must be explicit that it is a new treatment area and unrelated to the previous course of treatment. You will then append a -24 modifier to the E and M service which will indicate this status to the payer this status. Payer policies may require medical records, but you will already have that covered.
Event #2: 77427, to add date span or to not add date span, that is the question. As most billers know, the only thing that is consistent in medical billing is payer inconsistency. In Radiation Oncology, we have payers that want only the ”from” date submitted for 77427 and a billing note with the date span and # of fractions listed. Then some do not require the note at all. Others, want both the “from” and “to” dates. The most complicated are the payers that will not pay 77427 if the claim date spans different months or years… what a headache. It is imperative to know what they want and give it to them.
Iridium Suite Practice Management Software has a built in claim “scrubber” rule that you can enable to advise if you are submitting a code within the 90 day global period. It also has several rules that can be customized and assigned to specific payers that can assist you in meeting special 77427 billing requirements.
Event #3: Medically Unlikely Edits (MUEs) and billing multiple units. Briefly an MUE is an automated claim processing edit that compares the number of units submitted for a procedure code against the designated maximum units that are typically reported for that code on the vast majority of appropriately reported claims. The edit is applied to services billed by a single provider/supplier to a single beneficiary on the same date of service.
Common Rad/Onc codes that are billed with multiple units are 77332-77334, 77300, and 77331. You can access the MUE values on the CMS website. Some MUE values are confidential and may not be published. Other payers may have their own MUE type payment policies that should be researched thoroughly to prevent denials and under payments.
2XEvent #4: Billing for “BID” treatments. Many complicated Head and Neck cancers require that patients receive therapy twice a day. This means “repeating” the same procedure at a different session, such as IGRT (CPT code 77421). Breast brachytherapy is also performed twice a day so some codes like 77290 are done at each session. Appending a -76 modifier on the second unit performed advises the payer that this was a separate service, not a duplicate entry.
I could fill many more pages with the trials and tribulations of Radiation Oncology billing. Instead, please follow this link to the Education Section of our website, www.iridiumsuite.com. You will find helpful sections such as: Billers Blog, Forums, Infographics, White Papers andeBooks. These resources are all there to assist you in the Olympic-size challenge of Radiation Oncology Medical Billing.