Industry News, January 2019

Palmetto GBA Fee Change for CPT® Code 77371

Palmetto GBA (MAC for AL, GA, TN, NC, SC, VA and WV) conducted a contractor price review of CPT® code 77371, Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based.  Contractor pricing applies for services under MPFS which Medicare allows each individual MAC to set pricing per their jurisdiction.  Per the review Palmetto GBA indicated there is no record of the code being paid under the JM (NC, SC, VA and WV) but is implementing changes to standardize pricing between JM and JJ contracts.  The fees will be updated within 30 days for claims with dates of service July 1, 2018 or after.


eviCore Updates Radiation Therapy Clinical Guidelines Effective March 1, 2019

Healthcare management company eviCore released updates to the Radiation Therapy Clinical Guidelines, effective March 1, 2019.  Releases include a redline version,  and clean version

Within the redline version there are many changes under the Proton Beam Therapy section.  For example, proton therapy for prostate cancer after prostatectomy is considered experimental, investigation or unproven (EIU).  Additionally, proton therapy is considered EIU when in combination with photon therapy for any tumor, for treatment of T1T2N0M0 laryngeal cancer, delivered in an ablative manner (i.e. SBRT) and for all other tumors.

It is recommended to review and be aware of the updates if eviCore is the healthcare management company employed by any of the commercial payers that a provider provides services to.

Palmetto GBA Identifies Denial Errors with Rituximab Due to Editing Issue

Palmetto GBA has identified an editing issue in which some claims with HCPCS codes J9311, Injection, rituximab 10 mg and hyaluronidase, and J9312, Injection, rituximab, 10 mg, for dates of service January 1, 2019 or after were denied incorrectly.  No action is needed, Palmetto GBA has updated the editing software and will adjust any affected claims.

CMS Releases Appropriate Use Criteria Fact Sheets

In preparation for the transition to Appropriate Use Criteria (AUC) for advanced diagnostic imaging, CMS released electronic version, and print friendly version,, fact sheets.

AUC will begin January 1, 2020 and will involve professionals ordering advanced diagnostic imaging (CT, MR and nuclear medicine, including PET) and the professionals and facilities rendering the imaging services.  In preparation providers are encouraged to familiarize themselves with AUC to ensure understanding and compliance.

CMS Re-Issues Guidance on Billing Date of Service on Professional Claims

CMS re-issued MLN Matters SE17023, Guidance on Billing Date of Service on Professional Claims, on January 24, 2019,  The transmittal does not include billing instructions for the individual services and does not present any new material, instead it reiterates current Medicare policy.  The transmittal addresses some, but not all, specialties and the billing date of service.  One of the specialties outlined is Radiology, it addresses billing date for testing services and the subsequent review and interpretation of the test by the physician.


January Coding Corner

Within this section, current topics will be the focus.  In some cases, the Q&A could reflect common questions received by Revenue Cycle Inc. and in other cases, represent current issues encountered by Revenue Cycle Inc. professionals.

Question:  We have a patient receiving chemotherapy over 30 minutes (9am-9:30am) through a syringe pump, is code 96409 the correct code?

Advice: Infusion codes are time based, not based on the method.  The correct code is 96413, Chemotherapy administration, intravenous infusion technique; up to 1 hour, single or initial substance/drug, since it is running over 15 minutes.  Code 96409 would apply to the initial chemo IV push.

Question:  Is it appropriate to charge 77290 when a patient is scanned for 2D planning (77307) for brain and IMRT (77301) for lung at the same time?

Advice:  Since this is all part of the same course and the IMRT is the higher-level charge and billed when planning on same date, then the simulation is not billable. The sim was used for both so it would be difficult to support only billing for 2D course.