Industry News, January 2021

The summary of events and newsworthy items for the month of January is provided on the following pages.  In most instances, the link to the full document of information is provided.  Any of the contents may be further discussed by reaching out to Revenue Cycle Coding Strategies LLC.

OIG to Conduct Audits of Telehealth Services During the PHE

The public health emergency (PHE) has brought the temporary expansion of telehealth services to provide care for Medicare beneficiaries during the COVID-19 pandemic. The Office of Inspector General (OIG) will be conducting a series of audits of Medicare Part B telehealth services to explore how telehealth services can be expanded beyond the PHE.  The audit will be conducted in two phases with phase one focusing on whether services such as evaluation and management, opioid use order, end-stage renal disease and psychotherapy meet Medicare requirements. The second phase will focus on reviewing if Medicare requirements are being met for services related to distant and originating site locations, virtual check-in services, electronic visits, remote patient monitoring, use of telehealth technology and annual wellness visits. More information can be located on the OIG website.

IMRT Comparative Billing Report

The Center for Medicare and Medicaid Services (CMS) will be issuing Comparative Billing Reports (CBRs) on Part B claims for intensity-modulated radiation therapy (IMRT). CBRs are free, comparative data reports CMS utilizes as an educational resource and tool for possible improvement. CBRs can prove to be useful to providers by reflecting billing patterns as comparted to their peers, providing specific coding guidelines and billing information, and inform providers whose billing patterns differ from those of their peers. CBRs cannot be viewed by the public, CMS directs providers to email to access your report. More information regarding the IMRT CBR:

  • View a webinar recording
  • Visit the CBR website
  • Register for a live webinar on February 10 at 1pm ET

IVIG Demonstration Extended

As part of the Consolidated Appropriations Act, 2021, the Intravenous Immune Globulin (IVIG) Demonstration, which was slated to end December 31, 2020, will be extended through December 31, 2023. The IVIG Demonstration’s purpose is to evaluate the benefits of providing payment and items for services needed for the in-home administration of intravenous immune globulin for the treatment of primary immune deficiency disease (PIDD).  New beneficiaries can continue to enroll in accordance with the demonstration procedures.  Any beneficiaries previously enrolled as of November 15, 2020, will be able to continue in the demonstration.  For more information visit the IVIG website.

CMS’ Evaluation of OCM

The Centers for Medicare and Medicaid Services (CMS) has issued an evaluation report for the Oncology Care Model (OCM) for performance periods (PP) one through five. OCM is an alternative payment model based on six-month episodes for cancer care to test whether financial incentives can improve quality and reduce Medicare spending. Performance periods one through five encompass episodes that began between July 1, 2016 and January 1, 2019, all of which had ended by June 30, 2019.  Radiation therapy payments make up approximately 3% of the total episode payments (TEP) in the OCM. The report indicates the OCM has had no impact on the use of radiation therapy services and reported a slight increase in radiation therapy payments in comparison to the baseline for OCM practices. The report also found the comparison group saw a decline in radiation therapy payments per episode. The report included findings that episodes in the OCM reflected a reduction in the use of IMRT for breast cancer and a reduction in the number of radiation therapy fractions for metastatic bone treatment.

Part B chemotherapy drugs and non-chemotherapy drugs make up a large component of the TEP in the OCM. The report found that the OCM had no impact on payments for chemotherapy drugs but did see a reduction in spending on non-chemotherapy drugs, especially for supportive care drugs.  Additionally, it was found that the OCM had no impact on the choice of drug treatment regimens or adoption of new treatments but did see a shift in use of biosimilar filgrastim, clinically appropriate and less-costly antiemetic treatments, and more value-based use of bone modifying agents. The report noted that the OCM did not limit access to high-cost immunotherapy treatment nor did it impact timeliness of chemotherapy after surgery for colorectal cancer or breast cancer.  Additional information can be found within the Evaluation of the Oncology Care Model: Performance Periods 1-5.

Documentation and Compliance

In order to ensure the accurate and timely processing and payment of claims, understanding Medicare coverage criteria and documentation guidelines is a necessity. Audits conducted by the Comprehensive Error Rate Testing (CERT) program, Recovery Audit Contractors (RACs), Recovery Auditors (RAs) and Medicare Administrative Contractors (MACs) commonly reveal medical records given by physicians lack sufficient documentation to justify an ordered item or service. The lack of physician documentation may result is delayed or denied care for your patient as well as payment for services.  Resources to ensure adequate documentation can be found below.

Error in Drug Claims Rejection

Medicare has announced that their systems are incorrectly rejecting certain claims for drugs identified by HCPCS codes J0897, J3111, and J3590. These drugs are being rejected when billed for treatment of conditions other than osteoporosis in the home health setting. The claims are being rejected with Fiscal Intermediary Shared System reason code 32453. Medicare Administrative Contractors will be correcting the error and will reprocess the claims over the next several weeks, no additional action is needed.

**REMINDER** 77295 Bundled Denials UPDATE

This is a repost to remind those in radiation oncology of the update which went into effective January 1, 2021.

A 2019 report issued by the Office of Inspector General (OIG) concluded that the Centers for Medicare and Medicaid (CMS) could have saved a significant amount of money if services were bundled into CPT® code 77295 3D radiotherapy plan in a similar manner as services bundled into CPT® 77301 IMRT treatment plan.  While CMS agreed with the OIG report, they did not release any official billing changes or bundling of codes into 77295. However, many Medicare Administrative Contractors (MACs) used the OIG report as an opportunity to begin denying simulation codes 77280, 77285, and 77290 as well as continuing medical physics services, 77336, when billed with 3D treatment planning code 77295.

Many specialty societies, including ASTRO worked to address these denials. As a result, the National Correct Coding Initiative (NCCI) has issued a notice regarding the previously implemented procedure-to-procedure (PTP) edits between 3D planning code 77295 and simulation codes 77280, 77285, 77290 and continuing physics code 77336. The PTP edit between the planning code and simulation codes will deleted, retroactive to January 1, 2020. Meaning the simulation codes are now considered billable on the same date of service as the 3D planning code 77295 and the denials seen because of this PTP were incorrectly denied when billed on the same date of service for CY 2020. Additionally, the PTP edit between 77295 and 77336 will remain but there will be an opportunity to append a modifier as supported and appropriate.