CMS Revises Billing for E/M with Superficial Treatment Delivery
CMS reissued and revised MM11137 on March 27, 2019, this was originally released on February 22, 2019, to be implemented on March 25, 2019 and retroactive to January 1, 2019. The transmittal from CMS has revised billing for superficial radiation therapy and the most current revision clarifies that providers will need to add modifier 25 when performing and billing evaluation and management (E/M) services on the same date as the superficial treatment delivery code 77401.
Per the release physicians can bill an established patient visit (99211, 99212 or 99213) only with CPT® code 77401 (superficial radiation treatment delivery) to account for the physician work associated with clinical treatment plan, treatment planning, physician management (when performed on the same date as the superficial radiation treatment delivery), device construction and physics consultation. The documentation will still need to support the E/M visit and the necessity for one along with the work by the physician associated with the superficial treatment delivery.
Medicare Administrative Contractors (MACs) will not search files for claims already paid or to retroactively pay claims, but MACs will adjust affected claims brought to their attention. This also means that providers will have to have the documentation of the E/M service already in the medical record as provided at the time of the superficial treatment delivery.
The full MedLearn Matters article can be found at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM11137.pdf.
CPT® Editorial Panel Release Summary of February 2019 Action
The CPT® Editorial Panel released the summary of the February Action Meeting and there are changes described to codes by the American Medical Association (AMA). Many of the changes by the AMA are in alignment with the changes to evaluation and management (E/M) codes by CMS for CY 2021. The following are highlights of the known changes coming to CPT® codes, the full summary can be found at https://www.ama-assn.org/system/files/2019-03/february-2019-summary-panel-actions_0.pdf.
Key to symbols – (Circle) New ? Revision + Add on D Deletion
- Name – Office or Other Outpatient Services
- Code # – D99201 ?99213 ?99202 ?99214 ?99203 ?99215 ?99204 ?99205 ?99211 ?99212
- Effective Date – January 1, 2021
- Description of Editorial Panel Action –
§ Accepted deletion of code 99201;
§ revision of codes 99202-99215 as follows:
§ (A) removing history and examination as key components for selecting the level of E/M service, but adding the requirement that a medically appropriate history and/or examination must be performed in order to report codes 99202-99215;
§ (B) making the basis for code selection either the level of medical decision making (MDM) performed or the total time spent performing the service on the day of the encounter;
§ (C) changing the definition of the time element associated with codes 99202-99215 from typical face-to-face time to total time spent on the day of the encounter, and changing the amount of time associated with each code; revision of the MDM elements associated with codes 99202-99215 as follows:
- (i) revising “Number of Diagnoses or Management Options” to “Number and Complexity of Problems Addressed”;
- (ii) revising “Amount and/or Complexity of Data to be Reviewed” to “Amount and/or Complexity of Data to be Reviewed and Analyzed”; and
- (iii) revising “Risk of Complications and/or Morbidity or Mortality” to “Risk of Complications and/or Morbidity or Mortality of Patient Management”;
§ revision of the E/M guidelines by:
- (A) restructuring the guidelines into three sections: “Guidelines Common to All E/M Services”, “Guidelines for Hospital Observation, Hospital Inpatient, Consultations, Emergency Department, Nursing Facility, Domiciliary, Rest Home or Custodial Care and Home E/M Services”, and “Guidelines for Office or Other Outpatient E/M Services” to distinguish the new reporting guidelines for the Office or Other Outpatient Services codes 99202-99215;
- (B) adding new guidelines that are applicable only to Office or Other Outpatient codes (99202-99215); adding a Summary of Guideline Differences table of the differences between the different sets of guidelines;
- (C) revised existing E/M guidelines to ensure there is no conflicting information between the different sets of guidelines;
- (D) adding definitions of terms associated with the elements of MDM applicable to codes 99202-99215;
- (E) adding a MDM table that is applicable to codes 99202-99215;
- (F) defining total time associated with codes 99202- 99215;
- (G) adding guidelines for reporting time when more than one individual performs distinct parts of an E/M service;
§ revision of the Medical Decision Making table (Table 2) in the Amount and/or Complexity of Data to be Reviewed and Analyzed column:
- (1) inserted a dash (-) after the asterisk in the asterisk definition, “* – Each unique test, order, or document may be summed if multiple,” to clarify this is the meaning of the asterisk and not an asterisked item itself;
- (2) for limited amount of data to be reviewed and analyzed (codes 99203/99213), the parenthetical regarding the number of categories for which requirements must be met was revised to state, “…categories of tests and documents, or independent historian(s)” rather than “categories within tests, documents, or independent historian(s)”; and
- (3) removing the word “or” after each of the bulleted items for limited, moderate (codes 99202/99214), and high (99205/99215) amount and/or complexity of data to be reviewed and analyzed
- Name – Prolonged Svcs With or Without Patient Contact
- Code # – (circle) 99XXX ?99354 ?99355 ?99356
- Effective Date – January 1, 2021
- Description of Editorial Panel Action – Accepted revision of codes 99354, 99355 to exclude reporting of Office and other Outpatient Services codes, and revision of 99356 to include observation; revision of the prolonged services guidelines; addition of code 99XXX to report prolonged office or other outpatient E/M services
- Name – Lung Biopsy-CT Guidance Bundle
- Code # – (circle) 324X0 D32405
- Effective Date – January 1, 2021
- Description of Editorial Panel Action – Accepted addition of code 324X0 to report core needle biopsy, lung or mediastinum; deletion of code 32405; and revision of introductory guidelines
- Name – Cardiac Device Evaluation-Delete 93299
- Code # – D93299
- Effective Date – January 1, 2020
- Description of Editorial Panel Action – Accepted deletion of code 93299
- Name – Category III Sundown
- Code # – 0394T 0395T (electronic brachytherapy treatment codes)
- Effective Date – January 1, 2020
- Description of Editorial Panel Action – Accepted retention of Category III codes 0394T and 0395T
New HCPCS Codes and Status for Drugs, Biologicals and Radiopharmaceuticals
Effective April 1, 2019 there are several new HCPCS codes for certain drugs, biologicals and radiopharmaceuticals as well as assignment of pass-through status to several others. The following are the tables released by CMS with new HCPCS codes and those which will receive pass-through status effective April 1, 2019.
POP-ART RT Study to Evaluate Prevalence of Adaptive and Real-time Radiotherapy
The Pattern of Practice for Adaptive and Real Time Radiation Therapy (POP-ART) is set to study how widespread are the uses of different technology to track the motion and tumor response to radiation. Specifically, the study is looking at the prevalence of adaptive therapy where by tracking the motion or response to radiation dosing is adapted in real-time either online or offline.
This was established by participants of the “Realtime and adaptive management of anatomical variations” track at October 2018’s 2nd European SocieTy for Radiotherapy & Oncology (ESTRO) physics workshop. There is an online survey for all institutions that perform radiation therapy to complete an participate in the study, https://www.surveymonkey.co.uk/r/RZRYF83.
The goals of the study include finding out how widespread the use of adaptive and real-time radiotherapy is being used and what issues or problems there are to implement or increasing use of this planning. The researchers plan to release findings through a scientific paper; no timeline was given for closing the study or releasing the results. Per the link the survey is expected to take anywhere from 5-30 minutes to complete.
ACR Clarifies “Incident to” Billing Rule for Radiologist Assistants
The American College of Radiology (ACR) issued clarification to Medicare’s “Incident to” rule covering services performed under supervision in an office setting by radiologist assistants (RAs). This clarification was in response to inquiries received after release of the CY 2019 Medicare Physician Fee Schedule Final Rule.
Per the revision of rules by CMS, RAs are recognized as radiologist staff members who can provide technical component imaging services under direct supervision, but without the radiologist required to be in the same room for the service. The full clarification by the ACR can be found at https://www.acr.org/-/media/ACR/NOINDEX/Advocacy/Advocacy-News/RA-Article-on-_-Incident-To_-Rule.pdf?la=en.
March 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: Do we need to do the independent second check in order to bill calculations 77300 for all IMRT plans?
Advice: Yes, payers require the MU calculations from the IMRT plan must be independently reviewed and approved by the physician prior to the first fraction of treatment. The calculations from the IMRT plan are not the billable services or documentation.
Question: Would it be appropriate to bill a special physics consult (77370) with IMRT if the patient has a pacemaker?
Advice: Code 77370 cannot be billed prior to or as part of the IMRT plan. If the special physics consult is performed for the IMRT planning in relation to the pacemaker and how the plan must be adjusted or to account for the pacemaker, it is not billable.