Deeper Than the Headlines:  Intensity-Modulated Radiation Therapy

Intensity-modulated radiation therapy (IMRT) is an advanced type of radiation procedure used to treat difficult-to-reach tumors. Not only can it be a complex medical procedure, the coding and billing compliance rules can also be complex.

The OIG recently published a report detailing their findings from a review of how one Medicare Administrative Contractor (Novitas) incorrectly paid hospitals for IMRT services. They also cited that some of the mistakes were due to the hospitals’ lack of understanding of the rules. If your organization is involved in providing IMRT, this report would be worth reading.

The OIG stated they performed this work because prior OIG reviews found that some hospitals received separate payments for individual IMRT services that should have been included in the bundled payment for IMRT planning. So they performed a focused review of selected at-risk claims for outpatient IMRT services to determine if they complied with Medicare requirements. Their main conclusion was that, although most of the IMRT services billed by hospitals were allowable, overpayments were also discovered for at least 1 service for 98 of the 100 beneficiaries sampled. Based on the sample results, OIG estimated that hospitals the hospitals serviced by Novitas received Medicare overpayments of at least $7.2 million for unallowable IMRT services during the audit period.

IMRT is a procedure that uses advanced computer programs to plan and deliver radiation to tumors with high precision. The intensity of the radiation can be adjusted to deliver higher doses to a treatment area while reducing exposure to surrounding healthy tissue. IMRT is provided in two treatment phases: planning and delivery. The planning phase is a multistep process in which imaging, calculations, and simulations are performed to develop an IMRT treatment plan (IMRT planning). During the delivery phase, radiation is delivered to a beneficiary’s treatment site (i.e., a tumor) at the various intensity levels prescribed in the IMRT treatment plan. Medicare requirements for IMRT specify the services included in the bundled payment for IMRT planning when they are performed as part of the development of an IMRT treatment plan (e.g., imaging). Such services may not be billed separately, regardless of whether they are billed on the same or a different date of IMRT planning.

To promote correct coding by providers and to prevent Medicare payments for improperly coded services, CMS developed the National Correct Coding Initiative (NCCI). The NCCI edits include procedure-to-procedure (PTP) edits that define pairs of HCPCS codes and/or CPT codes (i.e., code pairs) that generally should not be reported together for the same beneficiary on the same date of service. For example, some edits prevent payments for certain IMRT services billed for the same beneficiary on the same date of service as a bundled payment for IMRT planning. However, these edits do not prevent payments for when these services are billed on a date different from when IMRT planning services are billed.

Hospitals received separate reimbursement for individual IMRT services that should have been included in the hospitals’ bundled payment for the beneficiary’s IMRT planning. This happened for 94 of the 100 beneficiaries who had services reviewed. Specifically, medical review determined that these services were provided as part of the development of an IMRT treatment plan and should not have been billed separately from the bundled payment for IMRT planning (i.e., CPT code 77301).

For 50 beneficiaries, hospitals received reimbursement for services for which the associated medical record did not support the services billed. (None of these services were provided as part of the development of an IMRT treatment plan.) Specifically, for 46 beneficiaries, the documentation in the medical record did not adequately support the services billed. For example, a special physics consultation was billed for a beneficiary without documentation to support the service. Specifically, medical review determined that the case file included no order for the service and no records or documentation of the service or an explanation for why the consultation was needed.

In another example, a hospital billed for services that were not provided. The hospital stated that it incorrectly entered charges for IMRT because the beneficiary “was treated on a machine that is more commonly used for IMRT.”

For seven beneficiaries, the documentation did not support the number of units billed. For one beneficiary, the hospital billed for services with an incorrect billing modifier code, resulting in an overpayment. In this instance, the hospital billed for multiple treatment devices: one with a custom, complex design and two with intermediate complexity. The hospital billed with a modifier code for the two intermediate devices, which prevented NCCI PTP edits from disallowing payment when the use of these devices were not “separate and distinct” from the complex device.

For four beneficiaries, hospitals received reimbursement for IMRT services that were not medically necessary. Specifically, for two beneficiaries, the medical record indicated that the services provided were not the appropriate standard of care. Medical review determined that three-dimensional conformal radiation therapy—not IMRT—would have been the appropriate standard of care for these beneficiaries; therefore, the claims were unallowable. For two other beneficiaries, the medical records indicated that some services provided were not reasonable or necessary.

The OIG recommended that Novitas recover from hospitals the portion of the estimated $7,230,420 in identified overpayments for claims incorrectly billed that are within the reopening period. They also recommended to:

• Notify the hospitals responsible for the remaining portion of the estimated $7,230,420 in potential overpayments for claims that are outside of the Medicare reopening period, so that those hospitals can investigate and return any identified overpayments in accordance with the 60-day rule and track any returned overpayments;
• Identify and recover any additional similar overpayments for IMRT services made after the audit period;
• Work with CMS to implement edits that would prevent separate payments for individual IMRT services included in the bundled payment for IMRT planning; and
• Educate hospitals on properly billing Medicare for IMRT planning services.

If your organization provides IMRT and is within the Novitas jurisdiction, you might want to perform some proactive internal reviews of your own. And if you are outside of the Novitas jurisdiction, it still would be wise to review these types of services as these types of initiatives tend to spread to other jurisdictions. As always, if you need help, don’t hesitate to give us a call.