According to one of the OIG’s most recent audit report, Medicare could have saved millions of dollars in payments for separately billed three-dimensional conformal radiation therapy planning services.
Three-dimensional conformal radiation therapy (3D-CRT) allows doctors to sculpt radiation beams to the shape of a patient’s tumor. Medicare makes a single payment to hospitals for the development of a 3D-CRT treatment plan. Automated prepayment edits generally prevent additional payments for separately billed radiation planning services if they are billed on the same date of service as the 3D-CRT treatment plan. However, Medicare billing requirements do not prohibit, and system edits do not prevent, additional payments if the services are billed on a different date of service (e.g., 1 to 14 days before).
The OIG stated that if Medicare were to treat 3D-CRT like it does another type of radiation treatment planning, then Medicare would save millions of dollars. The other form of radiation therapy similar to 3D-CRT is intensity-modulated radiation therapy (IMRT). For IMRT, Medicare makes a bundled payment to hospitals to cover a range of radiation planning services that may be performed to develop an IMRT treatment plan. Medicare billing requirements prohibit, and system edits prevent, additional payments for separately billed planning services, regardless of when they are billed. The billing requirements have been in effect since January 1, 2008; the system edits have been in effect since April 1, 2018 (as the result of a prior OIG review).
OIG’s work in this particular review reflects how much Medicare could have saved if similar billing requirements and system edits had been implemented for 3D-CRT when the billing requirements for IMRT went into effect.
OIG determined that Medicare could have saved $125.4 million from CYs 2008 through 2017 by implementing billing requirements and system edits to prevent additional payments for separately billed 3D-CRT planning services. These services were primarily billed on a different date of service from the procedure code for the development of a 3D-CRT treatment plan. As of January 9, 2019, Medicare had paid $13.6 million for separately billed 3D-CRT planning services performed in CY 2018. 3D-CRT is typically used on tumors that have irregular shapes or that lie close to healthy tissues and organs, because it may limit radiation exposure to surrounding healthy tissue. There are two treatment phases for 3D-CRT: planning and delivery.
During the planning phase, digital datasets and 3D computer images of a beneficiary’s treatment site (i.e., a tumor) are used to develop a complex treatment plan to deliver highly conformed (focused) radiation while sparing normal adjacent tissue. During the delivery phase, radiation is delivered to the treatment site at the various intensity levels prescribed in the 3D-CRT treatment plan.
Hospitals bill Medicare for developing a 3D-CRT treatment plan using CPT code 77295. The NCCI PTP automated prepayment edits apply to CPT code 77295 and list radiation planning services that may not be separately billed on the same date of service. These services are not specific to 3D-CRT and include common radiology procedures. These edits generally prevent improper payments when the services are billed on the same date of service as CPT code 77295 but do not prevent these payments when the services are billed on a different date of service.
In contrast to 3D-CRT, Medicare doesn’t allow this practice for a similar service, IMRT. Unlike the case for 3D-CRT planning services, billing requirements prohibit payment for separately billed IMRT planning services when they are billed on a different date of service from IMRT planning CPT code 77301 (e.g., 1 to 14 days before). This requirement has been in effect since January 1, 2008. In response to the OIG’s work in this area, CMS concurred with OIG’s recommendation and stated that it will consider whether implementing billing requirements in the future to prevent payments for additional planning services when reported with 3D-CRT would be appropriate.
If your organization provides 3D-CRT radiation therapy services, you should be on the lookout for any changes CMS may make in relation to the billing edits and prohibitions in the future.