Radiation Oncology Billing and Coding Q&A – Part 1
By: Tammy McCausland
Teri Bedard, Executive Director, Client & Corporate Resources with Revenue Cycle Coding Strategies, discusses some common billing and coding issues. This content originally appeared in Radiation Oncology News for Administrators, Vol. 31 No. 3.
Q: Are you finding codes or problems that seem to be pervasive?
A: A couple of different codes cause issues. We’ve got SRS (stereotactic radiosurgery) and SBRT (stereotactic body radiotherapy). Over time, we’ve transitioned to shorter courses of treatment because patients want to be treated with shorter courses. It does benefit the patient in many ways. There’s limitation to these codes, which can be confusing because we want to treat multiple different areas. The definitions of these codes—77371, 77372 and 77373—have very specific limitations on how they can be billed, and because of that, it does create some need to evaluate what’s being ordered from the physician—that is, what was discussed at that initial consult. I see a lot of confusion with stereotactic radiotherapy and how it can be billed, how we bill for multiple sites [in the body] at the same time when we treat patients.
One of the other confusing areas is the ability to bill for a 3D plan, which is billed with 77295, and simulation codes 77280, 77285 and 77290. Since 1996, we haven’t been able to bill for the simulation on the same day as we do our 3D planning. There are edits in place to tell you, you can’t bill those codes, and the 3D plan is the higher code, but that changed. Medicare removed that edit, and it made it retroactive to last year—to January 1, 2020—but it went into effect on January 1, 2021, and it’s a huge shift for people to start thinking about the fact that they can bill an initial simulation and their 3D plan the same day, or they can bill their 3D plan and a verification the same day.
Now, it doesn’t mean that they can bill for two simulations on the same day for external beam. That’s only allowed for brachytherapy, BID, but there’s the ability now to bill for a code that, for quite some time, we haven’t been able to bill. Some of the commercial payers may not be accepting this change, and that can be causing some denials, too, so it’s something to be aware of.
One other code is 77014, which is a code that we use for cone beam CT or treatment planning CT, and when the AMA revamped our codes in 2015, 2016, they got rid of a lot. They deleted several codes, but they didn’t delete this one. A lot of payers don’t like this code because with IMRT there’s this whole dialogue about all these codes saying you can’t bill if you’re doing an IMRT plan, and 77014 is in this list of codes, yet also there are instances where it can be billed. It’s used for multiple different types of technology, and that’s where it gets confusing, so I think it’s been difficult because one of the payers, particularly Aetna, said, “OK, we want you to use a whole different code for this work,” and that’s how they set up their payment policies.
Q: If there is a denial, is there recourse where it can be overturned?
A: It will depend on who the denial comes from. The Medicare Administrative Contractors, the MACS, follow the NCCI edits, so if the denial is coming from them, then you can provide them the information.
The commercial payers have the ability to do what they want, essentially. They can follow what Medicare does. A lot of them will use Medicare as a baseline and say, “We’re going to follow Medicare, but we might tweak our policies just a little bit more.” Typically, they make their policies more stringent, and they may not follow the edits that Medicare has put in place because we’re now able to bill another code that we wouldn’t be able to bill or get paid for, for several years, so that’s money out of the pocket of some of those commercial payers. It’s going to come down to who the denial comes from, and then it may be where we can show payers that this edit was changed, and they may still come back and say, “We haven’t adopted that change.” From that standpoint, there may be no recourse, but it’s something where we should definitely explore the reason for the denial, and see if there’s an opportunity to appeal.
What billing/coding issues have you experienced?
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Related Content: Radiation Oncology News for Administrators, Vol. 31 No. 3
Links:
Society For Radiation Oncology Administrators (SROA)
Radiation Oncology News for Administrators, Vol. 31 No. 3
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