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Radiation Oncology Billing and Coding Q&A – Part 2

Radiation Oncology Billing and Coding Q&A featured by SROA

By: Tammy McCausland


Teri Bedard, Executive Director, Client & Corporate Resources with Revenue Cycle Coding Strategies, discusses the RO-APM. This content originally appeared in Radiation Oncology News for Administrators, Vol. 31 No. 3.

Q: Are your clients trying to get support on the RO–APM?

A: Yes, but everyone is in different stages. Some have used the last couple of years to prepare, while others have taken a more wait-and-see approach. Most providers want to know their financial impact based on their current practices to determine what it will mean in the model. Regardless, everyone has it on their radar. I’ve really been impressed by places that have task forces or teams that they’re putting together. Pending any Congressional action, the RO–APM is set to start January 1, 2022. There is work and discussions to still change, delay or cancel it, but I think everyone needs to prepare for January 2022.

CMS has been doing a better job with some of the info releases and educational sessions on their calendar, but there is still a lot of information and clarification needed. Some of their rationale or plans for identifying the cancer type to reimburse under when there are multiples, has some issues. I think the many scenarios with incomplete courses and how that will work out will be interesting. We are creative in radiation oncology and not everything fits into a nice box, but that is really part of why the RO Model was created, to get a better hold on what we do.


Q: Are people coming to you asking for billing and coding guidance that you may not be able to provide?

A: There are limitations right now. Some of the bigger questions are related to the billing. We have some basic information from Medicare, but it still needs to address several logistical issues. CMS has scheduled two webinars in August related to billing, which should hopefully give more clarification and guidance. For many this will be administratively burdensome, trying to understand the implications. Some administrators are nervous. Some of the data are only available through the RO Model portal with the login by the participant, and without some of the details there it is difficult to give exact answers to some items.


Q: Are people concerned? Is there still the same anxiety about radiation oncology billing and coding?

A: There is. For so long, we’ve been billing for services in the same way, and every year there may be some slight changes or nuance or things that have adjusted, but for the most part, it’s been the same concept for how we bill for a lot of services.

The RO–APM has a lot of layers, so depending on staffing that you may have, you could have three different claim forms that have to be submitted for one patient for a course of treatment, and each of them represents very different things. If the claim forms are not correct, you’ve got issues and potential denials, so there’s a lot of anxiety from that standpoint.

Also, reimbursement is a concern. COVID-19 was a tough hit for many cancer centers. They will bounce back, but there’s still that nervousness of, “We’ve gone through the ringer, and now we have to completely revamp how we’re doing things again.” From a financial standpoint, it’s “Here’s the amount of money you’re given. Spend it well.” But is that in the best interest of the patient? Overall, there’s a lot of uncertainty and concern as to what this is going to look like from a financial standpoint for a lot of cancer centers and physicians.


Q: How does the RO–APM fit together with MIPS and MACRA?

A: They’re two different programs. It’s a lot of administrative burden in some ways on physicians because the MIPS that came from the MACRA legislation really shifted from quantity to quality. They want to know that the course of treatment that the radiation oncologist was prescribing to that patient is really the best for that patient: How did they respond to the treatment? Did they have to be admitted several times? How did they tolerate what was going on? There are these different measures that the physicians report on to support the quality of care that they’re providing to their patient population. As MACRA had outlined when it came out in 2015, CMS is shifting how physicians are paid, and everybody’s moving to these advanced payment models with Medicare. One thing is Medicare doesn’t understand how radiation oncology patients are treated. For instance, there are different fractions or courses of treatments for patients that have the same diagnosis, so I think this is Medicare’s opportunity or attempt to understand how many fractions of treatment. Do you use IMRT? Do you use 3D? Brachytherapy for this diagnosis? There’s an opportunity to try to get more of a semblance of standard of care, and what Medicare considered appropriate.

One of the eye-opening things about looking into the need or support for the RO Model was treatment for patients with the same diagnosis, specifically if they were treated at a hospital or at an office center. The office center tended to bill more codes at higher levels even though they treated less of the population than hospitals for the exact same patient with the same diagnosis. That’s concerning because what would be the reason for that? If there’s no clinical value to it, then it’s likely tied to the reimbursement, which is a risk to Medicare.

Physicians who didn’t meet the criteria get penalized, so money gets deducted from what they would normally get paid. And the money that gets deducted goes to the physicians who met the criteria. Medicare is not allotting x amount of dollars to anyone that meets the threshold criteria; instead the monies going to the physicians that did well are coming from the negative adjustments [penalties] from those that did not. It depends on how many people participate and how well some do versus how poorly others do.

What has your cancer center done to prepare for the RO-APM? What are your biggest concerns about radiation oncology billing and coding?


We would love to hear your experiences.

Share your thoughts here, or login to SROA Connect and join the conversation. If you are not a member of SROA yet, learn more about joining the radiation oncology association serving the niche profession of Radiation Oncology Administrator.

Related Content: Radiation Oncology News for Administrators, Vol. 31 No. 3

Society For Radiation Oncology Administrators (SROA)
Radiation Oncology News for Administrators, Vol. 31 No. 3


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