Take note, hospitals and other outpatient facilities that bill Medicare for outpatient intensity-modulated radiation therapy (“IMRT”): The Department of Health and Human Services Office of Inspector General (the “OIG”) is focusing its attention on you. Specifically, the OIG recently announced that it will review Medicare payments for outpatient IMRT to determine whether payments have been made in accordance with Medicare billing rules and regulations. The OIG’s new agenda item appears in its Fiscal Year 2015 Work Plan Mid-Year Update, which was released on May 28, 2015. (IMRT is an advanced mode of high-precision radiotherapy in which computer-controlled linear accelerators deliver precise radiation doses to a malignant tumor or specific areas within the tumor.) If the OIG finds that a significant or even a substantial number of claims were prepared incorrectly, it will likely recommend that CMS focus more attention on IMRT claims, raising the probability that providers will be audited and potentially face demands for the refund of overpayments.
According to the Update, the OIG plans to scrutinize Medicare claims specifically for evidence of separate billing for procedures or services that are required to be bundled and billed together as services performed in developing an IMRT treatment plan. Under the Medicare billing rules, CPT code 77301 should be used to identify services performed for IMRT planning. Medicare Claims Processing Manual, CMS Pub. 100-04, Ch. 4, §§ 200.3.1-3.2. Payment for services identified by CPT codes 77014, 77280-77295, 77305-77321, 77331, 77336 and 77370 is included in the payment for IMRT planning when these services are performed in developing the plan. The latter CPT codes can be billed in addition to CPT code 77301, either on the same or different date of service as the IMRT plan, but only if the services were not provided in connection with development of the treatment plan. CPT codes 77401 through 77416 or 77418 may be billed on the same date of service as long as the services are furnished at separate treatment sessions. Modifier -59 should be appended to the appropriate code to indicate a distinct procedural service.
The OIG’s new Work Plan agenda item was evidently prompted by the agency’s previous findings that certain hospitals unbundled IMRT planning services by including, on the same claim, IMRT planning services and additional codes for services covered by the payment for development of the treatment plan. See, e.g., OIG, Medicare Compliance Review of Good Samaritan Hospital for Calendar Years 2010 and 2011, July 2014, No. A-09-13-02008; Medicare Compliance of Memorial Hospital for Calendar Years 2010 and 2011, Jan. 2014, No. A-07-13-01124; Medicare Compliance Review of MedStar Washington Hospital Center, Oct. 2013, No. A-03-12-06103. Based on these findings, the OIG recommended that the hospitals refund the associated overpayments to the Medicare program.
Facilities and others who bill for IMRT should review their billing procedures to ensure that their Medicare claims are following these rules.