1. RADMAX, LTD. Evaluating and Motivating Your Billing Staff
4/20/2017
Section 13
HOSPITAL BILLING For Radiation Therapy
Kevin M. Ewalt
8:00-9:30
031214
Modified for
4/1/2008

2. HOSPITAL RADIATION THERAPY BILLING
RADMAX, LTD. Evaluating and Motivating Your Billing Staff
4/20/2017 1
HOSPITAL RADIATION THERAPY BILLING
Billing radiation therapy in a hospital setting not only requires a different billing form, but has many idiosyncrasies you must follow, such as the Medicare 72 Hour Rule. In this section of the seminar we will focus on what makes hospital radiation therapy billing so unique. Hopefully you will leave with a better understanding of what is required in order to be properly reimbursed in this dynamic and complex hospital healthcare environment.
Introduction
Billing radiation therapy in a hospital setting not only requires a different billing form, but has many idiosyncrasies you must follow, such as the Medicare 72 Hour Rule. In this section of the seminar we will focus on what makes hospital radiation therapy billing so unique. Hopefully you will leave with a better understanding of what is required in order to be properly reimbursed in this dynamic and complex hospital healthcare environment.
4/1/2008

3. HOSPITAL RADIATION THERAPY BILLING
RADMAX, LTD. Evaluating and Motivating Your Billing Staff
4/20/2017 1
HOSPITAL RADIATION THERAPY BILLING
HOSPITAL BASED CANCER CENTER
Is a department of the hospital.
Can be on campus as well as off campus.
Bills charges under the hospital’s Tax ID number.
Follows policies and procedures set by hospital including compliance.
Bills technical facility charges only.
“Cannot bill professional physician charges on UB04 Form.”
Hospital Based Cancer Center Definition
Is a department of the hospital.
Bills charges under the hospital’s Tax ID number
Follows policies and procedures set by hospital including compliance.
Freestanding Cancer Center Definition
Is a separate entity and bills charges under its own Tax ID.
Has a separate Board of Directors and runs under its own policies and procedures.
A free standing cancer center can be owned by a hospital system and even located on campus but must run independently.
4/1/2008

4. HOSPITAL RADIATION THERAPY BILLING1
HOSPITAL RADIATION THERAPY BILLING
FREESTANDING CANCER CENTER (IN COMPARISON)
Is a separate entity and bills charges under its own Tax ID.
Has a separate Board of Directors and runs under its own policies and procedures.
A free standing cancer center can be owned by a hospital system, and even located on campus, but must run independently.
Can be both technical (facility based) and/or professional (physician) charges as well as combined charges (Global).
Depends on ownership!

5. HOSPITAL BILLING FORM (UB04)
RADMAX, LTD. Evaluating and Motivating Your Billing Staff
4/20/2017
HOSPITAL BILLING FORM (UB04)
1-3
UB04 Billing Form used to bill hospital based out-patient radiation therapy technical charges.
American Hospital Association (AMA) and National Uniform Billing Committee controls UB04.
Electronic Billing 837I.
HOSPITAL BILLING FORM (UB04)
UB04 billing form (example) used to bill hospital based out-patient radiation therapy technical charges.
American Hospital Association (AMA) and National Uniform Billing Committee controls UB04.
Electronic Billing 837I.
4/1/2008

6. HOSPITAL BILLING FORM (UB04)
RADMAX, LTD. Evaluating and Motivating Your Billing Staff
4/20/2017 1
HOSPITAL BILLING FORM (UB04)
Medicare requires electronic submission initially.
Unless the provider qualifies as exempt with the Administrative Simplification Compliance Act (ACSA).
No waiver request necessary if institution is less than 25 FTE’s.
Timely filing is required by most carriers.
Medicare requires claims be submitted within 12 months of date of service.
Line item ‘from’ date on claim form (single day).
Line item ‘through’ date on claim form (date span).
HOSPITAL BILLING FORM (UB04)
Medicare requires electronic submission initially.
Unless the provider qualifies as exempt with the Administrative Simplification Compliance Act (ACSA).
No waiver request necessary if institution is less than 25 FTE’s.
Timely filing is required by most carriers.
Medicare requires claims be submitted within 12 months of date of service.
Line item ‘from’ date on claim form (single day).
Line item ‘through’ date on claim form (date span).
4/1/2008

7. PHYSICIAN BILLING FORM (HCFA 1500)4
HCFA 1500 billing form (comparison only)
Used to bill physician professional radiation therapy charges or freestanding radiation therapy center technical or global charges.
Electronic billing 837P

8. HOSPITAL BILLING TERMS
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HOSPITAL BILLING TERMS
HOSPITAL OUTPATIENT PROSPECTIVE PAYMENT SYSTEM (HOPPS)
System was implemented August 1, 2000 by the Centers for Medicare and Medicaid Services (CMS) to reimburse hospital “outpatient” services.
Congress mandated that CMS develop a system to reduce beneficiary co-payments.
HOPPS bases payments on geometric mean costs.
Claims are matched to cost reporting data filed by individual hospitals.
NOTE: radiation therapy is paid per ‘line-item’ unlike most hospital out patient services.
Hospital Outpatient Prospective Payment System (HOPPS).
System was implemented August 1, 2000 by the Centers for Medicare and Medicaid Services (CMS) to reimburse hospital “outpatient” services.
Congress mandated that CMS develop a system to reduce beneficiary co-payments.
HOPPS bases payments on geometric mean costs.
Claims are matched to cost reporting data filed by individual hospitals.
NOTE: radiation therapy is paid per ‘line-item’ unlike most hospital out patient services.
4/1/2008

9. HOSPITAL BILLING TERMS
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HOSPITAL BILLING TERMS
OUTPATIENT QUALITY REPORTING (OQR)
HOPPS Conversion Factor
Hospitals that fail to meet the reporting requirements for outpatient services will see a reduction in the conversion factor of $ ($71.22).
Down from 2013 $
Hospitals that meet the OQR requirement will see an increase in their conversion factor to $ ($72.67) or a 1.7% increase.
Outpatient Quality Reporting (OQR)
HOPPS Conversion Factor
Hospitals that fail to meet the reporting requirements for outpatient services will see a reduction in the conversion factor of $ ($71.22).
Down from 2013 $
Hospitals that meet the OQR requirement will see an increase in their conversion factor to $ ($72.67) or a 1.7% increase.
4/1/2008

10. HOSPITAL BILLING TERMS
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4/20/2017
HOSPITAL BILLING TERMS 6
PAYMENT TO COST RATIO (PCR)
For cancer hospitals CMS provides additional payments to offset other HOPPS hospitals.
Offsets losses in cancer centers that are spending greater than 1.75 times the APC payment amount and the $2,900 fixed-dollar threshold over the APC payment rate.
Payment = 50% of the amount that the hospital exceeds cost of services that exceed 1.75 x’s the APC rate (when both the 1.75 multiple threshold and the fixed dollar threshold are met) / Formula = (cost-(APC payment x 1.75))/2
NOTE: according to CMS the outcome in updated HOPPS packaging policies and the CY 2014 fixed-dollar threshold can make for “significant changes to both the APC payment and estimated cost portions of the HOPPS outlier payment comparison.”
Payment to Cost Ratio for Hospitals (PCR)
For cancer hospitals CMS provides additional payments to offset other HOPPS hospitals.
Offsets loses in cancer centers that are spending more than 1.75 times the APC payment amount and the $2,900 fixed-dollar threshold over the APC payment rate.
Payment = 50% of the amount that the hospital exceeds cost of services that exceed 1.75 x’s the APC rate (when both the 1.75 multiple threshold and the fixed dollar threshold are met).
Formula = (cost-(APC payment x 1.75))/2
NOTE: according to CMS the outcome in updated HOPPS packaging policies and the CY 2014 fixed-dollar threshold can make for “significant changes to both the APC payment and estimated cost portions of the HOPPS outlier payment comparison.”
4/1/2008

11. HOSPITAL BILLING TERMS
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4/20/2017
HOSPITAL BILLING TERMS 6
MEDICARE PHYSICIAN FEE SCHEDULE (MPFS)
Comparison Only: free standing radiation therapy centers and radiation oncologists have always been paid as “fee for service” or per procedure (CPT).
Medicare Part B pays for physician services based on the Medicare PFS, which lists the more than 7,400 unique covered services and their payment rates.
Payment rates for an individual service are based on the following:
Relative Value Units (RVU) including work RVU, Practice Expense (PE) RVU, and Malpractice (MP) RVU.
Conversion Factor (CF).
Geographic Practice Cost Indices (GPCI).
Medicare Physician Fee Schedule (MPFS)
Comparison Only: free standing radiation therapy centers and radiation oncologists have always been paid as “fee for service” or per procedure (CPT).
Medicare Part B pays for physician services based on the Medicare PFS, which lists the more than 7,400 unique covered services and their payment rates.
Payment rates for an individual service are based on the following:
Relative Value Units (RVU) including work RVU, practice expense (PE) RVU, and malpractice (MP) RVU.
Conversion Factor (CF).
Geographic Practice Cost Indices (GPCI).
4/1/2008

12. HOSPITAL BILLING TERMS
RADMAX, LTD. Evaluating and Motivating Your Billing Staff
4/20/2017
HOSPITAL BILLING TERMS 6
DIAGNOSIS RELATED GROUP (DRG)
Medicare Hospital Inpatient Payment Methodology
Established in the 1970’s and implemented in 1982 to encourage access to care, rewards efficiency, improves transparency, and improves fairness by paying similarly across hospitals for similar care.
Was initiated in much the same way as packaging to make hospitals contain their costs/spending and shorten patient length of stay (hospitalization).
Paid on a per diem rate per patient (per product) for highest level of complexity.
Diagnosis Related Group (DRG)
Medicare Hospital Inpatient Payment Methodology
Established in 1982 to encourage access to care, rewards efficiency, improves transparency, and improves fairness by paying similarly across hospitals for similar care.
Was initiated in much the same way as packaging to make hospitals contain their costs/spending and shorten patient length of stay (hospitalization).
Paid on a per diem rate per patient (per product) for highest level of complexity.
4/1/2008

13. HOSPITAL BILLING TERMS
RADMAX, LTD. Evaluating and Motivating Your Billing Staff
4/20/2017
HOSPITAL BILLING TERMS 7
AMBULATORY PAYMENT CLASSIFICATIONS (APC)
APC’s are units of payment under the OPPS.
APC’s are a system of classification where CPT codes are concerted into APC groupings for reimbursement for hospital outpatient type services.
APC’s consolidate reimbursement for services that are similar in nature.
Example: (Simulation: Simple Confirmation) and (Physics Consultation) are both APC 0304 and pay the same reimbursement of $ (2014).
Note: most radiation therapy is still paid “per line item.”
AMBULATORY PAYMENT CLASSIFICATIONS (APC)
APC’s are units of payment under the OPPS.
APC’s are a system of classification where CPT codes are concerted into APC groupings for reimbursement for hospital outpatient type services.
APC’s consolidate reimbursement for services that are similar in nature.
Example: (Simulation: Simple Confirmation) and (Physics Consultation) are both APC 0304 and pay the same reimbursement of $ (2014).
Comprehensive APC definition: a single payment for procedures that includes the primary service as well as all ancillary (in support of primary) related services.
New services/technology are assigned APC’s that are similar to the resources used until cost data can be established and an APC code can then be assigned.
Payment rates for a new technology are set at the midpoint of the applicable New Technology APC’s cost range.
Note: most radiation therapy is still paid “per line item.”
4/1/2008

14. 8
FINAL OPPS APC LIST FOR 2014

15. HOSPITAL BILLING TERMS
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4/20/2017
HOSPITAL BILLING TERMS 8
PAYMENT STATUS INDICATORS (PSI)
PSI’s are another form of grouping for Medicare payments.
Important indicator codes:
S – significant procedure, multiple reductions apply.
V – clinic or ER visit.
X – ancillary services.
Q1 – packaged services subject to separate payment based on OPPS payment criteria .
Radiation therapy planning codes currently assigned with an Indicator ‘X’ planning code are paid per procedure.
Radiation therapy planning codes assigned with an Indicator of Q1 planning code are packaged with the main service for that date or time frame (comparable to NCCI edits).
Payment Status Indicators (PSI)
PSI is another form of grouping for Medicare payments.
Important indicator codes:
S – significant procedure, multiple reductions apply.
V – clinic or ER visit.
X – ancillary services.
Q1 – packaged services subject to separate payment based on OPPS payment criteria .
Radiation therapy planning codes currently assigned with an Indicator ‘X’ planning code are paid per procedure.
Radiation therapy planning codes assigned with an Indicator of Q1 planning code are packaged with the main service for that date or time frame (comparable to NCCI edits).
4/1/2008

16. PAYMENT STATUS INDICATORS9
PAYMENT STATUS INDICATORS

17. HOSPITAL BILLING TERMS
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4/20/2017 10
HOSPITAL BILLING TERMS
WAGE INDEX (BASED ON LAST YEAR [2013])
Wage Index for urban and rural areas based on CBSA labor market.
The Social Security Act requires that, as part of the methodology for determining prospective payments to hospitals, the Secretary must adjust the standardized amounts “for area differences in hospital wage levels by a factor reflecting the relative hospital wage level in the geographic area of the hospital compared to the national average hospital wage level.”
Must be updated annually.
Based on a survey of wages and wage-related costs of short-term, acute care hospitals.
Data included in the wage index derive from the Medicare Cost Report, the Hospital Wage Index Occupational Mix Survey, hospitals' payroll records, contracts, and other wage-related documentation.
Wage Index (based on last year [2013])
Wage Index for urban and rural areas based on CBSA labor market.
The Social Security Act requires that, as part of the methodology for determining prospective payments to hospitals, the Secretary must adjust the standardized amounts “for area differences in hospital wage levels by a factor reflecting the relative hospital wage level in the geographic area of the hospital compared to the national average hospital wage level.”
Must be updated annually.
Based on a survey of wages and wage-related costs of short-term, acute care hospitals.
Data included in the wage index derive from the Medicare Cost Report, the Hospital Wage Index Occupational Mix Survey, hospitals' payroll records, contracts, and other wage-related documentation.
4/1/2008

18. 11
Wage Index TABLES
In this addendum, we provide the wage index tables referred to throughout the preamble of the FY 2013 IRF PPS notice. The tables presented below are as follows:
Table A: FY 2013 Wage Index For Urban Areas Based On CBSA Labor Market Areas.
Table B: FY 2013 Wage Index Based On CBSA Labor Market Areas For Rural Areas.

19. HOSPITAL BILLING TERMS
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4/20/2017
HOSPITAL BILLING TERMS 12
REVENUE CODES/COST CENTER
Describes the dollar amount charged for hospital services provided to a patient.
Tells an insurance company whether the procedure was performed in the emergency room, operating room or another department (i.e. radiation therapy).
Radiation therapy is 333 Revenue Code.
Help group similar charges onto one line in the billing form.
Example: a revenue code attached to a supply code identifies the equipment and whether the equipment was used in the hospital or taken home by a patient.
REVENUE CODES/COST CENTER
Revenue Codes were developed for the Medicare system but were soon adopted as standard for hospitals.
Every item in a hospital’s charge master (catalog of all services performed by that hospital) must have one revenue code attached to it.
Revenue Codes are descriptions and dollar amounts charged for hospital services provided to a patient.
Revenue Codes tells an insurance company whether the procedure was performed in the emergency room, operating room or another department.
Revenue Codes help group similar charges onto one line in the billing form.
Example: if a revenue code is attached to a supply code, it identifies the equipment and whether the equipment was used in the hospital or taken home by a patient.
Has a large impact on reimbursement.
A valid procedure code must be accompanied by a revenue code for it to be accepted by the insurance provider.
Claim forms sent without a Revenue Code will be rejected.
Only covered Revenue Codes are paid.
There are 81 fields on the UB-04 and the Revenue Codes are located by field (FL42-49).
Radiation therapy is 333 Revenue Code.
Originally Revenue Codes were 3 digits but now are always 4 digits.
First digit is typically a zero and not required to be listed (payers assume the zero).
When the last digit of a Revenue Code is a zero this indicates that the service was unspecified.
When the last digit is a nine this indicates that “other” services (no assignment).
4/1/2008

20. Revenue Codes 13

21. FINAL HCPCS CODES FOR 2014
14-18

22. HOSPITAL BILLING RULES
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HOSPITAL BILLING RULES 19
PACKAGING (THINK HOSPITAL OUT-PATIENT DRG!)
Packaging is a combination of inter-related procedures (CPT codes) performed on a single day into one ‘daily’ payment.
Purpose/Designed: to motivate hospital out-patient facilities to be more cost-effective when treating patients.
Motivation: if the hospital is spending more money for patient radiation therapy treatment than it is getting reimbursed it will force the hospital to look at cost (bottom line).
The fear is facilities may delay patient treatment to increase payment for services.
CMS finalizing the policy to establish 29 comprehensive APC’s (which would have been status indicator ‘Q’) but delayed implementation until 2015.
Packaging (Think Hospital out-patient DRG!)
Packaging is a combination of inter-related procedures (CPT codes) performed on a single day into one ‘daily’ payment.
Purpose/Designed: to motivate hospital out-patient facilities to be more cost-effective when treating patients.
Motivation: if the hospital is spending more money for patient radiation therapy treatment than it is getting reimbursed it will force the hospital to look at cost (bottom line).
The fear is facilities may delay patient treatment to increase payment for services.
CMS finalizing the policy to establish 29 comprehensive APC’s (which would have been status indicator ‘Q’) but delayed implementation until 2015.
4/1/2008

23. HOSPITAL BILLING RULES
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4/20/2017
HOSPITAL BILLING RULES 19
HOSPITAL 72 HOUR RULE
Medicare’s 3-day payment window applies to Medicare hospital outpatient Part B services and requires the hospital to bundle the technical component of all outpatient diagnostic services and related non-diagnostic services (e.g. therapeutic radiation therapy) with the claim for an inpatient stay when services are furnished to a Medicare beneficiary in the 3 days preceding an inpatient admission.
In effect since 1998 and updated July 1, 2012 with PD modifier.
Cancer hospitals are only subject to a one day payment window.
Most CAH’s are exempt from this rule.
HOSPITAL 72 HOUR RULE
Medicare’s 3-day payment window applies to Medicare hospital outpatient Part B services and requires the hospital to bundle the technical component of all outpatient diagnostic services and related non-diagnostic services (e.g. therapeutic radiation therapy) with the claim for an inpatient stay when services are furnished to a Medicare beneficiary in the 3 days preceding an inpatient admission.
In effect since 1998 and updated July 1, 2012 with PD modifier.
Cancer hospitals are only subject to a one day payment window.
Most CAH’s are exempt from this rule.
4/1/2008

24. HOSPITAL BILLING RULES
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HOSPITAL BILLING RULES 19
Definitions for the 3 Levels of Supervision
Direct: physician/NPP must be immediately available to furnish assistance and direction throughout the performance of the procedure.
physician or NPP is not required to be present in the room when the procedure is performed.
General: procedure is furnished under the physician/NPP overall direction and control, but physician/NPP presence is not required during the performance of the procedure.
Personal: physician/NPP must be in the room during the procedure.
Definitions for the 3 Levels of Supervision
Direct: physician/NPP must be immediately available to furnish assistance and direction throughout the performance of the procedure.
physician or NPP is not required to be present in the room when the procedure is performed.
General: procedure is furnished under the physician/NPP overall direction and control, but physician/NPP presence is not required during the performance of the procedure.
Personal: physician/NPP must be in the room during the procedure.
4/1/2008

25. HOSPITAL BILLING RULES
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HOSPITAL BILLING RULES 20
RURAL HOSPITAL OUTPATIENT SERVICES
In 2012 the Advisory Panel on Hospital Outpatient Payment (HOP Panel) recommended that CMS adopt alternate supervision levels, including general supervision, for individual small and rural hospital outpatient therapeutic services.
Based on recommendations made by five hospitals who presented at the HOP Panel’s February and August 2012 meetings, CMS reduced the level of supervision for 49 outpatient therapeutic services from “direct” to “general” supervision.
American Hospital Association (AMA); 9/9/13
Rural hospital outpatient services
In 2012 the Advisory Panel on Hospital Outpatient Payment (HOP Panel) recommended that CMS adopt alternate supervision levels, including general supervision, for individual small and rural hospital outpatient therapeutic services. Based on recommendations made by five hospitals who presented at the HOP Panel’s February and August 2012 meetings, CMS reduced the level of supervision for 49 outpatient therapeutic services from “direct” to “general” supervision.
American Hospital Association (AMA); 9/9/13
4/1/2008

26. HOSPITAL BILLING RULES
RADMAX, LTD. Evaluating and Motivating Your Billing Staff
4/20/2017
HOSPITAL BILLING RULES 1
CHANGES FOR RURAL HOSPITALS (2014)
Hospital outpatient radiation therapy procedure supervision rules presently require the physician to have “direct” supervision over patient treatment.
Critical Access Hospitals (CAH’s) and rural hospitals (< 100 beds) had been exempt from this rule prior to 2014.
Beginning in 2014 supervision requirements of all Critical Access Hospitals (CAH’s) and rural hospitals will be enforced.
Radiation therapy can only be provided when there is a physician or non-physician practitioner immediately available who can provide assistance, direction, and orders.
CHANGES FOR rural hospitals (2014)
Hospital outpatient radiation therapy procedure supervision rules require the physician to have “direct” supervision over patient treatment.
Critical Access Hospitals (CAH’s) and rural hospitals (< 100 beds) had been exempt from this rule prior to 2014.
Beginning in 2014 supervision requirements of all Critical Access Hospitals (CAH’s) and rural hospitals will be enforced.
Radiation therapy can only be provided when there is a physician or non-physician practitioner immediately available who can provide assistance, direction, and orders.
4/1/2008

27. HOSPITAL BILLING RULES
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4/20/2017
HOSPITAL BILLING RULES 20
INCIDENT-TO SERVICES (INCLUDING CAH'S)
Must be performed by a “qualified” individuals:
Example: physicists incident-to physician.
Example: therapist [RT] incident-to physician.
Has to be in compliance with the hospital’s particular State’s requirements.
This is nothing new because Medicare already requires this. This is a regulatory change that adopts existing requirements as a condition of getting paid and for the concern and safety of patients.
Incident-to services (including CAH's)
Must be performed by a “qualified” individuals:
Example: physicists incident-to physician.
Example: therapist [RT] incident-to physician.
Has to be in compliance with the hospital’s particular State’s requirements.
This is nothing new because Medicare already requires this. This is a regulatory change that adopts existing requirements as a condition of getting paid and for the concern and safety of patients.
4/1/2008

28. HOSPITAL BILLING RULES
RADMAX, LTD. Evaluating and Motivating Your Billing Staff
4/20/2017
HOSPITAL BILLING RULES 20
NURSING HOMES/HOSPICE
Freestanding cancer centers are billed using place of service code ‘11’.
Place of service code 11 falls under Fee for Service Billing.
Nursing homes are considered “In-Patient” or Medicare Part A.
Freestanding cancer centers are considered “Out-Patient” or Medicare Part B.
Freestanding cancer centers must bill the nursing home/hospice direct for radiation oncology therapy services.
Cannot be billed simultaneously to Medicare.
Suggestion – work out an arrangement with Nursing Home (contract) for radiation therapy services up-front!
NURSING HOMES/HOSPICE
Freestanding cancer centers are billed using place of service code ‘11’.
Place of service code 11 falls under Fee for Service billing.
Nursing homes are considered “In-Patient” or Medicare Part A.
Freestanding cancer centers are considered “Out-Patient or Medicare Part B.
Freestanding cancer centers must bill the nursing home/hospice direct for radiation oncology therapy services.
Suggestion – work out an arrangement with Nursing Home (contract) for radiation therapy services up-front!
Cannot be billed simultaneously to Medicare.
4/1/2008

29. HOSPITAL BILLING RULES
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HOSPITAL BILLING RULES 20
NURSING HOMES/HOSPICE
Hospital based cancer centers are billed using place of service code ‘22’.
Place of service 22, radiation therapy services, fall under Medicare Consolidated Billing.
Location of facility defines the place of service – not the physician!
Hospital based outpatient cancer centers and nursing home/hospice can bill patient charges “separately” (simultaneously).
NURSING HOMES/HOSPICE
Hospital based cancer centers are billed using place of service code ‘22’.
Place of service 22 radiation therapy services fall under Medicare Consolidated billing.
Location of facility defines the place of service – not the physician!
Hospital based cancer centers and nursing home/hospice can bill “separately” at the same time (during patient’s treatment).
4/1/2008

30. HOSPITAL BILLING CHANGES
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HOSPITAL BILLING CHANGES 21
WHAT IS NEW FOR PACKAGING IN 2014?
CMS finalized five new categories of ancillary support items/services that will be packaged into primary diagnostic or therapeutic services (payment).
Drugs, biologicals, and radiopharmaceuticals used in diagnostics and procedures (does not include pass through).
Example: PET, F-18 (radioactive agent).
Drugs and biologicals used as supplies in surgeries.
Some clinical diagnostic lab tests.
Add-on procedures.
Removal of a device.
Example: HALO for stereotactic.
What is new for packaging in 2014?
CMS finalized five new categories of ancillary support items/services that will be packaged into primary diagnostic or therapeutic services (payment).
Drugs, biologicals, and radiopharmaceuticals used in diagnostics and procedures (does not include pass through).
Example: PET, F-18 (radioactive agent).
Drugs and biologicals used as supplies in surgeries.
Some clinical diagnostic lab tests.
Add-on procedures.
Does include add-on drug admin codes.
Removal of a device.
Example: HALO for stereotactic.
4/1/2008

31. HOSPITAL BILLING CHANGES
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HOSPITAL BILLING CHANGES 21
ONGOING IMAGE GUIDANCE PACKAGING
76950 – ultrasound guidance for placement of radioelements applications
76965 – ultrasound guidance for interstitial radioelements applications
77014 – therapeutic radiology for placement of radiation fields
77417 – therapeutic radiology port films
77421 – stereoscopic x-ray guidance for localization of target volume for the delivery of radiation therapy
0197T – intra-fraction localization and tracking of target or patient motion during the delivery of radiation therapy
Status “N” which means packaged into APC rates.
ONGOING IMAGE GUIDANCE PACKAGING
76950 – ultrasound guidance for placement of radioelements applications
76965 – ultrasound guidance for interstitial radioelements applications
77014 – therapeutic radiology for placement of radiation fields
77417 – therapeutic radiology port films
77421 – stereoscopic x-ray guidance for localization of target volume for the delivery of radiation therapy
0197T – intra-fraction localization and tracking of target or patient motion during the delivery of radiation therapy
Status “N” which means packaged into APC rates.
For the hospital, CT acquisition during treatment planning is packaged, and has been packaged for several years. No separate payment because the reimbursement for the packaged service is included in the payment for the primary procedure. Procedure code continues to have an “N” status (packaged) under OPPS for 2014.”
4/1/2008

32. HOSPITAL BILLING CHANGES
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HOSPITAL BILLING CHANGES 21
ONE OUTPATIENT ROOM CHARGE!
All HCPCS codes (five levels for new patient/established patient) now reduced to one (1) code.
No Longer Used – 99201, 99202, 99203, 99204, and 99205
No Longer Used – 99211, 99212, 99213, 99214, and 99215
New - G0463 (hospital outpatient clinic visit for assessment and management of a patient).
APC 0634 = $92.53.
Payment based on the average (mean) of the previous Level I through Level V visit codes.
One Outpatient Room Charge
All HCPCS codes (five levels for new patient/established patient) now reduced to one (1) code.
Out – 99201, 99202, 99203, 99204, and 99205
Out – 99211, 99212, 99213, 99214, and 99215
New - G0463 (hospital outpatient clinic visit for assessment and management of a patient).
APC 0634 = $92.53.
Payment based on the average (mean) of the previous Level I through Level V visit codes.
4/1/2008

33. HOSPITAL BILLING CHANGES
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4/20/2017
HOSPITAL BILLING CHANGES 22
NEW HCPCS CODES
(respiratory motion management simulation).
NOTE: Must be billed in addition to primary procedure code (3D Plan) or (IMRT Plan) on the “Same Claim” (together).
No APC (Status Indicator “N”)
Payment will be packaged to primary procedure.
New HCPCS Codes
(respiratory motion management simulation).
NOTE: Must be billed in addition to primary procedure code (3D Plan) or (IMRT Plan) on the “Same Claim” (together).
No APC (Status Indicator “N”)
Payment will be packaged to primary procedure.
4/1/2008

34. HOSPITAL BILLING CHANGES
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INTRAOPERATIVE
77424 IORT delivery, x-ray, single treatment session.
77425 IORT delivery, electrons, single treatment session.
Codes are not new (2012) but APC category renamed.
APC 0065 (IORT, MRgFUS, and MEG) = $1,
Note: C9726 (placement and removal of applicator into breast [radiation therapy]) will still be reported by hospital but no separate payment.
New HCPCS Codes (Intraoperative)
77424 IORT delivery, x-ray, single treatment session.
77425 IORT delivery, electrons, single treatment session.
Codes are not new (2012) but APC category renamed.
APC 0065 (IORT, MRgFUS, and MEG) = $1,
Note: C9726 (placement and removal of applicator into breast [radiation therapy]) will still be reported by hospital but no separate payment.
4/1/2008

35. HOSPITAL BILLING CHANGES
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HOSPITAL BILLING CHANGES
RADIOSURGERY G CODES DELETED FOR 2014
CMS felt is was no longer necessary to define “robotic” versus “non-robotic” Linac based SRS because most Linac based SRS treatment used robotic technology.
Deleted - G0173, G0251, G0339
Still available for contractor priced situations.
Deleted - G0340
Still available for MPFS contractor priced situations.
Radiosurgery/SBRT HCPCS Level II G codes deleted for 2014
CMS felt is was no longer necessary to define “robotic” versus “non-robotic” Linac based SRS because most Linac based SRS treatment used robotic technology.
Deleted - G0173, G0251, G0339
Still available for contractor priced situations.
Deleted - G0340
Still available for MPFS contractor priced situations.
4/1/2008

36. HOSPITAL BILLING CHANGES
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NEW RADIOSURGERY CODES FOR 2014
New (SRS single session cranial using multi-source cobalt 60 device).
APC 0067 = $3, (Level II SRS)
New (SRS single session cranial using linear accelerator).
New (SBRT - per fraction to one or more lesion including image guidance - not to exceed 5 fractions).
Exclusive code for any fractionated SRS treatment to any part of the body including cranial.
Includes first fraction.
APC 0066 = $1, (Level I SRS)
Radiosurgery/SRS HCPCS codes added for 2014
New (SRS single session cranial using multi-source cobalt 60 device).
APC 0067 = $3, (Level II SRS)
New (SRS single session cranial using linear accelerator).
New (SBRT - per fraction to one or more lesion including image guidance - not to exceed 5 fractions).
Exclusive code for any fractionated SRS treatment to any part of the body including cranial.
Includes first fraction.
APC 0066 = $1, (Level I SRS)
4/1/2008

37. HOSPITAL BILLING CHANGES
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COMPLEX PROTON BEAM SERVICES RATE INCREASE IN 2014
CMS did not approve the proposal to collapse all proton services into one (1) APC.
A single APC rate does not capture the significant clinical and resource differences between simple, intermediate, and complex proton beam therapy services.
Rates for complex proton beam services increased by more than 75%.
Rates for simple proton services decreased by 23%.
Complex Proton Beam Services Rates Increase in 2014
CMS did not approve the proposal to collapse all proton services into one (1) APC.
A single APC rate does not capture the significant clinical and resource differences between simple, intermediate, and complex proton beam therapy services.
Rates for complex proton beam services increased by more than 75%.
Rates for simple proton services decreased by 23%.
4/1/2008

38. HOSPITAL BILLING CHANGES
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BRACHYTHERAPY SOURCES PAYMENT RATES
CMS will continue to set the payment rates for brachytherapy sources using their established prospective payment methodology, which is based on geometric mean costs.
Methodology results in significant year-to-year swings in payment rates.
Brachytherapy Sources Payment Rates
CMS will continue to set the payment rates for brachytherapy sources using their established prospective payment methodology, which is based on geometric mean costs.
Methodology results in significant year-to-year swings in payment rates.
4/1/2008

39. HOSPITAL BILLING CHANGES
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LDR PROSTATE BRACHYTHERAPY INCREASE (19.36%)
CMS provides a single payment for LDR prostate brachytherapy when CPT codes (transperineal placement of needles/catheters) and (interstitial radiation source application) are furnished in a single hospital encounter (composite APC).
CMS bases the payment for composite APC 8001 (LDR prostate brachytherapy composite) on the geometric mean cost derived from claims for the same date of service that contain both CPT codes and
APC 8001 = $3,844.64
LDR Prostate Brachytherapy Increase (19.36%)
CMS provides a single payment for LDR prostate brachytherapy when CPT codes (transperineal placement of needles/catheters) and (interstitial radiation source application) are furnished in a single hospital encounter (composite APC).
CMS bases the payment for composite APC 8001 (LDR prostate brachytherapy composite) on the geometric mean cost derived from claims for the same date of service that contain both CPT codes and
APC 8001 = $3,844.64
4/1/2008

40. HOSPITAL BILLING CHANGES
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HOSPITAL MODIFIER PROPOSED CHANGES (HORIZON)
In response to a hospitals acquisition physician practices at a rapid pace, and being locations off-campus as Provider-Based outpatient Departments (PBD), CMS is soliciting comments (Proposed Rule) in regards to collecting data that would allow CMS to analyze the frequency, type, and payment for services furnished in off-campus PBD’s. CMS is considering:
New HCPCS modifier that could be reported with every code for services furnished in off-campus PBD’s.
Requiring hospitals to itemize costs and charges for their PBD’s as outpatient service cost centers on their Medicare cost reports.
CMS is still not sure how to best collect this data and it is still up for debate.
HOSPITAL MODIFIER PROPOSED CHANGES (HORIZON)
In response to a hospitals acquisition physician practices at a rapid pace, and being locations off-campus as Provider-Based outpatient Departments (PBD), CMS is soliciting comments (Proposed Rule) in regards to collecting data that would allow CMS to analyze the frequency, type, and payment for services furnished in off-campus PBD’s. CMS states that in its March 2012 Report to Congress, MedPAC questioned the appropriateness of increased Medicare payment and beneficiary cost-sharing for provider-based physician practices, and recommends that Medicare pay selected hospital outpatient services at the MPFS rates. CMS is considering:
New HCPCS modifier that could be reported with every code for services furnished in off-campus PBD’s.
Requiring hospitals to itemize costs and charges for their PBD’s as outpatient service cost centers on their Medicare cost reports.
CMS is still not sure how to best collect this data and it is still up for debate
4/1/2008

41. AMBULATORY SURGICAL CENTER (ASC)
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RATE INCREASE (BRACHYTHERAPY)
CMS increased the payment rate to ASC’s by 1.2%.
Final conversion factor = $ (meet quality reporting requirements).
Final conversion factor = $ (does not meet quality reporting requirements).
Hospitals and ASC’s that fail to meet Hospital OQR Program and Ambulatory Surgical Center Quality Reporting (ASCQR) requirements will receive a 2.0 percentage point reduction to their OPPS and ASC payment system reimbursements for the applicable payment year.
AMBULATORY SURGICAL CENTER (ASC)
Rate Increase (brachytherapy)
CMS increased the payment rate to ASC’s by 1.2%.
Final conversion factor = $ (meet quality reporting requirements).
Final conversion factor = $ (does not meet quality reporting requirements).
Hospitals and ASC’s that fail to meet Hospital OQR Program and Ambulatory Surgical Center Quality Reporting (ASCQR) requirements will receive a 2.0 percentage point reduction to their OPPS and ASC payment system reimbursements for the applicable payment year.
4/1/2008

42. HOSPITAL CLINICAL TRIALS
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CLINICAL TRIALS NUMBER NO LONGER OPTIONAL
In 2014 clinical trials hospitals must include a required eight (8) digit trial number on all claims that identifies services to the clinical trial patient.
After January 1, 2014 claims not containing this number will be returned and not processed.
If the provider does not have a capability to add the eight digits clinical trials number for claims submissions, they can us a generic 8-digit code ( ).
No blank fields.
Generic substitution code can only be used in calendar year 2014 (Jan – Dec).
HOSPITAL CLINICAL TRIALS
Clinical Trials Number No Longer Voluntary
In 2014 clinical trials hospitals must include a required eight (8) digit trial number on all claims that identifies services to the clinical trial patient.
After January 1, 2014 claims not containing this number will be returned and not processed.
If the provider does not have a capability to add this eight digit clinical trials number for claims submissions, they can us a generic 8-digit code ( ).
No blank fields.
Generic substitution code can only be used in calendar year 2014 (Jan – Dec).
4/1/2008

43. 2014 FINANCIAL CHANGES FOR HOSPITALS
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2014 FINANCIAL CHANGES FOR HOSPITALS
THE BIG PICTURE ($)
Medicare payment adjustment for hospitals under HOPPS had an average increase of 4% – 7% in 2014.
Rural Sole Community Hospitals (SCH’s) or Essential Access Community Hospitals (EACH’s) will continue to get a 7.1% payment increase in 2014 (most services).
2014 FINANCIAL CHANGES FOR HOSPITALS
The Big Picture
Medicare payment adjustment for hospitals under HOPPS had an average increase of 4% – 7% in 2014.
Rural Sole Community Hospitals or Essential Access Community Hospitals (EACH’s) will continue to get a 7.1% payment increase in 2014 (most services).
SCH and EACH payment adjustment do not include drugs, biologicals, items and services paid at charges reduced to cost, and items paid under the pass-through payment policy in accordance with section 1833(t)(13)(B) of the Act, as added by section 411 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 (MMA).
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44. 25
REFERENCES
CMS Manual System; Department of Health & Human Services (DHHS); Pub Medicare Claims Processing; December 27, 2013
ASTRO online article (CY 2014 Hospital Outpatient Payment Rates Released): anagemant/CY-2014-Hospitai-Outpaliert-Pa}ment-RaiBs-Released.aspx
DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services; Medicare Billing: 837I and Form CMS-1450; ICN March 2013
DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services; Medicare Physician Fee Schedule; PAYMENT SYSTEM FACT SHEET SERIES; ICN April 2013
DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services; Hospital Outpatient Prospective Payment System; PAYMENT SYSTEM FACT SHEET SERIES; ICN December 2012
The Diagnosis Related Groups (DRGs) to Adjust Payment-Mechanisms for Health System Providers; Inter-American Conference on Social Security; November-2005; CISS/WP/05122

45. RADMAX, LTD. Evaluating and Motivating Your Billing Staff
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END SECTION 13
THE END….
4/1/2008

46. If you don’t want your Lanyards, Please Recycle Them on your way out at the end of the seminar, thank you.

47. THANK YOU FOR YOUR ATTENDANCE PLEASE FILL OUT THE CRITIQUE SHEETS

48. PRINCIPLES OF BILLING, CODING AND COMPLIANCE IN RADIATION ONCOLOGY
END 13
BMSi 2014