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2016 Billing and Coding Update for Radiation & Medical Oncology
This presentation was prepared as a tool to assist attendees in learning about documentation, chargecapture and billing processes. It is not intended to affect clinical treatment patterns. While reasonableefforts have been made to assure the accuracy of the information within these pages, the responsibilityfor correct documentation and correct submission of claims and response to remittance advice lies withthe provider of the services. The material provided is for informational purposes only.
Efforts have been made to ensure the information within this document was accurate on the date ofpresentation. Reimbursement policies vary from insurer to insurer and the policies of the same payormay vary within different U.S. regions. All policies should be verified to ensure compliance.
CPT® codes, descriptions and other data are copyright 2016 American Medical Association (or suchother date of publication of CPT®). All Rights Reserved. CPT® is a registered trademark of theAmerican Medical Association. Code descriptions and billing scenarios are references from the AMA,CMS local and national coverage determinations (LCD/NCD), the ASTRO/ACR Guide to RadiationOncology Coding, the ACRO Practice Management Guide and common practice standards nationwide.
Conversion Factor (CF) Update• The Medicare Access and CHIP Reauthorization Act of 2015
(MACRA) put into law April 16, 2015– Repealed sustainable growth rate (SGR)– Revised and established PFS updates for several years– Established a Merit-based Incentive Payment System (MIPS)
• CY 2016 CF proposed to be $36.1096 & finalized at $35.8279 – 0.5% increase over CY 2015 CF of $35.9335, but…– Decrease of Budget Neutrality Factor– Decrease of Target Recapture Amount– BUT WAIT!...CMS published MPFS correction notice on
Work product, information & guidance provided by RCI are subject to the terms & limitations provided at http://www.revenuecycleinc.com/disclaimer.
2014 CPT Code 2015 & 2016 MPFS
Code2015 & 2016 Description
77014 (IGRT) 77014 Computed tomography guidance for placement of radiation therapy fields77401 77401 Radiation treatment delivery, superficial and/or orthovoltage, per day76950 G6001 Ultrasonic guidance for placement of radiation therapy fields77421 G6002 Stereoscopic X-ray guidance for localization of target volume for the delivery of radiation therapy
77402 G6003 Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks; up to5 MeV
77403 G6004 Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks; 6-10 MeV
77404 G6005 Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks; 11-19 MeV
77406 G6006 Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks; 20 MeV or greater
77407 G6007 Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks; up to 5 MeV
77408 G6008 Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks; 6-10 MeV
77409 G6009 Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks; 11-19 MeV
77411 G6010 Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks; 20 MeV or greater
77412 G6011 Radiation treatment delivery, 3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; up to 5 MeV
77413 G6012 Radiation treatment delivery, 3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 6-10 MeV
77414 G6013 Radiation treatment delivery, 3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 11-19 MeV
77416 G6014 Radiation treatment delivery, 3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 20 MeV or greater
77418 G6015 Intensity modulated treatment delivery, single or multiple fields/arcs, via narrow spatially and temporally modulated beams, binary, dynamic MLC, per treatment session
0073T G6016 Compensator-based beam modulation treatment delivery of inverse planned treatment using 3 or more high resolution (milled or cast) compensator convergent beam modulated fields, per treatment session
0197T G6017 Intra-fraction localization and tracking of target or patient motion during delivery of radiation therapy (eg, 3D positional tracking, gating, 3D surface tracking), each fraction of treatment
Image guidance• On-board imaging calculated as part of capital expense of treatment
machines, could not accurately calculate separately for image guidance codes per the RUC data.
• Time value of image guidance was accepted as correct, 16 minutes total at time of treatment.– 3 mins pre-service, 10 mins intraservice and 3 mins post service
• The RUC assumed the most used imaging code was 77014, when setting values for 77387 it used these values– Most used imaging code was 77421 with lower RVUs
• CMS did not agree with imaging bundled into IMRT txs and then allowing imaging to be billed with 3D txs. Creates issues with the hierarchy of codes; 3D would be higher than IMRT if it was accepted
Equipment Utilization Rate for Linear Accelerators cont.• Treatment times had issues
– The RUC stated IMRT is 60 mins/treatment– Data and public info said IMRT is 5-30 mins/treatment
• CMS adjusting utilization for Rad Onc from 50% to 70% over 2 years– CMS calculated utilization to be higher, but limiting the increase to
only 70%, rather than the 90% used for Diagnostic Radiology – Increase to 60% in 2016 and increase to 70% in 2017– Increase in utilization = decrease in Practice Expense (PE) RVUs =
potential decrease in payment for treatments• This is reason for overall negative impact in 2016
Incident to Changes• CMS finalizing changes to incident to definition and guidelines.• Incident to services continue to require direct supervision of auxiliary
personnel providing the service by physician or NPP• CMS adjusting language to include supervising is billing physician
– “To be certain that the incident to services furnished to a beneficiary are in fact an integral, although incidental, part of the physician’s or other practitioner’s personal professional service that is billed to Medicare, we believe that the physician or other practitioner who bills for the incident to service must also be the physician or other practitioner who directly supervises the service. It has been our position that billing practitioners should have a personal role in, and responsibility for, furnishing services for which they are billing and receiving payment as an incident to their own professional services.”
• Statement matches attestation statement on back of CMS1500 claim form
• Auxiliary personnel who have been excluded from Medicare, Medicaid and all other federally funded health care programs by the OIG cannot provide services under incident to (direct supervision) of the physician
• “As a condition of Medicare payment, auxiliary personnel who, under the direct supervision of a physician or other practitioner, provide incident to services to Medicare beneficiaries must comply with all applicable federal and state laws. This includes not having been excluded from Medicare, Medicaid and all other federally funded health care programs.”
Biosimilar Biological Products• Created by using living cells that treat disease by genetically modifying the
cells being treated– Due to the size and complexity of the molecules, highly sensitive in the
manufacturing process and how they are handled. – Generic drugs follow a known recipe that is typically comprised of
standard ingredients. – A biosimilar is trying to match the outcome of an already known and FDA
approved drug, but the make-up of the biosimilar is different than the biologic. They are both made to achieve the same outcome with different recipes.
• Approval process can be lengthy since clinical trials must be run to prove the outcome matches the known biologic. Generic drugs are approved based simply on the fact the chemical structure matches the biologic it is replacing.
• Affordable Care Act – reduced pathway for licensing for biosimilar products established– Allows proposed biological product demonstrated to be
biosimilar to a reference product can rely on certain existing scientific knowledge about the safety, purity, and potency of the reference product to support licensure
– Also defined payment methodology & outlined in CY 2011 MPFS final rule
– Provide for Medicare payment of biosimilar biological products using the average sale price (ASP) methodology
• Section 1847A(b) of the Affordable Care Act was also amended by adding a new paragraph to specify the payment amount for a biosimilar biological product will be the sum of the ASP and 6% of the payment amount determined using the methodology in section 1847A(b)(4) of the Act for the corresponding reference biological product.
• Effective date was July 1, 2010 – at time unsure of FDA pathway for approvals or when one would be approved
• March 6, 2015 FDA approved first biosimilar product– CMS expects additional ones to be approved
Need For Review• As the biosimilars are emerging, CMS has reviewed the existing
guidance on payment and realized potential inconsistencies between the interpretation of the statutory language
• Comments received pertinent to the proposed changes were received from individuals, pharmaceutical manufacturers, patient advocate groups, providers and members of the House of Representatives
• Many requested a different payment amount for each biosimilar product and recommendations were made to be mindful of the policy as the marketplace evolves
• Commenters expressed concern over the appropriate clinical use of the drugs and medical recordkeeping issues that might result
• CMS responded that these concerns were outside the scope of the final rule
• CMS did indicate they were not aware of provider confusion resulting from the drug groupings and provided an example– HCPCS J3489 includes drugs Reclast, Zometa and
• CMS has finalized the proposal to amend the regulation text and specify the payment amount will be based on the ASP of all NDCs assigned to the biosimilar biological products included within the same billing and payment code– Effective January 1, 2016
• CMS indicated due to the similarity biosimilars share with their reference products, they should be priced in groups similar to how multiple source or generic drugs are priced
• CMS will have the discretion to calculate the ASP-based payment for grouped biosimilars in same manner and methodology used for grouped multiple drugs
Biosimilar Payments• New payments for approved biosimilars will be determined by
involving the receipt of the manufacturers’ ASP sales data through the ASP data submission process and publication of national payment amounts consistent with pricing for other drugs and biologicals
• CMS anticipates biosimilar products will have lower ASP than corresponding reference products = Medicare savings
• As of final rule release CMS had not received ASP data for any biosimilars approved under FDA’s biosimilar approval pathway
• CMS unaware of how many biosimilar products will be approved, expects some degree of savings to be realized
APC Restructuring• Finalized restructuring of APCs into 9 individual clinical families
and based on the following principles:– Improved clinical homogeneity;– Improved resource homogeneity;– Reduced resource overlap in APCs within a clinical family;
and– Greater simplicity and improved understanding of the
structure of the APCs. • APCs also renumbered to provide consecutive APC numbers
within a clinical family. • Every code in same APC is reimbursed the same amount,
• Services which are as integral, ancillary, supportive, dependent, and adjunctive to the primary service and reported on the same claim as SRS treatment codes 77371 (Cobalt-60 based) or 77372 (Linac based) is packaged and not separately reimbursed
• All ancillary services are reported on the claim to assist in cost reporting for the service in setting C-APC future payments, but not separately reimbursed
• Upon review of CY 2014 claims data for SRS procedures and the codes ancillary to 77371 and 77372 - issues identified which can and do impact the C-APC for SRS
• Changes made to C-APC – removing codes to be reimbursed separately
Cobalt-60 vs. Linac Variances • Analysis of CY 2014 claims revealed that billing practices for Cobalt-60 based
vs. Linac based technologies varied• SRS delivery with Cobalt-60 typically had all services (specifically imaging,
simulation, treatment plan and physics services) related to the procedure billed on the same date and claim as the treatment itself.
• Linac based services were found to have services such as imaging, simulation, treatment plan and physics services reported on different dates of service and separate claims. – Services such as simulation and planning reported up to a month prior to
Linac based SRS tx on different claim forms• Regulation passed in 2013 requires both 77371 and 77372 be reimbursed the
same amount. Changes finalized to account for possible increased reimbursement of linac based services performed over multiple dates vs. Gamma Knife which are performed on single date.
C-APC Changes 2016 & 2017• CMS removing some services from the C-APC and provide payment to these
separately, even when billed with the SRS treatment code which has a status indicator of “J1” in CYs 2016 & 2017
• The following codes will be removed from the SRS C-APC and reimbursed separately (up to 30 days prior to tx only), when reported on the same or claim 30 days prior as the SRS treatment code 77371 or 77372– CT localization (HCPCS codes 77011 and 77014);– MRI imaging (HCPCS codes 70551, 70552, and 70553);– Clinical treatment planning (HCPCS codes 77280, 77285, 77290, and
77295);– Physics consultation (HCPCS code 77336)
• Modifier “CP” to be reported on above codes when billed for services related in the preparation and delivery of SRS treatment, both Cobalt-60 and Linac based, but only when performed on different date than treatment
77372 Srs linear based 0067 $9,765.40 5627 $7,300.24 -25%
Remember, the new C-APC has removed codes which may be separately reimbursed when appropriate and due to edits. The negative impact for CY 2016 cannot be compared equally to CY 2015.
Frameless SRS Course Performed Over Multiple Dates of Service (Co-60 and Linac based)
Category CPT CPT Description2015
Quantity Paid
2016 Quantity Paid
2015 Total APC Pmt
2016 Total APC Pmt
Pre-SimG0463 Hospital outpt clinic visit $ - $ -
77470 Special radiation treatment $ - $ -
Simulation
70552 Mri brain stem w/dye 1 $ - $ 454.32
77290 Set radiation therapy field 1 $ - $ 291.77
77334 Radiation treatment aid(s) $ - $ -
Planning
77370 Radiation physics consult $ - $ -
77295 3-d radiotherapy plan 1 $ - $ 1,026.81
77300* Radiation therapy dose plan $ - $ -
77334 Radiation treatment aid(s) $ - $ -
Treatment77371 or 77372 Srs linear based 1 1 $ 9,765.40 $ 7,300.24
77336 Radiation physics consult 1 $ - $ 107.40
*MU Calculations are cannot be reported on the claim form in 2016 due to an edit with the planning code 77295. The course scenario has the simulation taking place on a date separate than the treatment plan and treatment delivery.
Headframe SRS Course Performed on Single Date of Service (Co-60 and Linac based)
Category CPT CPT Description2015
Quantity Paid
2016 Quantity Paid
2015 Total APC Pmt
2016 Total APC Pmt
Pre-SimG0463 Hospital outpt clinic visit $ - $ -
77470 Special radiation treatment $ - $ -
Simulation
70552 Mri brain stem w/dye 1 $ - $ 454.32
77290* Set radiation therapy field 0 $ - $ -
77334 Radiation treatment aid(s) $ - $ -
Planning
77370 Radiation physics consult $ - $ -
77295 3-d radiotherapy plan 1 $ - $ 1,026.81
77300** Radiation therapy dose plan $ - $ -
77334 Radiation treatment aid(s) $ - $ -
Treatment77371 or 77372 Srs linear based 1 1 $ 9,765.40 $ 7,300.24
77336 Radiation physics consult 1 $ - $ 107.40
*Code 77290 is lost to edit with treatment planning code 77295 on same date of service. *MU Calculations are cannot be reported on the claim form in 2016 due to an edit with the planning code 77295
Hospital OQR Bone Mets cont.• Designed to address concerns with unnecessary exposure to EBRT for bone
pain and reduce overuse of EBRT services, also address treatment gaps in the variations of courses used to treat the similar patients
• Measure to address all patients (all payors) using following dosing schedules– 30 Gy over course of 10 fractions– 24 Gy over course of 6 fractions– 20 Gy over course of 5 fractions– Single 8 Gy fraction
• Measure is not open to following patients– Patients who have had previous radiation to the same site; – Patients with femoral axis cortical involvement greater than 3 cm in length; – Patients who have undergone a surgical stabilization procedure; – Patients with spinal cord compression, cauda equina compression or
“Payment for the services identified by CPT codes 77014, 77280-77295, 77305-77321, 77331, 77336, and 77370 is included in the APC payment for IMRT planning when these services are performed as part of developing an IMRT plan that is reported using CPT code 77301. Under those circumstances, these codes should not be billed in addition to CPT code 77301 for IMRT planning.”
Initial Simulation with IMRT Course cont.• National Correct Coding Initiative (NCCI) guidance in the
NCCI Policy Manual for Medicare Services, Chapter 9, page IX-17
“12. Intensity modulated radiotherapy (IMRT) plan (CPT code 77301) includes therapeutic radiology simulation-aided field settings. Simulation field settings for IMRT should not be reported separately with CPT codes 77280 through 77295. Although procedure-to-procedure edits based on this principle exist in NCCI for procedures performed on the same date of service, these edits should not be circumvented by performing the two procedures described by a code pair edit on different dates of service.”
Initial Simulation with IMRT Course cont.• CMS provided the following statement to support their rationale for this
decision.“…We believe that the types of services included in IMRT treatment planning include simulation…we believe CMS’ longstanding Manual and coding guidance issued in CY 2008 has been precise in conveying its policy and instructions regarding coding for IMRT services and that, generally, IMRT services have been properly reported by hospitals.
It is our policy that payments for the services identified by CPT codes 77280 through 77295 are included in the APC payment for IMRT planning services, and that the services described by these CPT codes should not be reported separately from services described by CPT code 77301, regardless of when the various services that comprise CPT code 77301 are performed. If a hospital submits a claim that separately reports services described by one of these simulation CPT codes in addition to separately reporting IMRT planning services that are performed, we would consider this reporting to constitute unbundling of the APC payment, which is prohibited. We will revise and update the Medicare Claims Processing Manual and coding guidance in the near future to ensure that this policy is more directly stated. The clarified coding guidance will state the following:
“Payment for the services identified by CPT codes 77014, 77280 through 77295, 77305 through 77321, 77331, and 77370 is included in the APC payment for CPT code 77301 (IMRT planning). These codes should not be reported in addition to CPT code 77301 (on either the same or a different date of service) unless these services are being performed in support of a separate and distinct non-IMRT radiation therapy for a different tumor.”
Initial Simulation with IMRT Course cont.• However…codes 77301 and 77295 will continue to be
reimbursed the same amount in 2016! A 3D course of treatment does not have the simulation bundled into the planning.
• The final geometric mean cost of the services described by CPT code 77301 is approximately $1,125.
• CMS stated “if the clarification of our coding guidance for IMRT planning services results in a significant change in the geometric mean cost of services described by CPT code 77301 in future years, we will consider an alternative APC assignment for the code other than APC 5614.”
Packaged Oncology Codes• The following codes are designated with a Status Indicator (SI) of
Q1, which defines the code as conditionally packaged. When reported with another service paid under HOPPS with a Status Indicator of S, T or V, the payment will be packaged; however, when furnished alone, payment will be made separately. – CPT 96523 Irrigation of implanted venous access device for
drug delivery systems– CPT 36591 Collection of blood specimen from a completely
implantable venous access device– CPT 36592 Collection of blood specimen using established
central or peripheral catheter, venous, not otherwise specified
Payments of Drugs, Biologicals, and Radiopharmaceuticals
• Payments for those drugs and biologicals which do not have pass-through status are proposed to be set at the statutory default Average Sales Price (ASP) plus 6%
• Medicare finalized the proposal to expire pass-through status of twelve (12) drugs and biologicals on December 31, 2015
• Includes drugs and biologicals that have received OPPS pass-through payment for at least two (2) years and no longer than three (3) years by this expiration date
Table 43 – Drugs and Biologicals For Which Pass-Through Payment Status Expires December 31, 2015
CY 2016 HCPCS Code
CY 2016 Long DescriptorFinal CY 2016 SI
Final CY 2016 APC
J1556 Injection, immune globulin (Bivigam), 500 mg K 9130
J9047 Injection, carfilzomib, 1 mg K 9295
J9354 Injection, ado-trastuzumab emtansine, 1 mg K 9131
J9400 Injection, Ziv-Aflibercept, 1 mg K 9296
Pass-through Status• Medicare has finalized to continue pass-through status in CY 2016 for 38 drugs and biologicals.• For CY 2016, CMS will pay for pass-through drugs and biologicals at the Average Sales Price
(ASP) plus 6 percent and continue to update pass-through payment rates on a quarterly basis through the CMS website.
Table 44 –Drugs and Biologicals With Pass-Through Payment Status In CY 2016
CY 2015 HCPCS Code
CY 2016 HCPCS Code
CY 2016 Long Descriptor CY 2016 SICY
2016 APC*
C9025 J9035 Injection, ramucirumab, 5 mg G 1488C9027 C9027 Injection, pembrolizumab, 1 mg G 1490C9442 J9032 Injection, belinostat, 10 mg G 1658C9449 J9039 Injection, blinatumomab, 1 mcg G 9449C9453 J9299 Injection, nivolumab, 1 mg G 9453Q9970 J1439 Injection, ferric carboxymaltose, 1 mg G 9441J1446 J1446 Injection, TBO-Filgrastim, 5 micrograms G 1477C9021 J9301 Injection, obinutuzumab, 10 mg G 1476J9371 J9371 Injection, Vincristine Sulfate Liposome, 1 mg G 1466
Q5101 Q5101 Injection, Filgrastim (G-CSF), Biosimilar, 1 microgram G 1822
Packaged Payment Rate• CMS finalized the packaged threshold payment in CY 2016 to have a
cost per day less than $100.00, slight increase from CY 2015 which was $95
• CMS will continue to pay separately for items with an estimated per day cost greater than $100 with the exception of diagnostic radiopharmaceuticals, contrast agents, anesthesia drugs, drugs, biologicals and radiopharmaceuticals that function as supplies when used in a diagnostic test or procedure, and drugs and biologicals that function as supplies or devices when used in a surgical procedure.
• CMS will continue the policy of making packaging determinations on a drug-specific basis rather than by HCPCS code for those codes that describe the same drug or biological but in different dosages.
• Policy and packaging determinations on drug-specific basis, rather than HCPCS code – For codes that describe the same drug or biological, but in different
dosages• HCPCS codes describing different doses, est. cost/day of each drug or
biological is calculated by, – Weighted avg. ASP+6%/unit payment amount for all dosage levels
of specific drug or biological x est. units/day for all HCPCS codes that describe each drug or biological claims data
• HCPCS codes for the same drug or biologicals at less than or equal to $100 would be packaged as described above and those codes greater than $100 would be separately payable
Table 51– HCPCS Codes To Which The CY 2016 Drug-Specific Packaging Determination Methodology Applies
CY 2016 HCPCS Code
CY 2016 Long Descriptor CY 2016 SI
J9035 Injection, bevacizumab, 10 mg KJ1642 Injection, heparin sodium, (heparin lock flush), per 10 units NJ1644 Injection, heparin sodium, per 1000 units NJ7050 Infusion, normal saline solution , 250 cc NJ7040 Infusion, normal saline solution, sterile (500 ml=1 unit) NJ7030 Infusion, normal saline solution , 1000 cc NJ9250 Methotrexate sodium, 5 mg NJ9260 Methotrexate sodium, 50 mg N
Drug Packaging Payment Rate
• CMS also addresses drugs and biologicals lacking claims data and pricing information for ASP methodology
• CSM will continue to assign status indicator “E” (not paid by Medicare when submitted on outpatient claims [any outpatient bill type]) see Table 53
• CMS will continue to utilize status indicator “K” and pay for these codes separately for the remainder of CY 2015, if pricing information is available, which are represented within Table 52
Table 53 – Drugs And Biologicals Without CY 2014 Claims Data And Without Pricing Information For The ASP Methodology
CY 2016 HCPCS Code
CY 2016 Long Descriptor CY 2016 SI
J9160 Injection, denileukin diftitox, 300 micrograms E
J9215 Injection, interferon, alfa-n3, (human leukocyte derived),250,000 iu E
J9300 Injection, gemtuzumab ozogamicin, 5 mg E
Self-Administered Drugs (SADs) Technical Correction• The Affordable Care Act defines covered “medical and other
health services” to include both “services and supplies” and “hospital services” including drugs and biologicals not usually self-administered by the patient.
• CMS identified a paragraph which excludes payment for any drug or biological that can be self-administered
• CMS made a technical correction to amend the description of these drugs and biologicals, to reflect the statutory language. – Deletion of the phrase “any drug or biological that can be
self-administered” and replace it with the phrase “any drug or biological which is usually self-administered by the patient”.
• Codes 77785, 77786 & 77787 deleted in 2016• New codes added - Skin Surface HDR Radionuclide
Treatments– 77767 – Remote afterloading high dose rate radionuclide
skin surface brachytherapy; includes basic dosimetry, when performed; lesion diameter up to 2.0 cm or 1 channel
– 77768 - Remote afterloading high dose rate radionuclide skin surface brachytherapy; includes basic dosimetry, when performed; lesion diameter over 2.0 cm and 2 or more channels, or multiple lesions
Radionuclide Brachytherapy Codes cont.• Codes 77785, 77786 & 77787 deleted in 2016• New codes added - Interstitial or Intracavitary HDR Radionuclide
Treatments– 77770 - Remote afterloading high dose rate radionuclide
interstitial or intracavitary brachytherapy; includes basic dosimetry, when performed; 1 channel
– 77771 - Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy; includes basic dosimetry, when performed; 2 to 12 channels
– 77772 - Remote afterloading high dose rate radionuclide interstitial or intracavitary brachytherapy; includes basic dosimetry, when performed; over 12 channels
• Bipartisan Budget Act of 2015 signed into law 11/2/15• SEC. 603. Treatment of Off-campus Outpatient Departments of a Provider
references 42 CFR 413.65 - Requirements for a determination that a facility or an organization has provider-based status within the law.
• MedPAC (Medicare Payment Advisory Commission) concerned that CMS pays varying payments based on location or designation of an entity for the same services and hospitals are acquiring practices to increase payments– Procedure in office/freestanding cancer center paid under MPFS– Procedure in hospital setting, pay facility fee under HOPPS and
professional fee under MPFS, typically results in higher amount paid than just for procedure in an office
– Procedure in ASC reimbursement is less than if receives same service in a hospital
Provider Based Department Changes cont.• Bipartisan Budget Act of 2015, Section 603, effective January 1,
2017 when a service is provided in an off-campus outpatient department of a hospital, unless they were billing as a dept. of the hospital prior to January 1, 2017, CMS will reimburse services under either the MPFS or ASC fee schedule.
• Off-campus departments billing for services prior to 1/1/17 are exempt, but CMS could change or adjust future rules to add further limitations
• Hospitals will be required to report as requested per the HHS Secretary info appropriate to implement means of collecting data, which may include use of a modifier or code
• On-campus vs. off-campus, what’s the difference?– Per 42 CFR 413.65, “Campus means the physical area immediately
adjacent to the provider's main buildings, other areas and structures that are not strictly contiguous to the main buildings but are located within 250 yards of the main buildings, and any other areas determined on an individual case basis, by the CMS regional office, to be part of the provider's campus.”
• Locations not on-campus are considered off-campus– Hospitals need to evaluate their campuses and how they defined the
locations with CMS• Remote locations of a hospital will be considered on-campus• Any new acquisitions or off-campus locations need to be evaluated for
• POS codes to identify services provided in on-campus outpatient hospital vs. off-campus outpatient hospital
New and Revised POS Codes Effective January 1, 2016Code Descriptor
POS 19 Off Campus-Outpatient Hospital
Descriptor: A portion of an off-campus hospital provider based department which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.
POS 22 On Campus-Outpatient Hospital
Descriptor: A portion of a hospital’s main campus which provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services to sick or injured persons who do not require hospitalization or institutionalization.
• Effective January 1, 2016 CPT code 77300 will edit with Code 77295!
• Code 77300 would be billable with following possible scenarios– IMRT, IORT, SIRT, Radiopharmaceuticals & Superficial– Nomograms for PSI– Hand calculations– Re-calculating dose later during course due to changes
• Code 77300 is a column 2 code to the following primary codes• 77295, 77306 & 77307 & 77316 – 77318• 77767, 77768, 77770, 77771 & 77772• 0394T & 0395T