Oncology & Hematology Coding Alert

Arbitrary crosswalks may mislead; RUC recommendations should be considered.

Are you curious how your relative value units (RVU) might change in 2017? You can get a glimpse by examining the American Society for Radiology Oncology's (ASTRO) response to Medicare. In September 2016, the ASTRO submitted a response to the "Medicare Program; Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2017" published in the Federal Register as a proposed rule on July 15, 2016. The proposed rule updates the payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (MPFS) effective January 1, 2017.

For updates proposed for 2017, ASTRO has the following suggestions:

1. Existing RUC approved RVUs for treatment device codes are justified and may be sustained in future.
2. RUC recommendation for CPT® code 77470 (Special treatment procedure [e.g., total body irradiation, hemibody radiation, per oral or endocavitary irradiation]) needs no modification.
3. RUC recommended RVUs of 8.78 for CPT® Code 77778 (Interstitial radiation source application, complex, includes supervision, handling, loading of radiation source, when performed) are rational and justified.
4. Arbitrary crosswalks cannot make a basis for lowering work RVU values in 2017.
5. Some radiation oncology services may qualify for use of PACS system.

Response letter: You can access the submitted response on: https://www.astro.org/uploadedFiles/_MAIN_SITE/Daily_Practice/Reimbursement/Medicare/Content_Pieces/2017ProposedMPFSComments.pdf.

Here is the key summary for the response submitted by ASTRO.

Proposed Survey Times Underestimate Device Services

ASTRO has opposed the modified work RVU recommendations for the treatment device codes: 77332 (Treatment devices, design and construction; simple [simple block, simple bolus]), 77333 (Treatment devices, design and construction; intermediate [multiple blocks, stents, bite blocks, special bolus]), and 77334 (Treatment devices, design and construction; complex [irregular blocks, special shields, compensators, wedges, molds or casts]). "We are greatly concerned with CMS' decision not to accept the RUC recommendations for radiation therapy treatment devices," says Laura I. Thevenot, Chief Executive Officer, ASTRO.

Data in support: ASTRO firmly recommends that CMS implements the existing RUC approved values (0.54, 0.84, and 1.24 for codes 77332, 77333, and 77334, respectively) and defends the recommendation with the supporting RUC survey data and the descriptions of work submitted by ASTRO. CMS is proposing RVUs of 0.45, 0.75, and 1.15 for these codes. For code 77332, CMS has evaluated the service time and intensity and proposed a cross walk to codes 93287 (Peri-procedural device evaluation [in person]...) and 97760 (Orthotic[s] management and training...), both of which have a work RVU of 0.45. ASTRO describes this crosswalk as 'arbitrary' as it is not based on any data analysis.

What this means for you: If the ASTRO recommendations are not considered by CMS, you should prepare to let go part of your deserved payment. For example, the ASTRO recommendation for 77332 is 0.54 implying a payment of $19.33. However, applying the CMS evaluations, your earnings are likely to drop to $16.11 (RVU of 0.45).

"ASTRO further supports that the RUC approved values (existing values), which have been supported by the RUC survey data and descriptions of work ASTRO had submitted, be left unmodified," says Kelly C. Loya, CPC-I, CHC, CPhT, CRMA, Managing Director of Pinnacle Enterprise Risk Consulting Services ("PERCS"), a division of Pinnacle Healthcare Consulting.

77470 RVUs Need No Modification

CMS has approved the RUC recommended work RVU value of 2.03 for CPT® Code 77470 (Special treatment procedure [e.g., total body irradiation, hemibody radiation, per oral or endocavitary irradiation]) which was identified under the high expenditure services' screen. However, CMS is still seeking feedback on the proposal to establish two G codes that will describe the physician work portion and PE portion of the service.

ASTRO does not see any rationale to establish two G codes and has suggested that the work and practice expense RUC recommendations need no modifications.

ASTRO further explains in their letter that, "The direct practice expense inputs include clinical labor and no supplies or equipment. When the code is used for another diagnosis the resource consumption would be the same and does not pose any issues. We note the typical claim is for a -26 Professional Fee. If the Agency is suggesting that there should be multiple CPT® Codes for every possible diagnosis for the use of this code, ASTRO would not support that approach. That is simply not how CPT 77470 works or is applied in the delivery of care."

Reduction in RVUs for 77778 Does Not Account for Physician Work

CMS is proposing to finalize the work RVU for CPT® code 77778 (Interstitial radiation source application; complex...) at an interim assigned value of 8.0 against the value of 8.78 proposed by RUC. The code 77778 is inclusive of supervision which was earlier reported with the now bundled code 77790 (Supervision, handling, loading of radiation source).

ASTRO has disagreed with the CMS decision to reduce the RVUs from 8.78 to 8.0 as the former is a fair assessment of physician work involved. "The letter goes on to explain how the work was calculated and supported at the higher value. In addition, an edit bundling the time was put in place and therefore should remain as recommended at 8.78," Loya says.

ASTRO Says 10% RVU Reduction for G6011 is Irrational

The Patient Access and Medicare Protection Act (PAMPA) has frozen the Treatment Delivery, IMRT and IGRT G Codes and the associated "definitions, units, and inputs for such services" for 2017 and 2018.

PAMPA statement: Patient Access and Medicare Protection Act of 2015. Public Law 114-115. 129 Stat. 3131. 28 December 2015. https://www.congress.gov/bill/114th-congress/senate-bill/2425/text/pl

CMS Proposal: CMS has proposed non-facility (NF) practice expense (PE) RVUs for G6011 Radiation Treatment Delivery as 8.09 for 2017. This is a 10 percent decrease from the current 9.03 NF PE RVUs.

ASTRO's urge: CMS proposal is inconsistent with the PAMPA recommendation and the agency has not shared any explanation. CMS may either submit a justification for the proposed 10 percent decrease in RVUs or may ideally accept the PAMPA recommendation.

Arbitrary Crosswalks Are Baseless

In an attempt to review the recommended code values for CY 2017 in context of time and intensity of services, CMS has assessed the changes in time and changes in work RVUs for 2014 and 2015. CMS has invited suggestions for any potential alternatives that would help to make a fair assessment of the intensity of services.

ASTRO has strongly suggested that intensity of services rendered is key to determining RVUs and CMS should not ignore this component. A fair assessment of the physician work will help to assign justified RVUs. Any arbitrary crosswalks will only lead to an irrational reduction of RVUs, ASTRO says.

PACS Applies to Radiation Oncology Services

CMS has proposed to exclude the professional picture archiving and communication system (PACS) workstation from the Radiation Therapy section (77261 through 77799). ASTRO has requested that CMS should consider using the professional PACS system ED053 for radiation oncology services. However, the evaluation for ED053 may be made on a case-to-case basis depending upon the use of PACS in the radiation service.