CURRENT TOPICS IN RADIATION ONCOLOGY:

Transcription

1 New England Chapter of the AAPM Providence, RI June 15, 2012 CURRENT TOPICS IN RADIATION ONCOLOGY: REIMBURSEMENT, DOCUMENTATION, COMPLIANCE AND REGULATORY James E. Hugh, III, MHA, ROCC, CHBME Contributions by Linda L. Lively, MHA, CCS-P, RCC, ROCC, CHBME Copyright AMAC 2012 All rights reserved.

2 DISCLAIMER Warning: Reimbursement policies vary widely from insurer to insurer and reimbursement policies of the same third party payor may vary in different sections of the United States. As reimbursement policies are subject to change, AMAC will endeavor, on a periodic basis, to review and revise, as necessary, all pertinent reimbursement information. Therefore, the information contained herein (while accurate at the time of print) may not be accurate at the time of use. Prior to submission of a claim for reimbursement, the user should contact the third party payor (i.e., Medicare, Medicaid or private payer) to verify applicable codes and reimbursement levels. PLEASE NOTE: All five-digit numeric CPT codes, descriptions, instructions and guidelines are Copyright of the American Medical Association (AMA). To purchase AMA's products please contact the American Medical Association at AMAC assumes no responsibility for the consequences related to the use of information contained in this publication. All codes presented in this guide are for informational purposes only. The presentation may contain menus of codes and is not intended for treatment prescription guidelines. AMAC realizes there are variations between physicians, clinical staff and provider policies concerning the treatment and performance of procedures, documentation, charging and training of staff. Code descriptions and billing scenarios are references from and credited to the AMA CPT-4 current procedural terminology, Healthcare Common Procedure Coding System (HCPCS), AMA case studies. CMS local and national coverage determinations (LCD, NCD) and the ASTRO/ACR Guide to Radiation Oncology Coding. DRG guidelines will determine inpatient reimbursement for Medicare recipients. Only the specific services performed by the healthcare provider should be billed. The physician must order, perform, document all procedures, staff must document all ordered procedures by physician. Operative or procedure reports should be detailed, dictated, signed, and placed in the medical chart. 6/15/12 Copyright AMAC

3 DISCLOSURE AMAC currently works with most cancer centers, societies, physicians, insurance companies and manufacturers as it relates to medical record documentation, reimbursement and coding. Our talk will consist of the above and will not specifically address any manufacturer. 6/15/12 Copyright AMAC

4 Top 10 Ways to Know You are a Cancer Survivor 10. Your alarm clock goes off at 6 a.m. and you're glad to hear it. 9. Your mother-in-law invites you to lunch and you just say NO. 8. You're back in the family rotation to take out the garbage. 7. When you no longer have an urge to choke the person who says, "all you need to beat cancer is the right attitude." 6. When your dental floss runs out and you buy 1000 yards. 5. When you use your toothbrush to brush your teeth and not comb your hair. 4. You have a chance to buy additional life insurance but you buy a new convertible car instead. 3. Your doctor tells you to lose weight and do something about your cholesterol and you actually listen. 2. When your biggest annual celebration is again your birthday, and not the day you were diagnosed. 1. When you use your Visa card more than your hospital parking pass. 6/15/12 Copyright AMAC

5 From the mile high perspective... a review of events THE PATIENT PROTECTION AND AFFORDABLE CARE ACT OF 2010 [(H.R. 3590) AS AMENDED BY THE HEALTH CARE AND EDUCATION RECOVERY ACT OF 2010 (P.L TOGETHER REFERRED TO AS THE AFFORDABLE CARE ACT (ACA) 6/15/12 Copyright AMAC

6 THE PATIENT PROTECTION AND AFFORDABLE CARE ACT ESSENTIAL COMPONENTS OF REFORM QUALITY, AFFORDABLE HEALTH CARE FOR ALL AMERICANS THE ROLE OF PUBLIC PROGRAMS IMPROVING THE QUALITY AND EFFICIENCY OF HEALTH CARE PREVENTION OF CHRONIC DISEASE AND IMPROVING PUBLIC HEALTH HEALTH CARE WORKFORCE TRANSPARENCY AND PROGRAM INTEGRITY IMPROVING ACCESS TO INNOVATIVE MEDICAL THERAPIES COMMUNITY LIVING ASSISTANCE SERVICES AND SUPPORTS REVENUE PROVISIONS 6/15/12 Copyright AMAC

7 CMS - Snapshot In 2011, Medicare covered 48.7 million people: 40.4 million aged 65 and older 8.3 million disabled 25 percent of beneficiaries enroll in Part C private health plans that contract with Medicare to provide Part A and Part B health services Total expenditures in 2011 were $549.1 billion Total income was $530.0 billion 6/15/12 Copyright AMAC

8 6/15/12 6/15/12 Copyright AMAC

9 THE DEBATE FRAUD WASTE MEDICAL MISTAKES OUTCOMES ENTITLEMENT UNEMPLOYMENT /UNINSURED 6/15/12 Copyright AMAC

10 INITIATIVES AND PROPOSALS 10 AFFORDABLE CARE ACT ACCOUNTABLE CARE ORGANIZATIONS BUNDLING PHYSICIAN FEE FREEZES INCENTIVES ERX EHR PQRS 6/15/12 Copyright AMAC

11 11 Fraud Prevention Initiatives Recommendations from the Government Accounting Office to HHS provided five key strategies to help reduce fraud, waste, abuse, and improper payments in Medicare and Medicaid: Strengthening standards and procedures for provider enrollment Improving prepayment review of claims. Focusing post-payment claims review on most vulnerable areas. Improving oversight of contractors. Developing a robust process for addressing identified vulnerabilities In FY 2012, CMS estimates that $400 M has already been recovered In fiscal year 2011 anti-fraud activities resulted in more than $4 billion in recoveries Kathleen Sebelius HHS Secretary 6/15/12 Copyright AMAC

12 Interim CMS Administrator 12 Marilyn B.Tavenner Tavenner is former Virginia Secretary of HHS; at CMS since Feb years -- at the Hospital Corp. of America BS in Nursing and Masters in Health Administration Nomination for Administrator s position will require Senate confirmation 6/15/12 Copyright AMAC

13 Auditing and Monitoring The Centers for Medicare & Medicaid Services oversees several auditing initiatives to identify overpayments to physicians and hospitals. These programs include: Medicare Administrative Contractors (MAC) Comprehensive error rate testing contractors(cert) Medicaid recovery auditors and integrity contractors Medicare recovery audit contractors (RAC) Payment error rate measurement contractors Program safeguard contractors Zone program integrity contractors (ZPIC) 6/15/12 Copyright AMAC

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15 Medicare RAC Contractors 6/15/12 Copyright AMAC

16 MAC PALMETTO FOR JURISDICTION 11 CONDUCTING PREPAYMENT MEDICAL REVIEW PROBE Jurisdiction 11 Part B Medical Review Probe: Outpatient Oncology Radiation Therapy Procedure Codes The J11 A/B MAC Medical Review department is performing a service-specific prepay probe review on outpatient claims in North Carolina, South Carolina, Virginia and West Virginia. Data analysis identified 13 oncology radiation therapy outpatient services with significant frequency in these states. The Medicare Program Integrity Manual authorizes MACs to conduct prepayment medical reviews of claims to determine compliance with Medicare coverage, coding and billing rules. 6/15/12 Copyright AMAC

17 CPT code Short form descriptor Radiation treatment delivery Radiology port film(s) Radiation tx delivery imrt Radiation therapy planning Set radiation therapy field Set radiation therapy field Set radiation therapy field Radiation therapy dose plan Special radiation dosimetry Radiation treatment aid(s) Radiation physics consult Radiation tx management x Special radiation treatment 6/15/12 Copyright AMAC

18 Patient Protection and Affordable Care Act (ACA) The Supreme Court of the United States has completed hearing oral arguments over the lawsuit (Florida, et al Vs. Department of Health and Human Services) brought by 26 states and the National Federation of Independent Business (NFIB) challenging the constitutionality of the Patient Protection and Affordable Care Act (ACA). The oral arguments are available: s/argument_audio.aspx 6/15/12 Copyright AMAC

19 PPACA 1. Is a lawsuit challenging the individual mandate permissible at this time because the "penalty" for failure to show evidence of having health insurance is a"tax" under federal law? 2. Is the individual mandate constitutional? 3. Is the Medicaid expansion an unreasonable encroachment by the federal government on state autonomy? 4. The final issue considered by the U.S. Supreme Court had to do with the issue of severability. 6/15/12 Copyright AMAC

20 ACA and Supreme Court Justices Sonia Sotomayor, Elena Kagan, Stephen Breyer, and Ruth Bader Ginsburg are expected to vote to uphold the individual mandate and the PPACA. Justices Antonin Scalia, Samuel Alito, and Clarence Thomas are expected to vote to overturn the individual mandate. Justice Anthony Kennedy possibly Chief Justice John Roberts will be pivotal votes. 6/15/12 Copyright AMAC

21 ACA and Supreme Court The loss of the individual mandate could require that other reforms be severed from PPACA, including the guarantee issue provision, pre-existing condition exclusions, and the use of an adjusted community rating system. Without individual mandates, higher premiums, coverage disruptions, and fewer choices for consumers probable. 6/15/12 Copyright AMAC

22 ACA and Supreme Court 6/15/12 Copyright AMAC

23 Drivers of Reform What is Sustainable Growth Rate WHAT IS SGR? Under the SGR formula, if expenditures over a period of time are less than the cumulative spending target, the annual update is increased; if spending exceeds the cumulative spending target, the update is reduced. 6/15/12 Copyright AMAC

24 CHALLENGE: FIX THE SGR THE MAJOR CHALLENGE WITH FIXING THE SGR PROBLEM CONTINUES TO BE HOW TO PAY FOR CHANGES IN THE WAY THE PHYSICIAN FEE SCHEDULE PAYMENTS ARE UPDATED. A WAIVER OF THE SGR FORMULA WOULD RESULT IN INCREASED MEDICARE EXPENDITURES OF APPROXIMATELY $300 BILLION OVER THE NEXT 10 YEARS. 6/15/12 Copyright AMAC

25 Hospital Compare and Value Based Purchasing 25 Under the Affordable Care Act and the Inpatient Prospective Payment System (IPPS) proposed rule (4/24/12), CMS proposes to use "cost per Medicare beneficiary as 20% of a hospital's value-based purchasing score to determine incentive payments for discharges starting Oct. 1, The "cost per Medicare beneficiary" score for acute care hospitals is posted on the Hospital Compare website and shows differences in costs for Medicare services for 3,375 hospitals for specific episodes of care as reported on Medicare claims for services between 5/15/10 to 2/14/11 6/15/12 Copyright AMAC

26 Value Based Purchasing CMS as Robin Hood 26 Each episode covers a period three days prior to admission to 30 days after discharge for care delivered by any provider paid under Medicare Part A or Part B. Under value-based purchasing rules, hospitals will have 1.5% of their Medicare DRG total withheld from their payments by According to CMS, the cost efficiency scores are risk adjusted for age and severity of illness; cancer or other specialty hospitals treating more severely ill patients are fairly compared. The 1.5% funds will create a pool to be redistributed as incentive payments to top performing hospitals. 6/15/12 Copyright AMAC

27 Value Based Purchasing 27 30% patient experience 30% outcome measures 20% clinical process of care 20% efficiency score *Performance period from May 1 to Dec. 31, /15/12 Copyright AMAC

28 CCI Simplification for Version 18.1 CMS consolidated their two edit files into one Column One/Column Two Correct Coding edit file. This change occurred for practitioner NCCI edits in NCCI version 18.1 on April 1, It will only be necessary to search the Column One/Column Two Correct Coding edit file for active or previously deleted edits. Effective April 1, 2012, CMS will no longer publish a Mutually Exclusive edit file on its website for either practitioner or outpatient hospital services. Separate consolidations will occur for the two practitioner NCCI edit files and the two NCCI edit files used for OCE. Prior to January 1, 2012 NCCI edits incorporated into outpatient code editor (OCE) appeared in OCE one calendar quarter after they appeared in NCCI. Effective January 1, 2012, NCCI edits in OCE appear synchronously with NCCI edits for practitioners. Source: Coding-Edits.html 6/15/12 Copyright AMAC

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30 This commentary indicates that a physician has a perpetual duty to research whether any overpayment may exist. This requirement would be extremely burdensome for physicians, as it would impose a boundless duty to troll medical records in search of innumerable vulnerabilities. Moreover, 6402(a) does not impose such a requirement. We understand that CMS requirements for periodic self-audits and compliance checks will be promulgated in a separate rulemaking pursuant to 6401(a) of the ACA; that rulemaking is a more appropriate vehicle for CMS proposals on those topics. CMS should make clear that in the context of 6402(a), physicians are not obliged to proactively search for an overpayment without reason to believe that a specific overpayment exists. Source: The American Medical Association et al. letter to the Centers for Medicare & Medicaid Services, April 16, /15/12 Copyright AMAC

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32 HEAT PROVIDER COMPLIANCE TRAINING DEPARTMENT OF HEALTH AND HUMAN SERVICES WEBCAST AND DOWNLOAD PROGRAM MATERIALS 6/15/12 Copyright AMAC

33 Accountable Care Organizations Created by the Affordable Care Act The Medicare Shared Savings Program provides incentives for participating health care providers who agree to work together and become accountable for coordinating care for patients. Providers who band together through this model and who meet certain quality standards based upon, among other measures, patient outcomes and care coordination among the provider team, may share in savings they achieve for the Medicare program. The higher the quality of care providers deliver, the more shared savings the providers may keep. The Advance Payment model will provide additional support to physician-owned and rural providers participating in the Medicare Shared Savings Program who also would benefit from additional start-up resources to build the necessary infrastructure, such as new staff or information technology systems. The advanced payments would be recovered from any future shared savings achieved by the Accountable Care Organization. 6/15/12 Copyright AMAC

34 34 CMS Revalidation A provision of the Affordable Care Act Centers for Medicare and Medicaid Services (CMS) posted a list of providers who have been sent a request to revalidate their Medicare enrollment. The list contains the name and national provider identifier of each provider sent a letter as well as the date the letter was sent. The list is available in the Downloads section of the CMS Medicare revalidation page. CMS actively revalidating providers who enrolled prior to 3/25/11; You must wait until you receive a letter; CMS is extending the timeframe of their revalidation initiative through 2015 Providers and suppliers must revalidate their enrollment information under the new screening provisions. Medicare contractors have already sent over 100,000 revalidation requests. Those who have been sent revalidation requests must respond within the required 60 day timeframe. _Revalidations.asp#TopOfPage 6/15/12 Copyright AMAC

35 CURRENT REGULATION STATES THAT CLAIMS FOR SERVICES PROVIDED ON OR AFTER OCT 1, 2013 MUST USE ICD-10 CODES FOR MEDICAL DIAGNOSIS AND INPATIENT PROCEDURES CMS HAS NOW PROPOSED A ONE-YEAR DELAY FOR COMPLIANCE WITH ICD-10 UNTIL OCTOBER 1, 2014 THE AMA OPPOSED THE CONVERSION CITING COST ISSUES IN ADDITION TO OTHER CONCERNS: "The implementation of ICD-10 will create significant burdens on the practice of medicine with no direct benefit to individual patients' care. 6/15/12 Copyright AMAC

36 36 Electronic Transactions 5010 Medicare Fee-For-Service Update, Week of June 11, 2012 Medicare Fee-For-Service (FFS) is continuing to assist trading partners as they transition to the new Health Insurance Portability and Accountability Act (HIPAA) electronically exchanged health care transactions. For the week of June 11, Medicare FFS has the following updates regarding deadlines and an announcement for an upcoming webinar. Inbound transactions sent to Medicare FFS after close of business on June 29, 2012 must only include the following versions: Accredited Standards Committee (ASC) X12 Version (5010) Health Care Claim: Professional (837P) Health Care Claim: Institutional (837I) Heath Care Claim Status Request (276) National Council for Prescription Drug Program (NCPDP) Version D.0 Claim If Medicare FFS inbound transactions in version 4010/A1 or CCPDP 5.1 format are sent to Medicare Administrative Contractors (MACs) after close business on June 29, 2012, they will be rejected. Notices regarding rejected claims will be sent by the MAC in their specific format. A list of the rejection error messages can be found on the CMS Important Rejection Information on the CMS website at: Rejection-Information.html. Starting July 1, 2012 the Coordination of Benefits (outbound ASC X12 837) and Health Care Claim Status Response (ASC X12 277) will be sent out in version 5010 only. Medicare will also allow an additional 30 days to finalize the transition to the ASC X12 Health Care/Claim Advice (835) otherwise known as Remittance Advice. This establishes August 1, 2012 as the date in which all Remittance Advice will be sent out to trading partners in 5010 format. It is crucial that everyone tests the receiving and processing functions with their MACs using the 5010 versions during the transaction period. Copyright AMAC

37 Value Based Modifier Affordable Care Act requires CMS to initiate valuebased payment adjustments to some physicians in 2015 and to all physicians by 2017 CMS finalized its decision to use CY 2013 as the initial performance period for calculating the valuebased payment modifier that will apply to items and services furnished by specific physicians and groups of physicians under the 2015 PFS. 6/15/12 Copyright AMAC

38 E-prescribing Significant Hardship Exemptions The eligible professional is unable to electronically prescribe due to local, state, or federal law or regulation. The eligible professional has or will prescribe fewer than 100 prescriptions during a 6- month reporting period (January 1 June 30, 2012). The eligible professional practices in a rural area without sufficient high-speed Internet access (G8642). The eligible professional practices in an area without sufficient available pharmacies for electronic prescribing (G8643). Deadline to submit requests for significant hardship exemptions: 2013 Payment Adjustment: June 30, Payment Adjustment: June 30, % penalty in 2012; In 2013 and 2014, the penalty increases to 1.5 percent and 2.0 percent respectively. 6/15/12 Copyright AMAC

39 E-Prescribing Hardship 39 /communications_support_system/234 Many radiation oncologists requested exemptions in 2011 for the 2012 payment adjustment because prescriptions are not usually written during a new patient or follow up visit. Note that this exemption will not be valid in 2012 because the code G8553 can now be reported with any CPT code. The change in criteria eliminates this as a hardship exemption. 6/15/12 Copyright AMAC

40 Physician Compare PQRS The applicable incentive amounts are : 2012: 0.5 percent 2013: 0.5 percent 2014: 0.5 percent The applicable payment adjustment amounts are as follows: 2015: 1.5 percent 2016 and each subsequent year: 2.0 percent The Physician Quality Reporting System will be the basis for the Value-Based Modifier CLAIMS REPORTING PERIOD JAN-DEC REPORT AT LEAST 3 MEASURES FOR MINIMUM 50% OF ELIGIBLE PART B FFS PATIENTS DURING THE REPORTING PERIOD 6/15/12 Copyright AMAC

41 2012 PQRS 71- BREAST CANCER: HORMONAL THERAPY FOR STAGE IC-IIIC ESTROGEN RECEPTOR/PROGESTERONE (ER/PR) POSITIVE BREAST CANCER 102- PROSTATE CANCER: AVOIDANCE OF OVERUSE OF BONE SCAN FOR STAGING LOW- RISK PROSTATE CANCER PATIENTS 104- PROSTATE CANCER: ADJUVANT HORMONAL THERAPY 105- PROSTATE CANCER: THREE-DIMENSIONAL (3D) RADIOTHERAPY 143- ONCOLOGY: MEDICAL AND RADIATION PAIN INTENSITY QUANTIFIED 144- ONCOLOGY: MEDICAL AND RADIATION PLAN OF CARE FOR PAIN 156- ONCOLOGY- RADIATION DOSE LIMITS TO NORMAL TISSUE 194- ONCOLOGY- CANCER STAGE DOCUMENTED * No known 2012 changes to 2011 Measures impacting Rad Oncs 6/15/12 Copyright AMAC

42 3-Day Payment Window Policy and the Impact on Wholly Owned or Wholly Operated Physician Practices Delayed implementation to July 1, 2012 Per CMS we will ill establish a new HCPCS modifier (PD) through sub-regulatory guidance. We would require that this modifier be appended to the physician preadmission diagnostic and admissionrelated non-diagnostic services, reported with HCPCS codes, which are subject to the 3-day payment window policy. Each wholly owned or wholly operated physician's practice would need to manage its billing processes to ensure that it billed for its physician services appropriately when a related inpatient admission has occurred. 6/15/12 Copyright AMAC

43 We indicated that outpatient therapeutic services and supplies must be furnished under the order of a physician or other appropriate non-physician practitioner, and by hospital personnel under the direct supervision of a physician or appropriate non-physician practitioner. Additionally, we believe that there is a similar level of clinical risk in the therapeutic hospital outpatient services covered under other benefit categories that are not explicitly defined as incident to services. For example, stereotactic radiosurgery (a radiation therapy service under section 1861(s)(4) of the Act) is a high risk and technically demanding surgical procedure. We do not believe that the current requirements under regarding supervision, under arrangement, provider-based, and other aspects of service, were intended to apply only to a subset of hospital outpatient therapeutic services and supplies, or that the agency ever intended to omit large classes of services that are routinely furnished to hospital outpatients from being governed by this regulation. (same as 2011) 6/15/12 Copyright AMAC

44 In summary, we are proposing to establish the Federal Advisory APC Panel as an independent review body that would evaluate individual outpatient therapeutic services for potential assignment by CMS of general (lower) or personal (higher) supervision. We also are proposing clinical and other evaluation criteria that the Panel would use in recommending a supervision level that would apply at the individual CPT code level. As we have not yet defined personal supervision or general supervision for all hospital outpatient therapeutic services, we are proposing definitions for these terms in this proposed rule 6/15/12 Copyright AMAC

45 In rulemaking for CY 2012, CMS established a process under which the Advisory Panel on Hospital Outpatient Payment will begin in CY 2012 to evaluate requests for changes in the required supervision level of individual hospital outpatient therapeutic services. CMS is now extending this instruction an additional year through CY For purposes of this notice, CMS defines small rural hospitals as hospitals with 100 or fewer beds that are geographically located in a rural area or that are paid under the hospital outpatient prospective payment system with a rural wage index. CMS continues to expect the hospitals covered under this notice to fulfill all other Medicare program requirements when providing services to Medicare beneficiaries and when billing Medicare for those services. While CMS is instructing contractors not to enforce the supervision requirements for outpatient therapeutic services in these hospitals for CY , we continue to emphasize quality and safety for services provided to all patients in these facilities. AMAC Comment: You asked for it and you got it! 6/15/12 Copyright AMAC

46 77424 Intraoperative radiation treatment delivery, x- ray, single treatment session (hospital ASC) Intraoperative radiation treatment delivery, electrons, single treatment session (Hospital ASC) Indicator code N Packaged NI - New code for the next calendar year or existing code with substantial revision to its code descriptor in the next calendar year as compared to current calendar year, interim APC assignment; comments will be accepted on the interim APC assignment for the new code. Confirmed by phone call from CMS, proposed rules for 2013 will have APC payment rates for the above CPT codes July /15/12 Copyright AMAC

47 In the CY 2008 OPPS/ASC final rule with comment period (72 FR through 66659), we adopted the packaging of payment for items and services in seven categories into the payment for the primary diagnostic or therapeutic modality to which we believe these items and services are typically ancillary and supportive. The seven categories are: (1) guidance services; (2) image processing services; (3) intraoperative services; (4) imaging supervision and interpretation services; (5) diagnostic radiopharmaceuticals; (6) contrast media; and (7) observation services. We specifically chose these categories of HCPCS codes for packaging because we believe that the items and services described by the codes in these categories are typically ancillary and supportive to a primary diagnostic or therapeutic modality and, in those cases, are an integral part of the primary service they support. AMAC and others are working on changing the payment rate from $0 to a respectful dollar amount. We need your letters to change this. 6/15/12 Copyright AMAC

48 77469 Intraoperative radiation treatment management (includes 77470) Average payment $296 Copyright AMAC /15/12 48

49 Per CMS: Therefore, we proposed to pay for brachytherapy sources at prospective payment rates based on their source-specific median costs for CY Nevertheless, we believe that prospective payment for brachytherapy sources based on median costs from claims calculated according to the standard OPPS methodology is appropriate and provides hospitals with the greatest incentives for efficiency in furnishing brachytherapy treatment. Specifically, we are finalizing our proposals to continue payment for stranded and non-stranded NOS codes, HCPCS codes C2698 and C2699, at a rate equal to the lowest stranded or non-stranded prospective payment for such sources, respectively as discussed in the CY 2008 OPPS/ASC final rule Therefore, in establishing their charges for HDR iridium, we expect hospitals to project the number of treatments that would be provided over the life of the source and establish their charges for the source accordingly, as we have stated previously (72 FR 66783; 74 FR 60535; 75 FR 71980). 6/15/12 Copyright AMAC

50 In addition, we are finalizing our proposals, without modification, to continue to assign CPT codes and to status indicator B, not paid under the OPPS. We continue to believe it would be confusing to hospitals if we were to revise the code descriptors for HCPCS codes G0173, G0251, G0339, and G0340 at this point in time and could lead to instability in our median costs and inaccurate payments for some services. Therefore, we believe that modifying the HCPCS G-code descriptors is not necessary for us to continue to provide appropriate payment for the services they describe. Further, we have provided instruction on the reporting of these SRS codes in Chapter 4, Section of the Medicare Claims Processing Manual of the Internet-Only Manual. AMAC comment: STOP writing letters to change this! 6/15/12 Copyright AMAC

51 In 2010 the AMA replaced CPT code (treatment devices, design and construction; complex [irregular blocks, special shields, compensators, wedges, molds or casts]) with code (multi-leaf collimator [MLC] device[s] for intensity modulated radiation therapy [IMRT], design and construction per IMRT plan). Hospitals are restricted to reporting one unit of service. CMS did not finalize its proposal for 2011; listened to commenters regarding units issue - facilities had failed to update their charge masters with correct payment/charge amount; placed in a higher paying APC. CMS 2012 again proposed assigning code to APC 0305 (Level II therapeutic radiation treatment preparation), a very low-level APC compared to what hospitals previously received for this service. CMS ignored provider comments about billing practices and instead finalized its proposal to use its usual rate setting methodology; relied on claims data to generate the median cost for CPT 77338; placed in APC 305; hospitals will see large reductions in reimbursement 6/15/12 Copyright AMAC

52 UNDER ARRANGEMENTS Freestanding Center Freestanding Center Source:Kutak Rock LLP 6/15/12 Copyright AMAC

53 Under arrangements transactions may pose a risk of non-compliance with the Antikickback Statute. The OIG would be likely to scrutinize an under arrangements transaction to determine whether payments received by the physician-owners of the service provider, whether as returns on investment or as payment for services, could constitute payment for referrals to the hospital. Kutak Rock LLP 6/15/12 Copyright AMAC

54 OIG - Medicare - HCCA - New York Medicaid Website - AMAC Many others 6/15/12 Copyright AMAC

55 1. Once the procedure has been ordered, performed, and documented by the physician and/or staff, you may now code this procedure. 2. Radiation Oncology is a provider driven specialty, each clinician records their own charges. 3. Many occasions in Radiation Oncology there may be more than one way to code a particular procedure depending upon orders and documentation. 4. Physics is difficult to code and in many cases subjective, for example 3-D and 2-D plans. 5. Once the staff understands the rules, regulations, and history permit the staff to select the appropriate procedure code(s). 6. Many of the coding and clinical guidelines are grey for a reason. Radiation Oncology is the same as any other specialty, it is the practice of medicine. 7. Use Society guidelines; if LCDs differ from these guidelines and other LCDs then seek assistance from societies to change your LCDs. 8. Just because you receive payment for a procedure from the third party payor, does not mean your billing is correct. 9. Just because you can charge, does not always make it right. 6/15/12 Copyright AMAC

56 REIMBURSEMENT REGULATIONS & LANGUAGE HOSPITAL W A L L CLINIC FREESTANDING DOCTOR S OFFICE PHYSICIANS CORPORATE VENDOR AMAC ALL ASC 6/15/12 Copyright AMAC

57 Professional: Physician component The professional only codes below do not need a modifier: /15/12 Copyright AMAC

58 Technical: Hospital (Clinic, Facility) Component Technical Only Codes: , 0073T G0173 G0251 G0339 G0340 6/15/12 Copyright AMAC

59 Global: Physicians Office/Freestanding Center Global Codes: If billed professionally us a 26 modifier, if billed technically only use a TC modifier hospitals and ASCs bill with no modifier. All Other Codes For example IGRT T, 77421, 77014, T 6/15/12 Copyright AMAC

60 Distinct and separate service from clinical treatment planning Therapeutic radiology simulation-aided field setting; 3 dimensional Documentation requires computer generated graphic permanent record covering the following elements: 3D tumor volume Appropriate critical normal structures Reconstruction and 3D representation of dose distribution Identification of medical necessity or clinical indication from the previously listed criteria should be included Physician review in form of signature or initials and date May be reported once per treatment course per treatment volume Includes activities necessary to perform 3-D treatment plan Cannot be reported on same date of service as /15/12 Copyright AMAC

61 Monday Tuesday Wednesday Thursday Friday Set up Physics planning Verification Physics Treatment Simulation (laser, tattoo, immobilize) IMRT plan dose Verification MU (or different date) Physics Consult (rare cases) Treatment Immobilization device (vac-loc, alphacradle, aquaplast) Devices For all MLCs (comp based bill for comp and blocks) IMRT QA Final Verification Isocenter Check (or Thursday) CT (technical only) dose Verification MU (or different date) Film Dosimetry no charge Isocenter Check (or Friday) IGRT Daily CT, intrafraction, MV/KV or US (do not bill with 77280) Special Procedure (rare cases) Professional Prescription Please note one must have a dose verification system other than the planning system to verify each gantry angle or arc or sub-arcs. Devices For all MLCs (modifier 59 possible issue) (comp based bill for comp and blocks) N/A 6/15/12 Copyright AMAC

62 Example: Clinical Flow 2-D and 3-D Monday Tuesday Wednesday Thursday Friday Setup Physics planning Verification Physics Treatment Simulation (laser, tattoo, immobilize) or or dose Verification MU (or different date) Physics Consult, if something is special Treatment Immobilization (vac-loc, alphacradle, aquaplast) CT (technical only) Devices MLCs, blocks, Wedges Compensator (or different date) dose Verification MU (or different date) Please note one must have a dose verification system other than the planning system to verify each gantry angle or arc or subarcs. Block or isocenter check IGRT Daily CT, Fluoro, MV/KV or US Special Procedure, if something is special Devices MLCs, blocks, Wedges Compensator (or different date) Professional prescription N/A 6/15/12 Copyright AMAC

63 Procedures performed need written directives or orders: Non-Physician Performed Services: Continuing weekly physics (77336) Treatments ( ) Port Films (77417) IGRT (what kind, 77421, 77014, 76950, 0197T) Physics (Plans, QA, Verifications 77301, 77300, ) Preparation and set up (77290, 77334, ) Therapists, Nurses, Dosimetrists, Physicists 6/15/12 Copyright AMAC

64 1. How do you record your productivity and why this is essential 1. RVUs 2. Multiple non billable services (plans) 2. Income and why it is important 1. Loss of FTEs 3. Recording charges correctly in EMR (HER) 1. Finishing a plan late afternoon charging the next business day 4. Who do I believe, consultants (opinions), ACR, ASTRO, AAPM, OIG, third party payor guidelines 6/15/12 Copyright AMAC

65 5. Recording procedures/coding 5. Use the CPT universal language 6. Grey and nebulous (coding and docuemntation) 5. Good 7. Clarity (the outcome may be bad) 5. Some times bad 6. Think before writing your letters 6/15/12 Copyright AMAC

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67 2011 Wage Index 2012 Wage Index Atlanta Chicago Dallas Los Angeles San Francisco Puerto Rico /15/12 Copyright AMAC

68 2011 Wage Index 2012 Wage Index Georgia Illinois California Texas /15/12 Copyright AMAC

69 CPT Description Final Payment Rate 2011 Final Payment Rate 2012 RED IS lower BLACK Higher Final 2012 PERCENTAGE INCREASE OR DECREASE Place po breast cath for rad $4, $4, $ % Place breast cath for rad $4, $4, $ % Place breast rad tube/caths $4, $4, $ % Place ndl musc/tis for rt $2, $2, $ % Diagnostic laryngoscopy $64.03 $75.12 $ % Diagnostic laryngoscopy $ $ $ % Place needles h&n for rt $1, $1, $ % Upper GI endoscopy with tube $ $ $ % Percut/needle insert, pros $2, $2, $ % Place needles pelvic for rt $1, $1, $ % Insert uteri tandems/ovoids $ $ $ % Insert heyman uteri capsule $1, $1, $ % Echo exam, transrectal $96.28 $96.49 $ % Echograp trans r, pros study $96.28 $96.49 $ % Set radiation therapy field $ $ $ % Set radiation therapy field $ $ $ % Set radiation therapy field $ $ $ % Set radiation therapy field $ $ $ % 6/15/12 Copyright AMAC

70 CPT Description Final Payment Rate 2011 Final Payment Rate 2012 RED IS lower BLACK Higher Final 2012 PERCENTAGE INCREASE OR DECREASE Radiation therapy dose plan $ $ $ % Radiotherapy dos plan, IMRT $ $ $ % Radiation therapy dose plan $ $ $ % Radiation therapy dose plan $ $ $ % Radiation therapy dose plan $ $ $ % Radiation therapy port plan $ $ $ % Radiation therapy dose plan $ $ $ % Radiation therapy dose plan $ $ $ % Radiation therapy dose plan $ $ $ % Special radiation dosimetry $ $ $ % Radiation treatment aid(s) $ $ $ % Radiation treatment aid(s) $ $ $ % Radiation treatment aid(s) $ $ $ % Radiation treatment aid(s) IMRT $ $ $ % Radiation physics consult $ $ $ % Radiation physics consult $ $ $ % External radiation dosimetry $ $ $ % 6/15/12 Copyright AMAC

71 CPT Description Final Payment Rate 2011 Final Payment Rate 2012 RED IS lower BLACK Higher Final 2012 PERCENTAGE INCREASE OR DECREASE Radiation treatment delivery $97.82 $99.79 $ % Radiation treatment delivery $97.82 $99.79 $ % Radiation treatment delivery $97.82 $99.79 $ % Radiation treatment delivery $97.82 $99.79 $ % Radiation treatment delivery $97.82 $99.79 $ % Radiation treatment delivery $97.82 $99.79 $ % Radiation treatment delivery $97.82 $ $ % Radiation treatment delivery $97.82 $ $ % Radiation treatment delivery $ $ $ % Radiation treatment delivery $ $ $ % Radiation treatment delivery $ $ $ % Radiation treatment delivery $ $ $ % Radiation treatment delivery $ $ $ % Radiation tx delivery, imrt $ $ $ % Special radiation treatment $ $ $ % Proton trmt, simple w/o comp $1, $1, $ % Proton trmt, simple w/comp $1, $1, $ % Proton trmt, intermediate $1, $1, $ % Proton treatment, complex $1, $1, $ % 6/15/12 Copyright AMAC

72 CPT Description Final Payment Rate 2011 Final Payment Rate 2012 RED IS lower BLACK Higher Final 2012 PERCENTAGE INCREASE OR DECREASE Hyperthermia treatment $ $ $ % Hyperthermia treatment $ $ $ % Hyperthermia treatment $ $ $ % Hyperthermia treatment $ $ $ % Hyperthermia treatment $ $ $ % Infuse radioactive materials $ $ $ % Apply intrcav radiat simple $ $ $ % Apply intrcav radiat interm $ $ $ % Apply intrcav radiat compl $ $ $ % Apply interstit radiat simpl $ $ $ % Apply interstit radiat inter $ $ $ % Apply iterstit radiat compl $1, $ $ % High intensity brachytherapy $ $ $ % High intensity brachytherapy $ $ $ % High intensity brachytherapy $ $ $ % Apply surface radiation $97.82 $99.79 $ % 6/15/12 Copyright AMAC

73 CPT Description Final Payment Rate 2011 Final Payment Rate 2012 RED IS lower BLACK Higher Final 2012 PERCENTAGE INCREASE OR DECREASE Office/outpatient visit, new $52.36 $53.84 $ % Office/outpatient visit, new $75.13 $72.19 $ % Office/outpatient visit, new $99.71 $95.14 $ % Office/outpatient visit, new $ $ $ % Office/outpatient visit, new $ $ $ % Office/outpatient visit, est $52.36 $53.84 $ % Office/outpatient visit, est $75.13 $72.19 $ % Office/outpatient visit, est $75.13 $72.19 $ % Office/outpatient visit, est $99.71 $95.14 $ % Office/outpatient visit, est $ $ $ % 6/15/12 Copyright AMAC

74 CPT Description Final Payment Rate 2011 Final Payment Rate 2012 RED IS lower BLACK Higher Final 2012 PERCENTAGE INCREASE OR DECREASE C1717 Brachytx source, HDR Ir-192 (NF) $ $ $ % C1719 Brachytx seed,non-hdr Ir-192 $28.07 $31.82 $ % C9725 Place endorectal app $ $ $ % C9726 Rxt breast appl place/remov $1, $1, $ % SRS, multisource Gammaknife $7, $7, $ % G0173 Stereo radoisurgery,complete non robotic $3, $3, $ % G0339 Robot lin-radsurg com, first $3, $3, $ % G0340 Robot lin-radsurg fractions 2-5 $2, $2, $ % G0251 Linear acc based stero radio multisession non robotic $ $ $ % 6/15/12 Copyright AMAC

75 The following assumptions were used in all slides : Wage Index is 1 IMRT patient percentage is at a third IGRT a little more than a third Total patient volume 360 patients treated in one year 6/15/12 Copyright AMAC

76 YEAR APC Payment Rate 2011 (FINAL) $4,677, (FINAL) $4,746,729 Percentage Difference Increase >1.5% 6/15/12 Copyright AMAC

77 HOSPITAL FINAL 2012 CASE MIX ASSUMPTIONS Number of Patients Treated 2012 FINAL Payments Breast IMRT 1 $13,884 Breast Standard 1 $9,674 Prostate IMRT 40 fractions 1 $22,805 Prostate IMRT with Seed Boost 25 fractions 1 $14,702 Prostate Standard 1 $13,639 Lung IMRT 1 $19,177 Lung Standard 1 $11,456 Brain IMRT 1 $12,303 Radiosurgery multi-session non robotic 1 $9,074 Radiosurgery single session non robotic 1 $7,721 Radiosurgery single session robotic 1 $7,721 Radiosurgery multi-session robotic 1 $18,016 Abdominal IMRT 1 $20,900 Abdominal Standard 1 $12,066 Palliative cases brain and bone (mets) 1 $3,523 Head & Neck IMRT 1 $23,269 Hyperthermia Interstitial (additional) 1 $2,298 Hyperthermia Superficial (additional) 1 $2,298 HDR GYN/Lung (no external beam) 1 $7,454 HDR Prostate 3 fractions over two days 1 $8,012 HDR Breast (no external bean) multicatheter 1 $17,066 6/15/12 Copyright AMAC

78 Hospital FINAL 2011 CASE MIX ASSUMPTIONS Number of Patients Treated 2011 FINAL PAYMENTS Breast IMRT 1 $14,547 Breast Standard 1 $9,362 Prostate IMRT 40 fractions 1 $23,254 Prostate IMRT with Seed Boost 25 fractions 1 $14,813 Prostate Standard 1 $13,294 Lung IMRT 1 $19,091 Lung Standard 1 $11,109 Brain IMRT 1 $12,518 Radiosurgery multi-session non robotic 1 $9,394 Radiosurgery single session non robotic 1 $7,708 Radiosurgery single session robotic 1 $7,708 Radiosurgery multi-session robotic 1 $17,936 Abdominal IMRT 1 $21,472 Abdominal Standard 1 $11,760 Palliative cases brain and bone (mets) 1 $3,445 Head & Neck IMRT 1 $22,379 Hyperthermia Interstitial (additional) 1 $2,294 Hyperthermia Superficial (additional) 1 $2,294 HDR GYN/Lung (no external beam) 1 $7,351 HDR Prostate 3 fractions over two days 1 $7,918 HDR Breast (no external beam) multicatheter 1 $16,926 6/15/12 Copyright AMAC

79 6/15/12 Copyright AMAC

80 Contractor Locality Locality name State 2012 Work GPCI PE GPCI MP GPCI Alabama Alabama Alaska** Alaska Arizona Arizona Arkansas Arkansas Anaheim/Santa Ana, CA California Los Angeles, CA California Marin/Napa/Solano, CA California Oakland/Berkeley, CA California Rest of California* California Rest of California* California San Francisco, CA California San Mateo, CA California Santa Clara, CA California Ventura, CA California Colorado Colorado /15/12 Copyright AMAC

81 2011 HCPCS CPT DESCRIPTION 2011 WORK RVU 2012 Proposed HCPCS CPT 2012 Proposed DESCRIPTION WORK RVU TRANSITIONED NON FACILITY PE RVU TRANSITIONED NON FACILITY PE RVU TRANSITIONED FACILITY PE RVU TRANSITIONED FACILITY PE RVU MALPRACTICE RVU MALPRACTICE RVU Non Facility Freestanding by Location Non Facility Freestanding by Location Facility Hospital Based by Location Radiation therapy planning $72.37 $ Radiation therapy planning $ $ Radiation therapy planning $ $ Radiation tx management x $ $ Radiation therapy management $98.87 $ Stereotactic radiation trmt $ $ Sbrt management $ $ Facility Hospital Based by Location Radiation therapy planning $70.33 $ Radiation therapy planning $ $ Radiation therapy planning $ $ Radiation tx management x $ $ Radiation therapy management $96.15 $ Stereotactic radiation trmt $ $ Sbrt management $ $ Facility = Hospital based Non facility = office based 6/15/12 Copyright AMAC

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84 The following assumptions were used: GPCI is 1, 1, 1 IMRT patient percentage is at a third IGRT a little more than a third Total patient volume 360 patients treated in one year 6/15/12 Copyright AMAC

85 YEAR Medicare Professional Medicare Technical Medicare Global 2011 $1,119,832 $5,649,234 $6,769, $1,076,760 $5,216,328 $6,293,088 Percentage difference -4% -7% -7% 6/15/12 Copyright AMAC

86 Freestanding Reimbursement for 2012 CASE MIX ASSUMPTIONS: Number of Patients Treated 2012 Professional 2012 Technical 2012 Global Breast IMRT 1 $2,138 $15,014 $17,152 Breast Standard 1 $2,448 $10,379 $12,826 Prostate IMRT 40 tx 1 $3,194 $22,960 $26,154 Prostate IMRT Seed Boost 25 tx 1 $2,265 $15,120 $17,385 Prostate Standard 1 $3,484 $14,533 $18,017 Lung IMRT 1 $2,527 $19,889 $22,416 Lung Standard 1 $2,942 $11,583 $14,525 Brain IMRT 1 $2,088 $12,666 $14,754 Radiosurgery Multi Non-Robotic 1 $2,171 $10,316 $12,486 Radiosurgery 1 Non-Robotic 1 $1,893 $2,867 $4,760 Radiosurgery 1 Robotic 1 $1,893 $3,625 $5,518 Radiosurgery Multi-Robotic 1 $2,171 $10,316 $12,486 Abdominal IMRT 1 $3,074 $20,988 $24,062 Abdominal Standard 1 $3,131 $12,728 $15,859 Palliative 1 $1,174 $3,630 $4,804 Head & Neck IMRT 1 $3,324 $23,151 $26,475 Hyperthermia Interstitial 1 $549 $3,251 $3,801 Hyperthermia Superficial 1 $656 $3,271 $3,926 HDR GYN Lung 1 $2,772 $2,976 $5,748 HDR Prostate 1 $2,507 $3,486 $5,993 HDR Breast 1 $2,831 $6,027 $8,858 IGRT Ultrasound 1 $29 $27 $55 IGRT Fluoro 1 $9 $57 $66 IGRT CT 1 $42 $102 $144 IGRT KV MV X-Ray 1 $19 $68 $86

87 Freestanding Reimbursement for 2011 Final CASE MIX ASSUMPTIONS: Number of Patients Treated 2011 FINAL Professional 2011 FINAL Technical 2011 FINAL Global Breast IMRT 1 $2,176 $16,227 $18,403 Breast Standard 1 $2,531 $10,330 $12,860 Prostate IMRT 40 tx 1 $3,297 $24,888 $28,185 Prostate IMRT Seed Boost 25 tx 1 $2,347 $16,384 $18,731 Prostate Standard 1 $3,588 $14,419 $18,006 Lung IMRT 1 $2,614 $21,600 $24,214 Lung Standard 1 $3,035 $11,543 $14,578 Brain IMRT 1 $2,166 $13,702 $15,869 Radiosurgery Multi Non-Robotic 1 $2,323 $10,741 $13,064 Radiosurgery 1 Non-Robotic 1 $1,985 $3,333 $5,318 Radiosurgery 1 Robotic 1 $1,985 $4,072 $6,056 Radiosurgery Multi-Robotic 1 $2,323 $10,741 $13,064 Abdominal IMRT 1 $3,175 $22,705 $25,880 Abdominal Standard 1 $3,227 $12,654 $15,881 Palliative 1 $1,232 $3,636 $4,868 Head & Neck IMRT 1 $3,430 $25,115 $28,544 Hyperthermia Interstitial 1 $559 $3,787 $4,345 Hyperthermia Superficial 1 $664 $3,931 $4,595 HDR GYN Lung 1 $2,529 $3,066 $5,595 HDR Prostate 1 $2,599 $3,565 $6,164 HDR Breast 1 $2,914 $6,248 $9,161 IGRT Ultrasound 1 $29 $40 $69 IGRT Fluoro 1 $8 $69 $78 IGRT CT 1 $42 $149 $192 IGRT KV MV X-Ray 1 $19 $91 $110 Totals 21 $50,794 $243,037 $293,831 6/15/12

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89 CPT Description Professional Payment Rate 2012 Professional Payment Rate 2011 PERCENTAGE INCREASE OR DECREASE Final 2011 to Final 2012 PROFESSIONAL Payment Rate Diagnostic laryngoscopy $85.09 $ % Diagnostic laryngoscopy $ $ % Percut/needle insert, pros $ $ % Insert uteri tandems/ovoids $ $ % Ins vag brachytx device $ $ % Fluoroscope examination $8.51 $8.49 0% Fluoroscope exam, extensive $35.06 $ % CAT scan for needle biopsy $55.48 $ % CAT scan for therapy guide $41.87 $ % CAT scan follow-up study $47.65 $ % Echo guide for biopsy $33.02 $ % Echo guidance radiotherapy $28.59 $ % Echo exam, transrectal $34.04 $ % Echograp trans r, pros study $76.24 $ % Echo guidance radiotherapy $66.37 $ % Radiation therapy planning $71.14 $ % Radiation therapy planning $ $ % Radiation therapy planning $ $ %

90 CPT Description Professional Payment Rate 2012 Professional Payment Rate 2011 PERCENTAGE INCREASE OR DECREASE Final 2011 to Final 2012 PROFESSIONAL Payment Rate Set radiation therapy field $34.38 $ % Set radiation therapy field $51.74 $ % Set radiation therapy field $76.58 $ % Set radiation therapy field $ $ % Radiation therapy dose plan $30.63 $ % Radiotherapy dos plan, imrt $ $ % Radiation therapy dose plan $34.38 $ % Radiation therapy dose plan $51.74 $ % Radiation therapy dose plan $76.58 $ % Radiation therapy port plan $46.63 $ % Radiation therapy dose plan $45.61 $ % Radiation therapy dose plan $68.42 $ % Radiation therapy dose plan $ $ % Special radiation dosimetry $42.89 $ % Radiation treatment aid(s) $26.55 $ % Radiation treatment aid(s) $41.19 $ % Radiation treatment aid(s) $60.59 $ % Radiation physics consult $0.00 $0.00 0% Design mlc device for imrt $ $ %

91 CPT Description Professional Payment Rate 2012 Professional Payment Rate 2011 PERCENTAGE INCREASE OR DECREASE Final 2011 to Final 2012 PROFESSIONAL Payment Rate Stereoscopic Xray guidance $18.72 $ % Radiation tx management, x5 $ $ % Radiation therapy management $97.35 $ % Stereotactic radiation trmt $ $ % SBRT management $ $ % IORT management one session $ $0.00 N/A Special radiation treatment $ $ % Hyperthermia treatment $76.58 $ % Hyperthermia treatment $ $ % Hyperthermia treatment $75.90 $ % Hyperthermia treatment $ $ % Hyperthermia treatment $75.56 $ % Infuse radioactive materials $ $ % Apply intrcav radiat simple $ $ % Apply intrcav radiat interm $ $ % Apply intrcav radiat compl $ $ % Apply interstit radiat simpl $ $ % Apply interstit radiat inter $ $ % Apply iterstit radiat compl $ $ % High intensity brachytherapy $69.99 $ % High intensity brachytherapy $ $ % High intensity brachytherapy $ $ % 0197T Intrafraction track motion $0.00 $0.00 0%

92 CPT Description Professional Payment Rate 2012 Professional Payment Rate 2011 PERCENTAGE INCREASE OR DECREASE Final 2011 to Final 2012 PROFESSIONAL Payment Rate Office/outpatient visit, new $42.55 $ % Office/outpatient visit, new $72.50 $ % Office/outpatient visit, new $ $ % Office/outpatient visit, new $ $ % Office/outpatient visit, new $ $ % Office/outpatient visit, est $19.74 $ % Office/outpatient visit, est $42.55 $ % Office/outpatient visit, est $70.46 $ % Office/outpatient visit, est $ $ % Office/outpatient visit, est $ $ % Place po breast cath for rad $4, $3, % Place needles pelvic for rt $ $ % Upper GI endoscopy with tube $ $ % Insert heyman uteri capsule $ $ % Diag bronchoscope/catheter $ $ % Place ndl musc/tis for rt $ $ % Place needles h&n for rt $ $ %

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94 CPT Description FINAL Technical Payment Rate 2012 Technical Payment Rate 2011 PERCENTAGE INCREASE OR DECREASEFinal 2011 to 2012 PROFESSIONAL Payment Rate Fluoroscope examination $57.18 $ % Fluoroscope exam, extensive $0.00 $0.00 0% CAT scan for needle biopsy $91.56 $ % CAT scan for therapy guide $ $ % CAT scan follow-up study $ $ % Echo guide for biopsy $ $ % Echo guidance radiotherapy $26.55 $ % Echo exam, transrectal $ $ % Echograp trans r, pros study $ $ % Echo guidance radiotherapy $37.10 $ % Set radiation therapy field $ $ % Set radiation therapy field $ $ % Set radiation therapy field $ $ % Set radiation therapy field $ $ % Radiation therapy dose plan $37.10 $ % Radiotherapy dos plan, imrt $1, $1, % Radiation therapy dose plan $27.91 $ % Radiation therapy dose plan $37.10 $ % Radiation therapy dose plan $60.93 $ % Radiation therapy port plan $51.74 $ % Radiation therapy dose plan $98.37 $ % Radiation therapy dose plan $ $ % Radiation therapy dose plan $ $ %

95 CPT Description FINAL Technical Payment Rate 2012 Technical Payment Rate 2011 PERCENTAGE INCREASE OR DECREASEFinal 2011 to 2012 PROFESSIONAL Payment Rate Special radiation dosimetry $19.06 $ % Radiation treatment aid(s) $50.72 $ % Radiation treatment aid(s) $13.27 $ % Radiation treatment aid(s) $87.82 $ % Radiation physics consult $46.43 $ % Design mlc device for imrt $ $ % Radiation physics consult $ $ % External radiation dosimetry $0.00 $0.00 0% Radiation treatment delivery $22.12 $ % Radiation treatment delivery $ $ % Radiation treatment delivery $ $ % Radiation treatment delivery $ $ % Radiation treatment delivery $ $ % Radiation treatment delivery $ $ % Radiation treatment delivery $ $ % Radiation treatment delivery $ $ % Radiation treatment delivery $ $ % Radiation treatment delivery $ $ % Radiation treatment delivery $ $ % Radiation treatment delivery $ $ % Radiation treatment delivery $ $ % Radiology port film(s) $14.30 $ % Radiation tx delivery, imrt $ $ %

96 CPT Description FINAL Technical Payment Rate 2012 Technical Payment Rate 2011 PERCENTAGE INCREASE OR DECREASEFinal 2011 to 2012 PROFESSIONAL Payment Rate Stereoscopic Xray guidance $67.73 $ % IORT TX delivery X-ray $0.00 $0.00 0% IORT TX delivery electrons $0.00 $0.00 0% Special radiation treatment $70.80 $ % Proton trmt, simple w/o comp $0.00 $0.00 0% Proton trmt, simple w/comp $0.00 $0.00 0% Proton trmt, intermediate $0.00 $0.00 0% Proton treatment, complex $0.00 $0.00 0% Hyperthermia treatment $ $ % Hyperthermia treatment $ $ % Hyperthermia treatment $ $ % Hyperthermia treatment $ $ % Hyperthermia treatment $ $ % Infuse radioactive materials $ $ % Apply intrcav radiat simple $ $ % Apply intrcav radiat interm $ $ % Apply intrcav radiat compl $ $ % Apply interstit radiat simpl $ $ % Apply interstit radiat inter $ $ % Apply iterstit radiat compl $ $ % High intensity brachytherapy $ $ % High intensity brachytherapy $ $ % High intensity brachytherapy $ $ % 0197T Intrafraction track motion $0.00 $0.00 0%

97 CPT Description FINAL Technical Payment Rate 2012 Technical Payment Rate 2011 PERCENTAGE INCREASE OR DECREASEFinal 2011 to 2012 PROFESSIONAL Payment Rate Apply surface radiation $55.48 $ % Radiation handling $39.82 $ % Radium/radioisotope therapy $0.00 $0.00 0% Intracavitary nuclear trmt $66.83 $ % Interstitial nuclear therapy $0.00 $0.00 0% Nuclear joint therapy $57.18 $ % 77371** Srs, multisource Gamma knife $0.00 $0.00 0% SRS cranial one session complete $ $ % SRT multisession up to 5 $1, $1, % G0339** Robot lin-radsurg com, first $0.00 $0.00 0% G0340** Robot lin-radsurg fractions 2-5 $0.00 $0.00 0%

98 98 Our company was founded on the premise that we understand... your markets, your concerns, your values. Phone: (770) Fax: (770) /15/12 Copyright AMAC