An OIG review shows Medicare overpaid outpatient hospitals as much as $25.8 million for complex simulations billed during audit period.

Between 2013 and 2015, Medicare paid 1,193 hospitals $109,197,933 in bundled payments for intensity modulated radiation therapy (IMRT) — about $25,754,171 more than they should have, according to the Office of Inspector General (OIG). The culprit? Unbundling.

Report IMRT with One Code

IMRT is an advanced type of radiation used to treat difficult-to-reach tumors. Advanced computer programs allow physicians to plan and deliver radiation to tumors with high precision. Medicare makes a bundled payment to hospitals to cover both IMRT planning and delivery when billed with CPT code:

77301 Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specifications

Do Not Separately Bill Planning Services

Specifically, the OIG found from its audit sample of 100 line items that hospitals were separately billing complex simulations 100 percent of the time, accounting for approximately 84 percent of the potential overpayments. Complex simulation is a planning service, reported using CPT code:

77290 Therapeutic radiology simulation-aided field setting; complex

The procedure code for IMRT (77301) includes time spent developing a complex, computer-based simulation of the procedure. Hospitals should not bill IMRT planning services separately, regardless of when they are performed.

A list of the excluded planning and preparation CPT codes is provided in the 2018 Outpatient Prospective Payment System and Ambulatory Surgical Center final rule.

APPENDIX B: SERVICES INCLUDED IN THE BUNDLED PAYMENT FOR IMRT PLANNING

Heed CMS’ New Guidance

The OIG concluded from its audit sample that hospitals are generally misinterpreting guidance established by the Centers for Medicare & Medicaid Services (CMS), and system edits are not catching unbundled procedures billed on different dates of service than their counterparts.

CMS has since updated its guidance to state that complex simulations are included in the Ambulatory Payment Classification (APC) for IMRT planning services “when provided prior to or as part of the development of the IMRT plan.” [emphasis added]

Per CMS’ Medicare Claims Processing Manual, Pub. 100-04, chapter 4, sections 200.3.1 and 200.3.2:

Payment for the services identified by CPT codes 77014, 77280, 77285, 77290, 77295, 77306 through 77321, 77331, and 77370 are included in the APC payment for CPT code 77301 (IMRT planning). These codes should not be reported in addition to CPT code 77301 when provided prior to or as part of the development of the IMRT plan. In addition, CPT codes 77280-77290 (simulation-aided field settings) should not be reported for verification of the treatment field during a course of IMRT.

The OIG recommends, in an August report, that CMS implement an edit to prevent improper payments for IMRT planning services billed before the procedure code (e.g., up to 14 days before) and educate hospitals on properly billing Medicare for IMRT planning services. CMS concurred. CMS had already implemented a time-based edit, effective April 2018, to adjust payments for certain planning services billed prior to CPT code 77301.

Source:

OIG, “Medicare Improperly Paid Hospitals Millions of Dollars for Intensity-Modulated Radiation Therapy Planning Services,” August 2018