11 Imrt 12-4-09

IMRT Planning & Dosimetry December 2-4, 2009 AMAC® Copyright 2009
www.amac-usa.com
IMRT
Las Vegas, Nevada December 2 - 4, 2009

Presentation by James E. Hugh III, MHA, ROCC®, CHBME
Contributions by Linda L. Lively, MHA, CCS-P, RCC, ROCC®, CHBME
12/4/2009 Copyright AMAC® 2009 1
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Agenda
¾ New Code
¾ IMRT Bundling Issues
¾ Correct Coding Initiative Edits 15.3
¾ Possible Clinical Staging Examples
¾ ACR IMRT Guideline Examples
¾ IMRT and Associated Codes
¾ Helical Systems
¾ Volumetric Systems
V l ti S t
¾ Documentation Examples
¾ Typical Income Examples
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NEW CODES
¾ 77338 – Multileaf collimator (MLC) device(s) for intensity
modulated radiation therapy (IMRT), design and construction
modulated radiation therapy (IMRT), design and construction
per IMRT plan
• Do not report 77338 more than once per IMRT plan
• For Immobilization in IMRT treatment see 77332‐77334
• Do not report 77338 in conjunction with 0073T
¾ This is only for MLCs used in IMRT, ”ONLY”!
• Professional $226.18 Technical $253.36
• Hospital APC $190.62
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IMRT Delivery 77418
2,082,279
2,100,000.00
1,795,879 16%
, ,
1,750,000.00
1,460,211
23%
1,400,000.00
1,059,503 38%
1,050,000.00
626,946
69%
700,000.00
168%
350,000.00
233,874
0.00
1 2 3 4
2002 2003 2004 2005 5 6
2006 2007

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IMRT Delivery Costs 77418
$1,062,098,290
$1,050,000,000.00
$916,861,080
$916,861,080
$900,000,000.00
$777,046,050
16%
$750,000,000.00
$604,024,950 18%
$600,000,000.00
29%
$450,000,000.00
$354,239,800
71%
$300 000 000 00
$300,000,000.00
165%
$133,886,400
$150,000,000.00
$0.00
1 2 3
2002 2003 2004 4
2005 5
2006 2007 6
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IMRT Planning Procedures 77301
120,000.00
111,429
105,000.00
99,436
12%
90,000.00
82,130
21%
75,000.00
61,115 34%
60,000.00
56%
45,000.00
39,188
30,000.00
17,333 126%
15,000.00
0.00
2002 2003 2004 2005
1 2 3 4 2006 2007
5 6

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IMRT Planning Costs 77301
$153,883,625
$150,000,000
$135,293,675
14%
$125,000,000
$111,608,250
21%
$100,000,000
$83,589,225
34%
$75,000,000
$53,528,100
$50,000,000 56%
$25,000,000
$22,910,825 134%
$0
2002 2003 2004 2005
1 2 3 4 52006 2007
6
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IMRT 77301
IMRT 77301
Bundling Issues

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IMRT 77301 Bundling Issue
After analyzing all the transmittals and corrections to
transmittals, it is evident what the intent of CMS has been
since 2002. Services “directly”
since 2002. Services directly related to the planning are
related to the planning are
bundled. The key is when the actual plan starts and ends. The
start occurs once the physicist begins to design the beams or
portals and doses to the tumor; the end occurs when the
physics plan is accepted and approved by the physician and
physicist.
The majority of the codes in question are not related, such as:
77336, 77290, and most of the time 77370. The other codes:
77336, 77 90, and most of the time 77370. The other codes:
77305‐77321 and 77295 would never be charged as they are
physics plans, and we would not have two physics plans for
the same treatment. One may only use and charge one
physics plan for each set‐up until a boost or cone down is
planned.
Copyright AMAC® 2009
12/4/2009 9
National Correct Coding Initiative
Correct Coding Solutions, LLC ‐ A Medicare Contractor
P.O. Box 907, Carmel, IN 46082‐0907
Fax: 317‐571‐1745
August 15, 2006
“CMS
“CMS wants to confirm that NCCI edits only apply to services performed
t t fi th t NCCI dit l l t i f d
on the same beneficiary by the same provider on the same date of
service . The NCCI edits have not been developed with the intent that
they are necessarily applicable to services on the same beneficiary by
the same provider but on different dates of service. Although some edits
might be applicable in such situations, it would be inappropriate for a
Carrier to apply NCCI edits in this fashion as part of the NCCI program.
However, each NCCI edit is based on a rationale/policy, and this
information is available to Carriers . This is one source of information
that Carriers may utilize in performing their medical review activities.”
Copyright AMAC® 2009 10

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Correct Coding Initiative Edits 15.3
g
(Hospitals under 15.2)
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77301 Edits Version 15.3
Modifier
0=not
0 not allowed
1=allowed
Column 1 Column 2 9=not applicable
77301 77014 0
77301 77261-77263 0
77301 77280 - 77290 0
77301 77295 0
77301 77305 - 77315 0
77301 77321 0
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Modifier
0=not allowed
1=allowed
77301 77326 - 77328 0
77301 77331 0
77301 77332 - 77334 1
77301 77336 0
77301 77370 0
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Modifier
0=not allowed
1=allowed
77301 77401 - 77416 1
77301 77417 0
77301 77421 0
77301 77422 -77423 1
77301 77431 1
77301 77432 0
77301 77470 0
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Clinical Staging Example:
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Example: Clinical Staging
Monday Tuesday Wednesday Thursday Friday
Staging Physics planning Verification Physics Treatment
Simulation – 77301 IMRT plan 77300 – dose 77370 – Treatment - 77418
77290 (laser, Verification MU Physics
tattoo, immobilize) (or different date) Consult
Immobilize Devices – 77338 Final Verification N/A isocenter check
77334 MLCs, 77334 77280
(vac-loc, alpha- Wedges
cradle, aquaplast) Compensator (or
different date)
CT – 77014 77300 – dose Film Dosimetry N/A IGRT Daily CT,

(technical only) Verification MU (or 77331 N/C Fluoro, MV/KV or
different date) US
77470 – N/A N/A N/A Devices
D i 77338
Special MLCs, 77334
Procedure Wedges
Compensator (or
different date)
77263 – N/A N/A N/A N/A

Professional
Prescription
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Physician Orders
¾Procedures performed need written directives or
orders:
• Non Physician Performed Services:
− Continuing weekly physics (77336)
− Treatments (77418)
− Port Films (77417)
− IGRT (what kind, 77421, 77014, 76950)
IGRT (what kind 77421 77014 76950)
− Physics (Plans, QA, Verifications 77301)
− Preparation and set up (77290, 77334, 77014)
− Therapists, Nurses, Dosimetrists, Physicists
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Physician Orders Orders Dates &

Doctor Initials
CT for placement of fields __________ location
Simulation (immobilization set up)
Simulation check (isocenter)
3-D physics plan
MLCs
IMRT physics plan
Dose calculations
IGRT – when;_____ what; Fluoro, CT, U/S, KV/MV
Special dosimetry
Medical Necessity_____________
Date of measurement __________ not for QA
Continuing Weekly Physics
Special Physics Consult
Reason - ____________________ (non standard IMRT)
Original Order Date & Signature: ________________________
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ACR IMRT Guidelines
(example)
There are many guidelines
There are many guidelines,
www.astro.org
ATC Guidelines
AAPM
www.acr.org
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Radiation Oncologist
The qualifications and responsibilities of the radiation oncologist shall be
clearly defined and should include the following:
1. Participate in and approve the immobilization/repositioning system in
consultation with other members of the team.
2 Define the goals and requirements of the treatment plan including the
2. Define the goals and requirements of the treatment plan, including the
specific dose constraints for the target(s) and nearby critical structures.
3. Delineate tumor and specify and approve target volumes, preferably
using appropriate International Commission on Radiation Units and
Measurements (ICRU) methodology.
4. Contour critical normal structures not clearly discernible on cross‐
section.
5. Review and approve all critical structures contoured.
6. Perform final evaluation and approve final intensity‐modulated
treatment plan for implementation.
7. Review and approve all implementation and verification images
(simulation and/or portal images).
8. Participate in peer review of contours and IMRT treatment plans in
conjunction with other members of the team.

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Qualified Medical Physicist
The responsibilities of the Qualified Medical Physicist shall be
clearly defined and should include the following:
1. Perform acceptance testing, commissioning, and implementation of the IMRT
Perform acceptance testing commissioning and implementation of the IMRT
treatment‐planning system and all subsequent upgrades, including the system’s
interface with the treatment delivery software and hardware units.
2. Understand the limitations and appropriate use of the radiation therapy treatment
planning (RTP) system, including the characteristics of the dose optimization
software, the precision of generated IMRT patient and beam geometry, and the
applicability of dose calculational algorithms to different clinical situations.
3. Establish and manage a QA program for the entire IMRT system, to include the
planning system, the delivery system, and the interface between these systems.
4. Act as a technical resource for the IMRT team.
5. Consult and participate with the radiation oncologist and other team members in
implementing the immobilization/repositioning system for the patient.
6. Participate in review of contours and anatomic structures for the IMRT plan.
7. Review each patient’s IMRT plan for technical accuracy and precision.
8. Provide physical measurements for verification of the IMRT plan.

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IMRT Treatment Delivery
IMRT dose delivery must use an MLC, a binary collimator
(
(tomotherapy), or a pencil beam with leaves or other collimating
py) p g
devices that project to a nominal beam width of 1 cm or less at the
treatment unit isocenter. The exact delivery method is currently
restricted to the above techniques that have the ability to
reproduce the highly modulated intensity patterns resulting from
the treatment planning process delineated above. Such delivery
methods include, for example, multiple static segment treatment
(step‐and‐shoot),
(step and shoot), dynamic segment treatment (sliding window),
dynamic segment treatment (sliding window),
binary‐collimator tomotherapy, and intensity‐modulated arc
techniques.

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Documentation
Documentation of delivered doses to volumes of target and
non target tissues, in the form of dose volume histograms and
representative cross‐sectional isodose treatment diagrams,
t ti ti li d t t t di
should be maintained in the patient’s written or electronic
record.
As noted above, various treatment verification
methodologies, including daily treatment unit parameters,
films confirming proper patient positioning, and records of
physical measurements confirming treatment dosimetry
physical measurements confirming treatment dosimetry,
should also be incorporated into the patient’s record.

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Dose Delivery Verification by Physical
Measurement
The medical physicist should assure verification of actual
radiation doses being received during treatment delivery.
Prior to the start of treatment, accuracy of dose delivery
should be documented by irradiating a phantom containing
either calibrated film to sample the dose distribution or an
equivalent measurement system to verify that the dose
delivered is the dose planned In addition the dose to a small
delivered is the dose planned. In addition, the dose to a small
region should be verified using an ionization chamber.

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IMRT Codes
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Medical Necessity
¾ Why is the patient being treated?
¾ What is the form of treatment?
¾ Why are you treating in this fashion and not another
method?
¾ ____ (Patient Name) ____ has prostate cancer. It was clear that there
were no maneuvers that would be available to reduce the GTV, CTV or
PTV to allow for an adequate and appropriate distribution other than the
use of intensity modulated radiation therapy.
¾ Because of the potential significant morbidity of treatment to the
p g y
immediately adjacent bladder and rectum, IMRT was chosen to keep that
risk of damage to a minimum.
¾ It was also clear that with 3D conformal treatment, we would not have
been able to shape the dose of radiation to the convex structure of the
prostate gland, minimizing the dose of the immediately adjacent normal
tissue, without the use of IMRT.
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Medical Necessity: Examples
BCBS
¾ IMRT of the prostate is considered medically necessary in patients with non‐metastatic
prostate cancer for dose escalation >75 Gy.
¾ IMRT is considered medically necessary in the treatment of patients with head and neck
cancer, with the exception of patients with early stage larynx cancer (stage I and II).
¾ IMRT is considered medically necessary in patients with CNS lesions with close proximity to
the optic nerve or brain stem.
¾ IMRT is considered medically necessary in patients with pediatric tumors (e.g., Ewing
Sarcoma, Wilms' Tumor).
¾ IMRT is considered medically necessary in patients with squamous cell carcinoma of the
anus.
¾ IMRT is considered medically necessary for all primary malignant gynecologic tumors
( t
(uterus, cervix, ovary, fallopian tube) when dosimetric planning predicts the volume of small
i f ll i t b ) h d i t i l i di t th l f ll
intestine receiving doses > 45 Gy would result in unacceptable risk of small intestine injury
(V45 > 10% or V49 > 5%).
¾ IMRT is considered medically necessary for locally advanced rectal adenocarcinoma when
dosimetric planning predicts the volume of small intestine receiving doses > 45 Gy would
result in unacceptable risk of small intestine injury (V45 > 10% or V49 > 5%).
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AETNA
¾ IMRT planning may be clinically indicated when one or more of the
following conditions are present:
following conditions are present:
¾ The target volume is in close proximity to critical structures that must be
protected.
¾ The volume of interest must be covered with narrow margins to
adequately protect immediately adjacent structures.
¾ An immediately adjacent area has been previously irradiated and abutting
portals must be established with high precision.
¾ The target volume is concave or convex, and the critical normal tissues are
within or around that convexity or concavity.
¾ Dose escalation is planned to deliver radiation doses in excess of those
commonly utilized for similar tumors with conventional treatment.
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AETNA
¾ According to the coding guide (ASTRO, 2007), the most common sites that currently
support the use of IMRT include:
¾ Primary, metastatic or benign tumors of the central nervous system, including the brain,
, p
brain stem, and spinal cord.
¾ Primary, metastatic tumors of the spine where spinal cord tolerance may be exceeded by
conventional treatment.
¾ Primary, metastatic or benign lesions to the head and neck area, including:
− Orbits
− Sinuses
− Skull base
− Aerodigestive tract
− Salivary glands
Salivary glands
¾ Carcinoma of the prostate
¾ Selected cases of thoracic and abdominal malignancies
¾ Selected cases (i.e., not routine) of breast cancers with close proximity to critical structures
¾ Other pelvic and retroperitoneal tumors thaat meet requirements for medical necessity
(as noted above)
¾ Reirradiation that meets the requirements for medical necessity (as noted above).
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IMRT Treatment Delivery
77418
¾ “Single or multiple fields/arcs, via narrow spatially
g p / , p y
and temporarily modulated beams (e.g., binary,
dynamic, MLC, per treatment session)” AMA
LCD’S
¾ L30316 (Noridian and Cahaba), L6336 (Palmetto) and
L26834 (Trailblazer)
( ilbl )
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Intensity Modulated Radiation
Therapy Planning
77301 – IMRT planning requires delineation of a
tumor bearing volume and a number of normal tissue
volumes, whose tolerance to radiation is less than that
of the tumor. Only one IMRT plan should be reported
per course of therapy; however, if the clinical
condition changes and treatment parameters are
altered, such as in a “boost,” then an additional plan
may be reported with appropriate
documentation.
LCD’S
¾ L7987 (Palmetto), L23754 (Noridian) and L26833 (Trailblazer)
Medical Necessity
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IMRT Planning 77301:
“Intensity modulated radiotherapy plan, including dose‐
volume histograms for target and critical structure
partial tolerance specifications (Dose plan is optimized
partial tolerance specifications. (Dose plan is optimized
using inverse or forward planning technique for
modulated beam delivery—e.g., binary, dynamic MLC to
create highly conformal dose distribution. Computer
plan distribution must be verified for positional accuracy
based on dosimetric verification of the intensity map
with verification of treatment set up and interpretation
of verification methodology).”
of verification methodology).

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IMRT Planning 77301
1. Multiple
p boosts?
2. 3-D with IMRT?
3. IMRT with 3-D?

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Simulations
¾ Simple Simulation – 77280
• Isocenter check
¾ Complex Simulation
• Tangents, blocks, MLC, wedges (EDW STD), immobilization
device, rotation
¾ Documentation
• Date, patient name, area, port #’s, description, devices,
ate, pat e t a e, a ea, po t s, desc pt o , de ces,
body position, head, tattoos, comments.
• ONE PER DAY
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77470 – Special Treatment Procedure
IMRT “________ is receiving definitive irradiation for
_______. ___ is being treated with IMRT and
is being treated with IMRT and
receiving chemotherapy. The patient will be set up,
planned and positioned daily for allowance for
movement and require extra work and time
involved.”
__________________________, MD
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Dosimetry (77300)
“Basic radiation dosimetry calculation, central axis depth dose,
TDF, NSD, gap calculation, off axis factor, tissue in homogeneity
, g radiation surface and depth
factors, calculation of nonionizing p
dose, as required during course of treatment, only when
prescribed by the treating physician.”
“The typical course of radiation therapy will consist of one to six
dosimetry calculations, depending on the complexity of the case.
(However, radiation treatments to the head/neck, prostate, and
Hodgkin’s disease may require eight or more calculations).
Frequency in excess of the upper end of this range will require
Frequency in excess of the upper end of this range will require
supporting documentation.”
¾Per Gantry Angle only
Separate verification of plan calculations need to be performed
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Physics Consults
(77336 and 77370)
77336 “Continuing medical physics consultation, including assessment of
treatment parameters, quality assurance of dose delivery, and review of
patient treatment documentation in support of the radiation oncologist,
reported per week of therapy.”
77370 “Special medical radiation physics consultation”
“The special medical radiation physics consultation code is used when
the radiation oncologist makes a direct request to the qualified medical
physicist for a special consultative report or for specific physics services
on an individual patient. Such a request may be made when the
comple it of the treatment plan is of s ch ma nit de that a thoro h
complexity of the treatment plan is of such magnitude that a thorough
written analysis is necessary to address a specific problem or when the
service to be performed requires the expertise of a qualified medical
physicist. The clinical indication that justified the request for the special
physics consultation should also be documented.”

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Treatment Devices (77333‐77334)
¾ 77333 “Treatment devices, design and construction;
intermediate (multiple blocks, stents, bite blocks,
intermediate (multiple blocks, stents, bite blocks,
special bolus)”
¾ 77334 – For Non MLC compensator based IMRT
(Compensator based IMRT use 77334 for
compensators) or Immobilization devices "Treatment
devices, design and construction; complex (irregular
blocks special shields compensators wedges molds
blocks, special shields, compensators, wedges, molds
or casts)” MLCs and immobilization
¾ 77338 – Multileaf collimator (MLC) device(s) for
intensity modulated radiation therapy (IMRT), design
and construction per IMRT plan
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Medical Necessity
Physics Planning
Verification
Verification
Verification
Physician approval
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Helical Arc Systems
y
Tomotherapy
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Usually Helical Systems
Have the Following:
1. 1
1 1 helical rotation
helical rotation
2. 1 Dose calculation (verified)
1 MLC (questionable on segmentation)
3. The more complicated the plan the longer
the treatment

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Volumetric Modulated Arc Therapy
(VMAT) Systems
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Usually Volumetric Systems
Have the Following:
1. 1+
1+ Rotation/Arc
Rotation/Arc
2. 1‐10 Dose calculations (verified)
1‐10 MLCs (dependant upon the orders,
equipment, and verification systems)
3. The more complicated the plan the longer
the treatment

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VERIFICATION FOR
Volumetric Systems
• Many
Many new software packages today to
new software packages today to
verify control points, for example:
• “Dosimetry Check”
• “Matrixx”
• “D lt 4”
“Delta4”
• Need input from Planning
system
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Documentation Examples
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Standard Linac Systems

Standard Linac Systems
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Usually Standard Linac systems have
the following:
1.
1 5 ‐ 11 gantry angles
5 11 gantry angles
2. 5 – 11 dose calculations (verified)
3. 5 – 11 MLCs
4. The higher number of gantry angles the
more complex and longer the treatment

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Documentation Examples
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Payments for 2009
Payments for 2009
and 2010
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2009 2010 Percentage of

PATIENT MIX MPFS PHYSICIAN Professional Professional Change
Breast IMRT $2,321 $2,258 -2.71%
Breast Standard $2,558 $2,595 1.44%
Prostate IMRT 40 fractions $3,603 $3,358 -6.80%
Prostate IMRT Seed Boost 25 fractions $2,573 $2,388 -7.19%
Prostate Standard $3,623 $3,677 1.50%
Lung IMRT $2,420 $2,684 10.91%
Lung Standard $3,062 $3,105 1.39%
Brain IMRT $2,385 $2,193 -8.06%
Radiosurgery Multisession brain body Non robotic $1,643 $1,635 -0.49%
Radiosurgery single session brain Non Robotic $1,930 $1,932 0.12%
Radiosurgery single session brain Robotic $1,930 $1,932 0.12%
Radiosurgery Multisession brain body robotic $2,272 $2,283 0.48%
Abdominal IMRT (pancreas, liver, body) $3,261 $3,257 -0.12%
Abdominal Standard $3,255 $3,300 1.38%
Palliative $1,220 $1,217 -0.30%
Head & Neck IMRT $3,894 $3,527 -9.42%
Hyperthermia Interstitial (additional) $556 $564 1.48%
H
Hyperthermia
th i Superficial
S fi i l (additional)
( dditi l) $636 $659 3 58%
3.58%
HDR GYN/Lung (no external beam) $1,517 $1,506 -0.72%
HDR Prostate 3 fractions over two days $1,712 $1,699 -0.77%
HDR Breast (no external beam) multicatheter $2,876 $2,875 -0.02%
IGRT Ultrasound tumor localization $1,169 $1,174 0.50%
IGRT Fluoro-Ray tumor localization $346 $348 0.50%
IGRT CT tumor localization $1,702 $1,725 1.35%
IGRT KV MV X-Ray tumor localization $779 $783 0.50%
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2009 Technical 2010 Technical Percentage of Change

PATIENT MIX MPFS PHYSICIAN
Breast IMRT $16,456 $15,927 -3.21%
Breast Standard $9,583 $9,548 -0.37%
Prostate IMRT Seed Boost 25 fractions $16,816 $15,991 -4.91%
Prostate Standard $13,331 $13,315 -0.11%
Lung IMRT $21,635 $21,050 -2.70%
Lung Standard $10,760 $10,690 -0.65%
Brain IMRT $14,137 $13,390 -5.28%
Radiosurgery Multisession brain body Non robotic $10,929 $10,740 -1.73%
Radiosurgery single session brain Non Robotic $3,690 $3,472 -5.91%
Radiosurgery single session brain Robotic $5,381 $5,162 -4.08%
Radiosurgery Multisession brain body robotic $19,795 $19,578 -1.10%

Abdominal IMRT (pancreas, liver, body) $22,980 $22,112 -3.78%
Abdominal Standard $11,747 $11,702 -0.38%
Palliative $3,358 $3,356 -0.05%
Head & Neck IMRT $26,021 $24,476 -5.94%
Hyperthermia Interstitial (additional) $2,977 $2,998 0.72%
Hyperthermia Superficial (additional) $3,030 $3,317 9.47%
HDR GYN/Lung (no external beam) $3,044 $2,857 -6.16%
HDR Prostate 3 fractions over two days $3,421 $3,145 -8.08%
HDR Breast (no external beam) multicatheter $6,262 $5,682 -9.25%

IGRT Ultrasound tumor localization $1,659 $1,551 -6.49%
IGRT Fluoro-Ray tumor localization $3,462 $3,552 2.59%
IGRT CT tumor localization $5,698 $5,582 -2.04%
IGRT KV MV X-Ray tumor localization $3,751 $3,538 -5.68%
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2009 final 2010 Final

PATIENT MIX HOSPITAL Payments Payments Percent Change
Breast IMRT $13,878 $13,428 -3.24%
Breast Standard $9,063 $9,037 -0.29%
Prostate IMRT with Seed Boost 25 fractions $14,598 $13,627 -6.65%
Prostate Standard $12,894 $12,862 -0.25%
Lung IMRT $17,725 $17,736 0.06%
g Standard
Lung $10,808
$ , $10,808
$ , 0.01%
Brain IMRT $12,429 $11,418 -8.14%
Radiosurgery multi-session non robotic $9,374 $9,391 0.18%
Radiosurgery single session non robotic $8,045 $7,781 -3.29%
Radiosurgery single session robotic $8,045 $7,781 -3.29%
Radiosurgery multi-session robotic $18,620 $17,999 -3.33%
Abdominal IMRT $19,982 $19,088 -4.47%
Abdominal Standard $11,410 $11,395 -0.13%
Pallative cases brain and bone (mets) $3,352 $3,355 0.07%
Head & Neck IMRT $23,713 $21,649 -8.70%
Hyperthermia Interstitial (additional) $2,231 $2,250 0.84%
Hyperthermia Superficial (additional) $2,231 $2,250 0.84%
HDR GYN/Lung (no external bean) $6,289 $6,380 1.45%
HDR Breast (no external bean) multicatheter $11,357 $11,680 2.84%
IGRT Ultrasound X-Ray tumor localization $0 $0 0.00%
IGRT Flouro-Ray tumor localization $0 $0 0.00%
IGRT CT Tumor localization $0 $0 0.00%
IGRT KV MV X-Ray tumor localization $0 $0 0.00%
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IMRT code payments for 2009 and 2010

RED IS
Professional Professional PERCENTAGE
lower
CPT Description Payment Rate Payment Rate INCREASE OR
BLACK
2010 2009 DECREASE
Higher
77301 Radiotherapyy dos plan, imrt $405.60 $400.69 $4.91 1%
77418 Radiation tx delivery, imrt $0.00 $0.00 $0.00 N/A
Technical Technical RED IS lower PERCENTAGE

CPT Description Payment Rate Payment Rate BLACK INCREASE OR
2010 2009 Higher DECREASE
77301 Radiotherapy dos plan, imrt $1,770.63 $1,756.05 $14.58 0.83%

77418 Radiation tx delivery, imrt $503.46 $516.83 $13.37 -2.59%
APC Final APC Final RED IS lower PERCENTAGE

CPT Description Payment Rate Payment Rate BLACK INCREASE OR
2010 2009 Higher DECREASE
77301 Radiotherapy dos plan, imrt $927.34 $892.90 $34.44 3.86%
77418 Radiation tx delivery, imrt $421.22 $410.83 $10.39 2.53%

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AUDIT
12/4/2009 Copyright AMAC® 2009 72

www.amac-usa.com
Date: 2/2/09
Ray D. Ashon, MD ICN: 2 345 23 83 234
#666 HIC: 3244566743A
324 linac Drive Acct.# 4888564587654
Audit, Montana 11111 RE: everyday Patient
Phys/supl: Z34333
Dear Doctor or Supplier:
We are processing a claim for everyday patient received on 1/2/09, and we
cannot complete this processing without the requested information below. Please
answer each question and return this letter within 30 days.
Please return this letter with the requested information. If the requested
information is not returned in 45 days, processing of the claim will be decided by
the information present. Payment may be reduced or denied if this information
has not been received.
Copy of report, physician orders, and medical necessity from 12/27/09 through
12/28/09 for 77418 for $1800.
Sincerely
Medicare Part B
800‐333‐3333
12/4/2009 Copyright AMAC® 2009 73
www.amac-usa.com
OH, NO!
WHAT DO THEY WANT?
WHY ME?
12/4/2009 Copyright AMAC® 2009 74

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These are standard letters to the provider of care or suppliers,
These are standard letters to the provider of care or suppliers,
1842 (a) (1) (c) Social Security Act. Everyone receives these
letters at one time or another as required by CMS of all their
contractors. These may be “pre‐payment” or “post‐ payment”
review. Most of these audits are based on the average dollars
or utilization of the code(s) by providers and are compared to
all the providers in the CMS contractors area of interest.
They may even supply you a graph to show where you are
They may even supply you a graph to show where you are
statistically in relation to your peers. You could be average and
not outside the norm and still be audited.
12/4/2009 Copyright AMAC® 2009 75
www.amac-usa.com
Please follow these simple rules:
1. Hire competent people
2. Read the letter and the request slowly from the payor
3. Supply the payor only what they are asking
4. Do not give the payor any more information than has
been requested
5
5. Go to the paper or electronic record and copy parts of
Go to the paper or electronic record and copy parts of
the documentation needed
6. Never say, “Why didn’t I document better!”
12/4/2009 Copyright AMAC® 2009 76

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Elements of a Complete Medical Record may
i l d
include:
1. Physician orders and/or certifications of medical
necessity
2. Patient questionnaires associated with physician services
3. Progress notes of another provider referenced in your
own notes
4. Treatment logs
5. Related professional consultation reports
6. Procedure, lab, X‐ray and diagnostic reports
12/4/2009 Copyright AMAC® 2009 77
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We reviewed the payors rules concerning code
77418. We then searched the medical chart and
decided on the following documentation:
decided on the following documentation:
1. Consult contained the diagnosis, so we used page 3 of the
consult and did not supply pages 1 and 2 medical necessity
2. The last page of the consult also contained the “PLAN” that
described why we were going to use IMRT and not 3‐D
conformal therapy medical necessity
3. We supplied the “written prescription,” “directive,” or “order”
that stated use IMRT for 40 fractions at 72Gy orders
4. Supplied the electronic record of the charge capture record
and verify system showing these two dates of treatment only
procedures performed on 12/27 and 12/28
12/4/2009 Copyright AMAC® 2009 78

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IMRT Planning & Dosimetry December 2-4, 2009 AMAC® Copyright 2009

Las Vegas, Nevada December 2 - 4, 2009

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www.amac-usa.com 770-693-6031 info.amac@amac-usa.com

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www.amac-usa.com 770-693-6031 info.amac@amac-usa.com

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www.amac-usa.com 770-693-6031 info.amac@amac-usa.com

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Copyright AMAC® 2009 10

www.amac-usa.com 770-693-6031 info.amac@amac-usa.com

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77301 77280 - 77290 0

77301 77305 - 77315 0

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www.amac-usa.com 770-693-6031 info.amac@amac-usa.com

77301 77326 - 77328 0

77301 77332 - 77334 1

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77301 77401 - 77416 1

77301 77422 -77423 1

www.amac-usa.com 770-693-6031 info.amac@amac-usa.com

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CT – 77014 77300 – dose Film Dosimetry N/A IGRT Daily CT,

77263 – N/A N/A N/A N/A

www.amac-usa.com 770-693-6031 info.amac@amac-usa.com

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Physician Orders Orders Dates &

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Copyright AMAC® 2009

www.amac-usa.com 770-693-6031 info.amac@amac-usa.com

Copyright AMAC® 2009

Copyright AMAC® 2009

www.amac-usa.com 770-693-6031 info.amac@amac-usa.com

Copyright AMAC® 2009

Copyright AMAC® 2009

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Copyright AMAC® 2009

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Copyright AMAC® 2009

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