77014-26; Professional code for CBCT

[BobbyHeenan]

We are starting to get more push back from some private insurers on professional fees for a daily CBCTs (cpt code 77014-26).

THe last I had checked I saw two sources suggesting this was still OK to bill on the professional side, but not on the technical side....

Anyone have any update on this or experience with this? Has anyone stopped billing for these CBCTs?

=========

I see an ASTRO FAQ still up on their website (can't see if this is the most updated take on this or not) suggesting 77014-26 still OK to bill. ​

​	IGRT Reporting in the Freestanding Setting​	IGRT Reporting in the Hospital Setting​
IGRT with IMRT Delivery	Office bills: IMRT code: G6015 or G6016 IGRT code: G6001, G6002 and/or 77014 (global)	Hospital bills: IMRT code: 77385 or 77386 Physician bills: IGRT code(s): G6001, G6002, and/or 77014 with the -26 modifier attached (PC)

Dr. Bogardus Q & A​

Question:

We are having issues with billing 77014 with any of the treatment codes. Are they bundling the CBCT with all tx codes? That is what the EOB's are telling us.
Answer:

It is not surprising that you're having problems with 77014. This is the technical component of a CT scan which for many years has been bundled into all of the primary CT and simulation procedures. The code absolutely will not be paid on the technical side for any procedure. The physician may still use the professional side of 77014 for his interpretation of a cone beam CT used for guidance only. The technical component will not be paid. At the present time, this code is not bundled with 77387; however, it is anticipated that it ultimately will be part of that code also.
Dr. Bogardus​

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[seper]

Is that the one worth 0.85 wRVU from a recent thread? A good source of productivity but also staff tension (at a large department). At my place, I have not heard of payor pushback yet.

 

[BobbyHeenan]

Is that the one worth 0.85 wRVU from a recent thread? A good source of productivity but also staff tension (at a large department). At my place, I have not heard of payor pushback yet.

I'm not sure about wRVU's - don't really pay much attention to that calculus since we bill professional fees separate from hospital.

I definitely get called to machine more for CBCT's but I have found them very helpful in many cases, so it's frustrating to think that once again something I do work for and used to get paid for this work is now potentially magically "bundled" into something else.

 

[evilbooyaa]

I always justify in my note why we are doing IMRT and why we are doing daily IGRT. Not sure if it makes a difference, but a thought OP

 

[BobbyHeenan]

I always justify in my note why we are doing IMRT and why we are doing daily IGRT. Not sure if it makes a difference, but a thought OP

Yeah, that's helped to some degree in the past; always put that in both my consult and my complex treatment planning note.

The insurance company doesn't cite a particular code/section, just boiler plate "CMS guidelines" suggest this code is bundled with our IMRT/VMAT treatment planning charge.

 

[scarbrtj]

Yeah, that's helped to some degree in the past; always put that in both my consult and my complex treatment planning note.

The insurance company doesn't cite a particular code/section, just boiler plate "CMS guidelines" suggest this code is bundled with our IMRT/VMAT treatment planning charge.

When it's done as sim "CT sim" it's bundled. But when it's done as daily CBCT, it's not bundled. Two wildly different things... same exact 5-digit code for which the insurance co. is trying to conflate. It's absolutely OK and either you've got a misinformed insurance co., a niggardly insurance co., or a biller who's somehow messing it up. Either way, you should get the charge. A minor fight might be involved.

 

[evilbooyaa]

I was under impression that 77014 at time of CT Sim was no longer separate (and was bundled, see here: 77014 CT Guidance - American Society for Radiation Oncology (ASTRO) - American Society for Radiation Oncology (ASTRO)), but I'm not aware of anything that says 77014 can't be billed for daily IGRT.

*EDIT* - Scooped by scarb. Completely agree.

 

[BobbyHeenan]

When it's done as sim "CT sim" it's bundled. But when it's done as daily CBCT, it's not bundled. Two wildly different things... same exact 5-digit code for which the insurance co. is trying to conflate. It's absolutely OK and either you've got a misinformed insurance co., a niggardly insurance co., or a biller who's somehow messing it up. Either way, you should get the charge. A minor fight might be involved.

Thanks.

That has been my take as well.

We never bill a CT sim or complex sim (77290) anyway with an IMRT plan (bundled). Only billing the 77014-26 for the daily image guidance charge.

 

[scarbrtj]

Thanks.

That has been my take as well.

We never bill a CT sim or complex sim (77290) anyway with an IMRT plan (bundled). Only billing the 77014-26 for the daily image guidance charge.

It should also be noted both 77014 sim and 77290 are bundled with 3D now too. Bye sim. We hardly knew ye.

 

[BobbyHeenan]

It should also be noted both 77014 sim and 77290 are bundled with 3D now too. Bye sim. We hardly knew ye.

I saw where you posted that - thank you. I asked our billers/coders to look into that and they haven't gotten back to me.

Is that "official" or was that the OIG rec or what? Any ASTRO or Bogardus info on this?

Are people not billing 77014 for 3D now either for IMRT or 3D?

 

[scarbrtj]

I saw where you posted that - thank you. I asked our billers/coders to look into that and they haven't gotten back to me.

Is that "official" or was that the OIG rec or what? Any ASTRO or Bogardus info on this?

Are people not billing 77014 for 3D now either for IMRT or 3D?

It's official, from way back in fact, and a weak spot in the armor against audits, fraud, etc. On the plus side, OIG said ~95% of everyone nationwide was committing the "fraud" of unbundling 77290 and 77295 so... we don't bill it anymore. And we made some proactive retrospective repayments (which you're technically supposed to do when you find out you've been overpaid) to make sure there's no future drama.
BTW, Bogardus is dead.

 

[BobbyHeenan]

It's official, from way back in fact, and a weak spot in the armor against audits, fraud, etc. On the plus side, OIG said ~95% of everyone nationwide was committing the "fraud" of unbundling 77290 and 77295 so... we don't bill it anymore. And we made some proactive retrospective repayments (which you're technically supposed to do when you find out you've been overpaid) to make sure there's no future drama.
BTW, Bogardus is dead.

Thanks.

Yes, knew about Bogardus, I meant more the Bogardus company rather than the gentleman himself.

 

[Radi8r]

CMS has never given guidance or made any rules that state sim charges are bundled into 77295. It seems that the OIG decided that on its own because there's a same day edit.

https://oig.hhs.gov/oas/reports/region9/91803026.pdf

From CMS response letter:

However, intensity modulated radiation therapy and three-dimensional conformal radiation therapy services do have
important differences in terms of coding guidance and payment rules. CMS will consider
whether implementing billing requirements in the future to prevent payments for additional
planning services when reported with three-dimensional conformal radiation therapy would be
appropriate.

It seems like CMS hedged its response. I don't think there's enough there to change billing practices yet.

 

[scarbrtj]

CMS has never given guidance or made any rules that state sim charges are bundled into 77295. It seems that the OIG decided that on its own because there's a same day edit.

https://oig.hhs.gov/oas/reports/region9/91803026.pdf

From CMS response letter:

However, intensity modulated radiation therapy and three-dimensional conformal radiation therapy services do have
important differences in terms of coding guidance and payment rules. CMS will consider
whether implementing billing requirements in the future to prevent payments for additional
planning services when reported with three-dimensional conformal radiation therapy would be
appropriate.

It seems like CMS hedged its response. I don't think there's enough there to change billing practices yet.

It won't ever get more clear than an OIG report saying this is not the right way to bill.

 

[medgator]

It won't ever get more clear than an OIG report saying this is not the right way to bill.

Until we read a multi million dollar qui tam about it on Becker's or the nyt

 

[Radi8r]

It won't ever get more clear than an OIG report saying this is not the right way to bill.

https://www.acr.org/Advocacy-and-Economics/Advocacy-News/Advocacy-News-Issues/In-the-June-29-2019-Issue/ACR-Disagrees-with-OIG

 

[BobbyHeenan]

Update.

Apparently Aetna (and now others I'm hearing) are trying to quit paying for 77014-26 (CBCT); instead they want you to bill 77387 - which in most expert opinion is more the appropriate code for INTRA fraction motion (like Calypso/real time tracking on a lung or liver case with fiducials). ASTRO addresses this below. 77387 I believe also has no set medicare reimbursement value either yet; I typically don't bill that on my real time radiosurgery tracking cases (some lungs, livers, etc), as I "bundle" that code into 77435 (?maybe I should start billing it?). I don't use Calypso for prostates.

This is infuriating. When ASTRO, Bogardus, and Evicore all say to bill 77014-26 for CBCTs but Aetna just declares unilaterally that you're billing it incorrectly....

Update on Image Guidance Billing for Aetna - American Society for Radiation Oncology (ASTRO)

www.astro.org

 

[scarbrtj]

Update.

Apparently Aetna (and now others I'm hearing) are trying to quit paying for 77014-26 (CBCT); instead they want you to bill 77387 - which in most expert opinion is more the appropriate code for INTRA fraction motion (like Calypso/real time tracking on a lung or liver case with fiducials). ASTRO addresses this below. 77387 I believe also has no set medicare reimbursement value either yet; I typically don't bill that on my real time radiosurgery tracking cases (some lungs, livers, etc), as I "bundle" that code into 77435 (?maybe I should start billing it?). I don't use Calypso for prostates.

This is infuriating. When ASTRO, Bogardus, and Evicore all say to bill 77014-26 for CBCTs but Aetna just declares unilaterally that you're billing it incorrectly....

Update on Image Guidance Billing for Aetna - American Society for Radiation Oncology (ASTRO)

www.astro.org

you talkin' daily CBCT IGRT they aren't paying?

 

[BobbyHeenan]

you talkin' daily CBCT IGRT they aren't paying?

Yes.

Apparently this isn't a new thing for for them - see the ASTRO link from 2/2018...it's just new to our practice and interaction with Aetna.

They (Aetna) are saying (and I've done a DEEEEPPPP dive on this - they're literally the only one initially saying this but now one other company is too) that you should bill 77387 (a potentially non-reimburseable code) for a daily CBCT rather than the 77014-26 code.

 

[scarbrtj]

I saw where you posted that - thank you. I asked our billers/coders to look into that and they haven't gotten back to me.

Is that "official" or was that the OIG rec or what? Any ASTRO or Bogardus info on this?

Well it seems to be prett-ay official now... no simulation charges allowed with 3DCRT (CPT 77295). And obviously if you're doing something that MACs are on the lookout for, it's risky for having to refund, whistleblowing, etc. If you'd have told me ~10 years ago I'd have to treat everyone without doing a simulation I'd have said: no way. Yet here we are. But ASTRO "disputing" OIG findings... they must be getting really desperate. Or maybe realizing they might have to speak up every once in a while.

ASTRO urges MACs to stop inappropriate 3-D CRT denials
ASTRO members recently received denials from Medicare Administrative Contractors (MACs) for Simulation and/or Continuing Medical Physics services when provided with 3-D CRT. The denials appear to stem from a 2019 OIG report, which asserts that Medicare could generate savings if billing requirements and system edits prevented additional payments for services related to CPT code 77295. ASTRO has disputed the OIG report and reached out to Novitas, Wisconsin Physician Services and Palmetto explaining that the OIG report does not recognize that the work described by CPT code 77295 does not include simulation or continuing medical physics. If your practice has received inappropriate denials, please contact [email protected]. For more information, read What’s Happening in Washington.

 

[Irradi8or]

Well it seems to be prett-ay official now... no simulation charges allowed with 3DCRT (CPT 77295). And obviously if you're doing something that MACs are on the lookout for, it's risky for having to refund, whistleblowing, etc. If you'd have told me ~10 years ago I'd have to treat everyone without doing a simulation I'd have said: no way. Yet here we are. But ASTRO "disputing" OIG findings... they must be getting really desperate. Or maybe realizing they might have to speak up every once in a while.

ASTRO urges MACs to stop inappropriate 3-D CRT denials
ASTRO members recently received denials from Medicare Administrative Contractors (MACs) for Simulation and/or Continuing Medical Physics services when provided with 3-D CRT. The denials appear to stem from a 2019 OIG report, which asserts that Medicare could generate savings if billing requirements and system edits prevented additional payments for services related to CPT code 77295. ASTRO has disputed the OIG report and reached out to Novitas, Wisconsin Physician Services and Palmetto explaining that the OIG report does not recognize that the work described by CPT code 77295 does not include simulation or continuing medical physics. If your practice has received inappropriate denials, please contact [email protected]. For more information, read What’s Happening in Washington.

OIG was wrong here - they tried to apply the logic of no separate sim charge for IMRT cases to 3DCRT. 77280/77290 valuation isn’t bundled into 77295