Derms do Rad Onc

[TheWallnerus]

Here are the recent office notes from a dermatologist.

He's doing all the rad onc billing, as a derm (and getting paid too I presume). Billing for weekly 77427. Billing a daily sim (77280) and G6001. Literally doing IGRT for simple skin cancer. Only in America.

This is a Medicare patient. When a Medicare patient gets billed for radiation therapy treatment, does CMS have the bandwidth/subtlety to know that it's derm doing the billing and not rad onc? The majority of radiation fractions delivered in the US today are probably coming from derm. Does this throw off the rad onc numbers making things like RO-APM an attack on only docs that do radiation which are called rad oncs instead of derms (if that makes sense)? Put another way... is RO-APM partially derm's fault? Will derms get to continue to do radiation therapy but never have to be subject to RO-APM like us dumb rad oncs?

* Love it that derms do first f/u 3 months after RT... this way they go outside the global period, and can actually bill for the first f/u! Always be learning children.

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[deleted941485]

Here are the recent office notes from a dermatologist.

He's doing all the rad onc billing, as a derm (and getting paid too I presume). Billing for weekly 77427. Billing a daily sim (77280) and G6001. Literally doing IGRT for simple skin cancer. Only in America.

This is a Medicare patient. When a Medicare patient gets billed for radiation therapy treatment, does CMS have the bandwidth/subtlety to know that it's derm doing the billing and not rad onc? The majority of radiation fractions delivered in the US today are probably coming from derm. Does this throw off the rad onc numbers making things like RO-APM an attack on only docs that do radiation which are called rad oncs instead of derms (if that makes sense)? Put another way... is RO-APM partially derm's fault? Will derms get to continue to do radiation therapy but never have to be subject to RO-APM like us dumb rad oncs?

* Love it that derms do first f/u 3 months after RT... this way they go outside the global period, and can actually bill for the first f/u! Always be learning children.

Oh I’m sure Astro will write a strongly worded position statement on the matter that no one will read.

Also seriously? Blaming derm? This is why I hate what I do.

 

[OTN]

Here are the recent office notes from a dermatologist.

He's doing all the rad onc billing, as a derm (and getting paid too I presume). Billing for weekly 77427. Billing a daily sim (77280) and G6001. Literally doing IGRT for simple skin cancer. Only in America.

This is a Medicare patient. When a Medicare patient gets billed for radiation therapy treatment, does CMS have the bandwidth/subtlety to know that it's derm doing the billing and not rad onc? The majority of radiation fractions delivered in the US today are probably coming from derm. Does this throw off the rad onc numbers making things like RO-APM an attack on only docs that do radiation which are called rad oncs instead of derms (if that makes sense)? Put another way... is RO-APM partially derm's fault? Will derms get to continue to do radiation therapy but never have to be subject to RO-APM like us dumb rad oncs?

* Love it that derms do first f/u 3 months after RT... this way they go outside the global period, and can actually bill for the first f/u! Always be learning children.

This is fraud. My wife used to work for the government, going after practices JUST like these (derm practices) that abused radonc codes.

Sure, they're doing it, and getting reimbursed for now, but the chance that they will need to pay all that money back and more in the future is NOT zero.

 

[TheWallnerus]

This is fraud. My wife used to work for the government, going after practices JUST like these (derm practices) that abused radonc codes.

Sure, they're doing it, and getting reimbursed for now, but the chance that they will need to pay all that money back and more in the future is NOT zero.

Interesting. More info? Was the fraud that they “abused” codes, or just billed rad onc codes in the first place. Because definitely on the latter we are talking… well we have derms in all the major journals publishing how they bill/administer radiation therapy.

 

[TheWallnerus]

Oh I’m sure Astro will write a strongly worded position statement on the matter that no one will read.

Also seriously? Blaming derm? This is why I hate what I do.

If derms’ RT work is sliding into CMS’ Part B “Rad onc spending,” this would be an incredibly germane fact to put it mildly. I have no reason to think it is, but then again, if we just go by CPT codes…

 

[OTN]

Interesting. More info? Was the fraud that they “abused” codes, or just billed rad onc codes in the first place. Because definitely on the latter we are talking… well we have derms in all the major journals publishing how they bill/administer radiation therapy.

It was the abuse of codes- repeat simulation charges, IGRT for superficial skin cancer as you mentioned, and abuse of 77247. There was one particular dermatologist who was MOST upset he couldn't bill a 77247 each time he treated a patient.

No one cares they billed radonc codes in the first place. That wasn't an issue at all.

I strongly believe derms' RT work is, indeed, included in CMS Part B radonc spending. Why would CMS care who the delivering doc is? They're just looking at what is paid for each code. I haven't seen any information whatsoever specifying they broke it down by type of specialist delivering the treatment. I doubt they would even have the data-driven ability to do that.

Edit: Kind of a moot point, though, regarding the CMS Part B spending. Radonc spending has, as you've noted many times before, gone down over the last several years. Makes no sense that we would be punished via an APM unless our specialty leadership was completely ineffective at lobbying against it. I mean, they would either have to be woefully, Titanically ineffective or figure their particular Center of Excellence could benefit from a trimming of the competition.

 

[elementaryschooleconomics]

This is fraud. My wife used to work for the government, going after practices JUST like these (derm practices) that abused radonc codes.

One man's fraud is another man's standard operating procedure...

 

[medgator]

One man's fraud is another man's standard operating procedure...

If they aren't doing rad onc "work" , they are doing pathology "work"

Florida Physician to Pay $26.1 Million to Resolve False Claims Allegations

Steven J. Wasserman, M.D., a dermatologist practicing in Venice, Fla., has agreed to pay $26.1 million to resolve allegations that he violated the False Claims Act by accepting illegal kickbacks from a pathology laboratory and by billing the Medicare program for medically unnecessary services.

www.justice.gov

 

[radoncopotamus]

Daily U/S guidance for skin cancer?

 

[TheWallnerus]

Daily U/S guidance for skin cancer?

Supposedly the Sensus 100 Vision has been FDA cleared to do daily U/S guidance for skin cancer

 

[metallica81788]

Daily U/S guidance for skin cancer?

Sounds like I need to start doing daily MRIs for my whole brain patients to compete

 

[seper]

Deferring the first fup until >90dd is more common than you might think

Here are the recent office notes from a dermatologist.

He's doing all the rad onc billing, as a derm (and getting paid too I presume). Billing for weekly 77427. Billing a daily sim (77280) and G6001. Literally doing IGRT for simple skin cancer. Only in America.

This is a Medicare patient. When a Medicare patient gets billed for radiation therapy treatment, does CMS have the bandwidth/subtlety to know that it's derm doing the billing and not rad onc? The majority of radiation fractions delivered in the US today are probably coming from derm. Does this throw off the rad onc numbers making things like RO-APM an attack on only docs that do radiation which are called rad oncs instead of derms (if that makes sense)? Put another way... is RO-APM partially derm's fault? Will derms get to continue to do radiation therapy but never have to be subject to RO-APM like us dumb rad oncs?

* Love it that derms do first f/u 3 months after RT... this way they go outside the global period, and can actually bill for the first f/u! Always be learning children.

 

[evilbooyaa]

Deferring the first fup until >90dd is more common than you might think

Agreed - I do the same for prostates, breasts that do fine, etc. What's the point of seeing them at 1 month when you know you're not going to get paid for it?

Even things like ApEx accreditation require f/u within 4 months of end of RT.

But yes, this seems like massive overbilling by the derm. Daily US guidance for a skin cancer? lol.

 

[Gfunk6]

I don't mind if the dermatologists do this honestly. I've already registered for a weekend Moh's course.

 

[seper]

"What's the point of doing something in medicine when you know you're not going to get paid for it?" That's debatable

 

[radoncopotamus]

"What's the point of doing something in medicine when you know you're not going to get paid for it?" That's debatable

I'll defer the one month follow-up to 3 months if I dont think it will be worth the patients time or mine (e.g. no significant side effects, no change in management/no imaging to review). No need to waste everyones time.

 

[evilbooyaa]

"What's the point of doing something in medicine when you know you're not going to get paid for it?" That's debatable

*SIGH*

Let me clarify, by adding in the qualifier that I hoped would be basic ****ing knowledge, "In the patients who it won't benefit"

Gyn, H&N, GI, etc. all (most) benefit from a shorter interval f/u. Most (not all) prostates and most (not all) breasts don't benefit.

 

[medgator]

*SIGH*

Let me clarify, by adding in the qualifier that I hoped would be basic ****ing knowledge, "In the patients who it won't benefit"

Gyn, H&N, GI, etc. all (most) benefit from a shorter interval f/u. Most (not all) prostates and most (not all) breasts don't benefit.

Correct...i routinely follow anal, h&n etc where I'm worried about acute toxicity during and after tx. Not sure what the point is to following an SBRT lung pt a month out from treatment

 

[seper]

this sometimes becomes awkward in the office. “Bring this lady back in 3 months or so, but please make sure it’s not earlier than 90 days from today”

 

[doctalaughs]

To be fair - this is not common in dermatology at all (coming from a dermatologist).

I know many hundreds (likely thousands) of derm colleagues and only 1 is doing XRT. The percentage of skin cancers where radiation is the best option is minuscule (probably < 0.1% of our volume) which means those that use it regularly and invest in the equipment are likely monetarily motivated.

Every specialty has bad apples.

 

[elementaryschooleconomics]

this sometimes becomes awkward in the office. “Bring this lady back in 3 months or so, but please make sure it’s not earlier than 90 days from today”

To be honest, I'm pretty blunt about it with the staff in situations like this if someone asks why I want a follow-up at a specific date, or why I don't want to do same-day VSIMs and treat for non-urgent definitive cases, etc.

Unfortunately, the culture of medicine really discourages us from talking about this, and medical students are indoctrinated into thinking this is taboo which continues the culture. It's why we've been manhandled by the MBAs and labeled "providers" and forced to practice for Press Gainey scores.

I started out like this, but have a lot of close friends who are in Veterinary Medicine. They CONSTANTLY tell me stories of how, daily, they get accused of being uncaring when they try to get pet owners to pay for their services. Unlike human medicine, there are generally no puppet master insurance companies behind the scenes conducting transactions well after care has been delivered. Veterinarians are forced to ask for pay for services concurrently with delivering those services. Their point is always - we absolutely care about the animals, but if we provide care for free, we can't keep the lights on. Training, expertise, office space, supplies...it all costs money.

Human medicine is no different, and we provide a lot of care for free. I don't know about you guys, but I spend a lot of nights and weekends on the phone with patients and other doctors, answering emails, sitting in meetings, participating in tumor boards and committees...I don't get paid for any of that, and neither do you. I have almost 20 years of education and training after high school that the average person doesn't have to be able to do the things I do. I think that's worth something, and I'm not embarrassed to get reimbursed when I can.

Obviously, scheduling a follow-up 90 days out is vastly different than what this Dermatologist was doing, and different people have their blurry "lines in the sand" at different levels regarding what is appropriate and what is unethical. I think 90 day follow-ups for non-urgent, definitive patients who tolerated radiation therapy with minimal side effects is incredibly reasonable.

 

[TheWallnerus]

To be fair - this is not common in dermatology at all (coming from a dermatologist).

I know many hundreds (likely thousands) of derm colleagues and only 1 is doing XRT. The percentage of skin cancers where radiation is the best option is minuscule (probably < 0.1% of our volume) which means those that use it regularly and invest in the equipment are likely monetarily motivated.

Every specialty has bad apples.

Business is booming for Sensus; is the machine which they made, and got govt approval for, in order to do IGRT during skin cancer RT a giant manufacturing fraud? Derms are buying "linacs."

And your academy, and its President, says dermatologists are the "primary users" of radiation therapy for skin cancer in the U.S.

Fake news? If so... great.

 

[medgator]

To be fair - this is not common in dermatology at all (coming from a dermatologist).

I know many hundreds (likely thousands) of derm colleagues and only 1 is doing XRT. The percentage of skin cancers where radiation is the best option is minuscule (probably < 0.1% of our volume) which means those that use it regularly and invest in the equipment are likely monetarily motivated.

Every specialty has bad apples.

I get way more referrals than that, esp for lesions of the ears, nose, oral commissure and pretibial skin. Those are difficult enough for mohs when they are small, and almost impossible when they are larger without significant skin defect and healing issues, esp in elderly vasculopaths.

Also failures after derms try to do superficial radiation inappropriately for deeper/thicker lesions

 

[deleted1111261]

I get way more referrals than that, esp for lesions of the ears, nose, oral commissure and pretibial skin. Those are difficult enough for mohs when they are small, and almost impossible when they are larger without significant skin defect and healing issues, esp in elderly vasculopaths.

Also failures after derms try to do superficial radiation inappropriately for deeper/thicker lesions

If only 0.1% of your skin cancers are amenable to RT (1/1000), you’re simply unaware about RT and skin cancer. And that sounds typical for a dermatologist.

 

[deleted941485]

If only 0.1% of your skin cancers are amenable to RT (1/1000), you’re simply unaware about RT and skin cancer. And that sounds typical for a dermatologist.

Willful ignorance sounds about right in that scenario.

 

[seper]

The obvious difference is that your vet friends are probably private practice, they’ve got techs to pay, etc.
A US Radonc is overwhelmingly likely to be an employee of a large hospital-based operation. So you are basically reaching deep into these patients’ pockets for the benefit of a concern, which is just about to get another tranche of federal covid grant.
Why? For like 1.5 wRVU

To be honest, I'm pretty blunt about it with the staff in situations like this if someone asks why I want a follow-up at a specific date, or why I don't want to do same-day VSIMs and treat for non-urgent definitive cases, etc.

Unfortunately, the culture of medicine really discourages us from talking about this, and medical students are indoctrinated into thinking this is taboo which continues the culture. It's why we've been manhandled by the MBAs and labeled "providers" and forced to practice for Press Gainey scores.

I started out like this, but have a lot of close friends who are in Veterinary Medicine. They CONSTANTLY tell me stories of how, daily, they get accused of being uncaring when they try to get pet owners to pay for their services. Unlike human medicine, there are generally no puppet master insurance companies behind the scenes conducting transactions well after care has been delivered. Veterinarians are forced to ask for pay for services concurrently with delivering those services. Their point is always - we absolutely care about the animals, but if we provide care for free, we can't keep the lights on. Training, expertise, office space, supplies...it all costs money.

Human medicine is no different, and we provide a lot of care for free. I don't know about you guys, but I spend a lot of nights and weekends on the phone with patients and other doctors, answering emails, sitting in meetings, participating in tumor boards and committees...I don't get paid for any of that, and neither do you. I have almost 20 years of education and training after high school that the average person doesn't have to be able to do the things I do. I think that's worth something, and I'm not embarrassed to get reimbursed when I can.

Obviously, scheduling a follow-up 90 days out is vastly different than what this Dermatologist was doing, and different people have their blurry "lines in the sand" at different levels regarding what is appropriate and what is unethical. I think 90 day follow-ups for non-urgent, definitive patients who tolerated radiation therapy with minimal side effects is incredibly reasonable.

 

[medgator]

The obvious difference is that your vet friends are probably private practice, they’ve got techs to pay, etc.
A US Radonc is overwhelmingly likely to be a employee of a large hospital-based operation. So you are basically reaching out deep into these patients pockets for the benefit of a concern, which is just about to get another tranche of federal covid grant.
Why? For like 1.5 wRVU

Plenty of us still out there in private practice, but yes shrinking in number as time goes on. In either case, why wouldn't you want to be performed for the work that you do?

 

[Palex80]

Daily ultrasound for skin therapy?

I usually palpate the lesion, take a look at the depth-dose-curve our physicists have developed for our kV machine and determine the optimal energy.
Then, I pick the next higher energy, to rule out any uncertainties

Oh, I do that a week or so before the patient starts treatment and then see the patient again only when she/he is done...

 

[elementaryschooleconomics]

The obvious difference is that your vet friends are probably private practice, they’ve got techs to pay, etc.
A US Radonc is overwhelmingly likely to be an employee of a large hospital-based operation. So you are basically reaching deep into these patients’ pockets for the benefit of a concern, which is just about to get another tranche of federal covid grant.
Why? For like 1.5 wRVU

I hear you. Perhaps this is where you draw your line. Do you go further? Do you perform and document FFOL exams? Those generate a charge, maybe leave that out and give the patient a break. Do your consult notes bill at 99205? Why not bill at 99204 or 99203? I'm absolutely certain there are folks out there who do that. For me, while I see nothing wrong with doing 90-day follow-ups for definitive cases without notable toxicity during treatment, I don't feel the same for palliative cases. Those folks I believe in seeing in the traditional global window to assess response and then instructing them to call me if they think they need me, instead of coming in for "routine" follow-up which usually generates a co-pay for them.

I'm in non-hospital employed private practice. I was looking at the practice's books this week. Over the last several years, we have generated similar (or more) levels of charges for increasingly decreased revenue. My work generates technical revenue for the hospital I usually cover, which, in turn, helps fund my entire department. My department has been forced to work with increasingly smaller budgets each year because of decreased reimbursements from CMS cuts, hypofrac, etc. It's projected to get worse with these upcoming CMS cuts, APM, etc.

There are already wolves in the tall grass, I don't feel the need to cause any self-inflicted wounds. Again, everyone's line is different. To me, making sure to capture a small charge like this is similar to wanting to finance a car from 2016 as opposed to 2019. In comparison to my physician salary, does the increased monthly payment on the 2019 model really matter? Some folks say no, some folks say that small difference adds up over time. Everyone has to decide for themselves.

 

[seper]

Not arguing with this. It’s just I always liked the rule for “non-billable” post XRT check. Kind of like postop visit after surgery. Patients are overwhelmingly onboard with those appointments

I hear you. Perhaps this is where you draw your line. Do you go further? Do you perform and document FFOL exams? Those generate a charge, maybe leave that out and give the patient a break. Do your consult notes bill at 99205? Why not bill at 99204 or 99203? I'm absolutely certain there are folks out there who do that. For me, while I see nothing wrong with doing 90-day follow-ups for definitive cases without notable toxicity during treatment, I don't feel the same for palliative cases. Those folks I believe in seeing in the traditional global window to assess response and then instructing them to call me if they think they need me, instead of coming in for "routine" follow-up which usually generates a co-pay for them.

I'm in non-hospital employed private practice. I was looking at the practice's books this week. Over the last several years, we have generated similar (or more) levels of charges for increasingly decreased revenue. My work generates technical revenue for the hospital I usually cover, which, in turn, helps fund my entire department. My department has been forced to work with increasingly smaller budgets each year because of decreased reimbursements from CMS cuts, hypofrac, etc. It's projected to get worse with these upcoming CMS cuts, APM, etc.

There are already wolves in the tall grass, I don't feel the need to cause any self-inflicted wounds. Again, everyone's line is different. To me, making sure to capture a small charge like this is similar to wanting to finance a car from 2016 as opposed to 2019. In comparison to my physician salary, does the increased monthly payment on the 2019 model really matter? Some folks say no, some folks say that small difference adds up over time. Everyone has to decide for themselves.

 

[Taurus]

If they aren't doing rad onc "work" , they are doing pathology "work"

Florida Physician to Pay $26.1 Million to Resolve False Claims Allegations

Steven J. Wasserman, M.D., a dermatologist practicing in Venice, Fla., has agreed to pay $26.1 million to resolve allegations that he violated the False Claims Act by accepting illegal kickbacks from a pathology laboratory and by billing the Medicare program for medically unnecessary services.

www.justice.gov

The whistleblower pathologist got $4M.

Tampa doctor gets $4M from blowing whistle on Medicare fraud

TAMPA — A Tampa pathologist who blew the whistle on Medicare fraud will get $4 million for his trouble, the U.S. Justice Department said Monday.

www.tampabay.com

 

[radiaterMike]

Not arguing with this. It’s just I always liked the rule for “non-billable” post XRT check. Kind of like postop visit after surgery. Patients are overwhelmingly onboard with those appointments

I document these like an OTV since I’m not worried about billing. This was more of a ‘perk’ before CMS simplified documentation requirements for follow ups though.

 

[deleted1111261]

I document these like an OTV since I’m not worried about billing. This was more of a ‘perk’ before CMS simplified documentation requirements for follow ups though.

What do you mean simplified for follow ups ?

 

[medgator]

The whistleblower pathologist got $4M.

Tampa doctor gets $4M from blowing whistle on Medicare fraud

TAMPA — A Tampa pathologist who blew the whistle on Medicare fraud will get $4 million for his trouble, the U.S. Justice Department said Monday.

www.tampabay.com

15-25% whistleblower payout is common, less i think if government/doj intervenes

 

[radiaterMike]

What do you mean simplified for follow ups ?

while you could always bill based on time, now (as of 2021) you can bill based on medical decision making … obviating the need to meet a specified # of HPI elements, organ systems for ROS or organ systems for physical exam. Most of what we do would qualify as high level of medical decision making (reviewing scans, high risk treatment …).

https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/eval-mgmt-serv-guide-icn006764.pdf

 

[deleted1111261]

while you could always bill based on time, now (as of 2021) you can bill based on medical decision making … obviating the need to meet a specified # of HPI elements, organ systems for ROS or organ systems for physical exam. Most of what we do would qualify as high level of medical decision making (reviewing scans, high risk treatment …).

https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/eval-mgmt-serv-guide-icn006764.pdf

Oh. Right. But that’s also simplified consults, too. I thought you meant something specific for follow ups, solely

 

[DrZap]

Since covid we started scheduling most 1 mo follow-ups as phone call follow-ups. It works well as far as efficiency and lets us address questions that come up before the 3 mo visit.