Virtual Supervision

[kimplera]

Which is pretty stupid.

Direct supervision means in the building with the patient.

If the patient is home while you're contouring/signing films, to truly meet direct supervision you need to be at the patient's kitchen table.

not for SBRT but for daily cone beams, etc...

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[TheWallnerus]

not for SBRT but for daily cone beams, etc...

I know. But you aren't signing off on the cone beams until well after the treatment and the patient is already back home or at work etc right. And this signage, it's professional work only. In reality the supervision concept doesn't apply. This is a very wonky argument, but when you sign a CBCT the charge is 77014-26. When a CBCT is performed, it's 77014-TC (and that is always paid zero, with IMRT, in a hospital). You can go into the Medicare physician fee schedule database and download the info on this code...

And download these two codes (77014-26 and 77014-TC) into Excel...

Under "Phys Supv" Medicare places a supervision code next to every HCPCS code. The supervision levels are defined thusly:

For 77014-TC, it's level 2, "direct supervision." For 77014-26 it's level 9; the supervision concept does not apply. This makes sense: you would have to supervise yourself in signing a film. You can't supervise anyone else when you sign a film. And wherever you are, there you are.

 

[evilbooyaa]

pretty sure we've been told to contour and sign films on site - but even on site i have to log into citrix to do so and i'm not sure what the difference is...

lmao what

 

[GI_RadOnc]

Agree modification for NP/PA reasonable in today's environment.

I would like to think that radonc is peculiar and presents real clinical challenges in real time that the average NP may be less equipped to handle than say prescribing anti-emetics, pain meds or steroids. I would like to think that the availability of the consulting MD to reassure patients thinking of quitting mid-week or assessing for futility dynamically during treatment is an MDs job.

I certainly don't think that the potential for medical catastrophe is the same in the therapeutic vs diagnostic radiology setting.

I admit, I am biased against the transfer of medicine as a whole to remote care. I think the wrong statistical tools will be used to show equivalence and that the performative aspect of medicine is damn critical. I have personally seen significant delay of diagnosis cases during COVID due to remote medicine supplanting in-patient examination. I also am not in a situation where relaxation of supervision standards is going to be a QOL or financial boon, but rather likely another step in the devaluation of my specialty within my community. My response to the marginalization of radonc has been a maximalist one, with more engagement with multi-disciplinary care, palliative care and pt ownership.

Again, I'm in the minority that thinks we should be giving cancer drugs.

I think we are on the same page here, actually regarding increased engagement in MDC, patient ownership, palliative care etc. I use virtual supervision options to add patients and add MDC options. Yesterday, I added three consults over my SBRTs yesterday; and was able to see them while taking 5 minutes in the surgeon's consult room to turn the computer and assist a couple of SBRT / adaptive treatments. I spent some of the time on the phone to talk to a patient who was refusing SRS (or any radiation) for her four brain metastases. Much appreciated by the surgeon and medical oncologist. This 'face time' and 'availability' will help increase my chances of being employed over the next twenty years!

 

[GI_RadOnc]

How are you able to remote into the treatment unit and what security do you have to keep the treatment unit from being hacked? Honest question. I thought they were supposed to be walled off from general network access for security purposes, though this may be more institutional policy than law.

With virtual supervision being the next battleground to lose, I truly remain amazed Astro and academic leaders continue to keep near record residency slots. It is nonsensical and greedy.

It's a secure application from inside the hospital network. I have to citrix into the hospital network (if I am off of it); then it needs to be turned on by the physicist/therapist at the console; where they don't turn it on until I call or message that I need access; and then they turn it off as soon as my work is done. It is built on the backbone of our remote service for the machine; so it followed the same security policies.

 

[TheWallnerus]