77470

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firewicket

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Im getting a slew of rejections now suddenly on this code from United for Medicare advantage plans.

Anyone elses getting these denied?

I am assuming I have not been inappropriately billing 77470 for SBRT cases for the past 10 years...and it is indeed the same across the nations and this is a routine charge for this situation.
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firewicket said:
Im getting a slew of rejections now suddenly on this code from United for Medicare advantage plans.

Anyone elses getting these denied?

I am assuming I have not been inappropriately billing 77470 for SBRT cases for the past 10 years...and it is indeed the same across the nations and this is a routine charge for this situation.
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Over the years more insurers are declining it for "routine" SBRT. Like a stage I lung or brain met .

If it is denied and there are unique situations (like overlapping prior radiation dose) then in my experience if you dictate a new note explaining why you're billing it it may get covered.
 
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Is there a professional charge for this code or just technical?
 
firewicket said:
Im getting a slew of rejections now suddenly on this code from United for Medicare advantage plans.

Anyone elses getting these denied?

I am assuming I have not been inappropriately billing 77470 for SBRT cases for the past 10 years...and it is indeed the same across the nations and this is a routine charge for this situation.
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I don't bill 77470 for SBRT unless I'm retreating the same area or pt is getting concurrent chemo
 
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Gfunk6 said:
I haven't not billed 77470 for SBRT in the last decade. 🤔
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Pointless said:
Same here. I always bill it, they can do whatever the hell they want with it.
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The funny* thing about these discussions is how the risk and accusation levels and smug sense of moral superiority levels can amp up, at will. “I always bill it” is a DoJ FCA lawyer’s whispered words of sweet nothings 😉

* ”Funny” as in Haneke’s ‘Funny Games,’ or ‘Goodfellas’.
 
Maybe special treatment procedure is like pornography: tough to define but we know it when we see it. I don’t feel it’s a giant risk billing this liberally for SRS and SBRT with Medicare patients. For insurance and Medicare Advantage there is, and increasingly will be, pushback. Evicore guidelines specifically forbid 77470 for SRS or SBRT eg. United had an unwritten policy to allow this whenever and billed for whatever reason up until summer of this year even in “violation” of their own written policy. For some reason that unwritten policy got nixed recently. As we all know, IMRT used to be a Medicare approved indication for 77470. “Hemibody” radiation has always been a Medicare approved indication for it. I’ve always wondered what clinical situation merits hemibody (from the waist down? just the right half of body?) RT.
 
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TheWallnerus said:
The funny* thing about these discussions is how the risk and accusation levels and smug sense of moral superiority levels can amp up, at will. “I always bill it” is a DoJ FCA lawyer’s whispered words of sweet nothings 😉

* ”Funny” as in Haneke’s ‘Funny Games,’ or ‘Goodfellas’.
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Not sure how you got moral superiority out of that, just commenting that I bill it with all SBRT/SRS cases. Take from that what you will, I guess.
 
Pointless said:
Not sure how you got moral superiority out of that, just commenting that I bill it with all SBRT/SRS cases. Take from that what you will, I guess.
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Ha, comment was in no ways aimed at you. It was aimed at us. Here’s a scenario where we have some saying they always bill it and some saying they never do. Supposedly if you bill it you do it. So one might presume some people never do this special treatment procedure with SBRT and some people always do it. If it’s done, also supposedly, it’s done because it’s “medically necessary.” How can so many rad oncs be so far apart on this issue that some think special procedure is never necessary and some think it’s always necessary? Or do some rad oncs always actually do a special treatment procedure… and just never bill it?

As much as I hate to admit, special treatment procedure might be THE example of why case based payments are needed in rad onc. We could eliminate the grey zones and a lot of “fraud.” For example, I always do IMRT for stage one breast. If I got on stage at ASTRO and said that, I’d get a few tomatoes thrown at me. If I got on stage and said I always do IMRT but I never bill IMRT, Ron D would call Merrick Garland. But you could get on stage and say “Yes, SBRT is a special treatment procedure, but we never bill it,” and no one would bat an eye.
 
TheWallnerus said:
Ha, comment was in no ways aimed at you. It was aimed at us. Here’s a scenario where we have some saying they always bill it and some saying they never do. Supposedly if you bill it you do it. So one might presume some people never do this special treatment procedure with SBRT and some people always do it. If it’s done, also supposedly, it’s done because it’s “medically necessary.” How can so many rad oncs be so far apart on this issue that some think special procedure is never necessary and some think it’s always necessary? Or do some rad oncs always actually do a special treatment procedure… and just never bill it?

As much as I hate to admit, special treatment procedure might be THE example of why case based payments are needed in rad onc. We could eliminate the grey zones and a lot of “fraud.” For example, I always do IMRT for stage one breast. If I got on stage at ASTRO and said that, I’d get a few tomatoes thrown at me. If I got on stage and said I always do IMRT but I never bill IMRT, Ron D would call Merrick Garland. But you could get on stage and say “Yes, SBRT is a special treatment procedure, but we never bill it,” and no one would bat an eye.
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Agreed on all counts.
 
STP charge used to be approved by CMS for 3D-CRT (as opposed to 2D) ! Expectations on what's "extra physician work" have changed
 
last time I check...it was direct supervision...I had to haul my a** over to the machine every time and check and image.

Didn't matter if I had to cut off a consult or follow up right in the middle or even the beginning of the appointment.

470 is substantiated...these insurance companies just cut cut cut cut cut everything. you guys need to stand up for yourselves and everyone else.
 
firewicket said:
last time I check...it was direct supervision...I had to haul my a** over to the machine every time and check and image.

Didn't matter if I had to cut off a consult or follow up right in the middle or even the beginning of the appointment.

470 is substantiated...these insurance companies just cut cut cut cut cut everything. you guys need to stand up for yourselves and everyone else.
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Agree with this.
 
Yeah. that is a good point and a very bothersome truth of SBRT/SRS. There's nothing worse than having to get up and leave in the middle of a difficult consult to go check a scan. That alone is worth the charge.
 
Pointless said:
Yeah. that is a good point and a very bothersome truth of SBRT/SRS. There's nothing worse than having to get up and leave in the middle of a difficult consult to go check a scan. That alone is worth the charge.
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rather not check with therapists if they’ll need you before going into consult? that’s why there is also doctor of the day in the Dept 🙂
 
was just pointing out why SBRT is not an indication for STP charge, according to ASTRO
 
medgator said:
ASTRO making sure we get paid less. Par for the course
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at a large group practice, SBRT to a lung nodule is literally the easiest treatment to give out of all oncology.
so ASTRO coding committee naturally excluded SBRT from the STP paragraph
 
Checking an IGRT SBRT image does not support 77470. As we know we can’t even bill IGRT (77014 eg) separately (the prof or the tech) because imaging is a part of the SBRT tx code by definition (IGRT is “getting reimbursed” via its bundling therein). Also we get the SBRT management (up)charge… which would include therapists calling to verify a setup (imho). Don’t get me wrong, SBRT involves “extra work.” But extra work doesn’t necessarily mean STP.

However there are no hard and fast rules, per se, on this. (ASTRO guidelines are definitely neither hard nor fast.) Again, I think you could bill 77470 for every Medicare SBRT and go a whole career with zero drama.
 
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