Direct supervision vs personal supervision SRS/SBRT

[firewicket]

Question for the group.

I understand that “direct supervision” is a gray area in some centers. But, I think we all can agree that the safest way to absolutely avoid fraud charges from CMS is to have a rad/Onc on-site (AKA in the department) while the beam is on.

My question concerns Radiosurgery. The provider is in the department and immediately “interruptible for direct supervision” rules to oversee the procedure (just like is typical for IMRT/CBCTs).

Do you need to be literally at the machine while beam is on with “personal supervision” for SRS/SBRT? Or is just being in the department with “direct supervision” like for IMRT cases and checking the imaging on offline review good enough?

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[medgator]

I think legally, you're in the clear as long as you are meeting that Medicare "direct" definition for linac-based srs/sbrt. It's still good practice to verify the igrt before (and if needed, during) the procedure. Personally I wouldn't wait till afterwards to check igrt in offline review unless it's conventionally-fractionated 3D/IMRT

If you're doing GK or HDR where there is an actual source, then you need to meet the "personal supervision" requirement from a legal standpoint because of the NRC guidelines that govern sources

 

[firewicket]

I think legally, you're in the clear as long as you are meeting that Medicare "direct" definition for linac-based srs/sbrt. It's still good practice to verify the igrt before (and if needed, during) the procedure

If you're doing GK or HDR where there is an actual source, then you need to meet the "personal supervision" requirement from a legal standpoint because of the NRC guidelines that govern sources

That’s great to hear for a busy clinic. It’s funny how at where I train such a huge deal is made about physician physical presence the entire time the beam is on.

Are you all placing procedure notes for every SBRT/SRS treatment? I noticed there is no professional fee associated with the procedure (only the weekly)...so why is an every fraction procedure note needed (like in hdr)??

 

[deleted18755]

That’s great to hear for a busy clinic. It’s funny how at where I train such a huge deal is made about physician physical presence the entire time the beam is on.

This is probably another academic arrogance situation: were you trained (which by definition was an academic center) I assume the attending has less than 20 patients under treatment with resident, PA, and RN coverage and a secretary plus office manager so he loves to say how vital it is for the physician to be physically present (likely reading cnn on checking his emails on his smartphone in the back corner of the treatment area) but in the real world of a packed clinic it's not possible but more importantly not necessary. I agree with Medgator that you should absolutely check the IGRT before treatment starts and be within "shouting distance" with everybody knowing exactly where you are and that you are readily available at any point during the SRS/SBRT "procedure."

On a related note, anytime the machine is on I physically stay under the roof of the hospital even going as far as grabbing a slice of pizza from the gross cafeteria 4-5 minutes away instead of literally running 1-2 minutes across the street to the delicious mom and pop shop since I would technically have been "off campus" for a minute even though I'm physically closer and have my cell phone me.[/QUOTE]

 

[firewicket]

This is probably another academic arrogance situation: were you trained (which by definition was an academic center) I assume the attending has less than 20 patients under treatment with resident, PA, and RN coverage and a secretary plus office manager so he loves to say how vital it is for the physician to be physically present (likely reading cnn on checking his emails on his smartphone in the back corner of the treatment area) but in the real world of a packed clinic it's not possible but more importantly not necessary. I agree with Medgator that you should absolutely check the IGRT before treatment starts and be within "shouting distance" with everybody knowing exactly where you are and that you are readily available at any point during the SRS/SBRT "procedure."

On a related note, anytime the machine is on I physically stay under the roof of the hospital even going as far as grabbing a slice of pizza from the gross cafeteria 4-5 minutes away instead of literally running 1-2 minutes across the street to the delicious mom and pop shop since I would technically have been "off campus" for a minute even though I'm physically closer and have my cell phone me.

[/QUOTE]

Yea, those academic guys have it super tough on their pedestal.

What about procedure notes for every fraction?

 

[medgator]

.

What about procedure notes for every fraction?

I believe that's part of the protocol for billing, even if it is just technical. On the private side, some pp bill globally so that technical is important and on the academic/hospital-based side, I doubt they are going to let it slide either...

 

[firewicket]

Thanks again for a real world answer.

 

[BobbyHeenan]

I bill professional fees only.

I have therapists generate a note for each SBRT fraction that basically states I was there at the linac for alignment for fraction number X of 1-5. I think only one carrier has ever asked us for a procedure note, but we do it anyway.

I go to the linac every time for SBRT. We use flattening filter free so treatments are very vast. I am always within shouting distance when beam on for SBRT.

 

[evilbooyaa]

Review IGRT prior to each fraction. Don't think there is a benefit of having to physically be at the machine for SRS like you do for HDR. Although I don't see the benefit of physically being at the machine for HDR either as long as a physicist is.

 

[seper]

With HDR, you must be present to emergently unload the implant in case of a nasty equipment failure. Situations like that still happen in US/Canada pretty often.
With 5 fractions SBRT, I've always been OK with the physicist lining up the patient.

Review IGRT prior to each fraction. Don't think there is a benefit of having to physically be at the machine for SRS like you do for HDR. Although I don't see the benefit of physically being at the machine for HDR either as long as a physicist is.

 

[medgator]

Review IGRT prior to each fraction. Don't think there is a benefit of having to physically be at the machine for SRS like you do for HDR. Although I don't see the benefit of physically being at the machine for HDR either as long as a physicist is.

I think it's NRC rules/regs that you have to be there during an HDR/GK procedure with an actual source in the machine.

U Pitt got dinged for this several years ago.