Rad onc supervision, the epilogue

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Ray D. Ayshun said:
Thanks, just found that on Aunt Minnie. Pertinent quote:

"However, if the interpretation takes place in a different payment locality, split PC/TC billing (attaching modifier -26 for the PC) must be used with the location of each component reported separately. An unusual or infrequent location, such as a hotel or other vacation location, is not to be entered on claim forms; instead, the address of the physician’s most common practice location is to be used."
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Are you doing this on vacation or because you live / own / lease property across state lines?

RACs love to audit and you never know when they come sniffing.
 
maxxor said:
Are you doing this on vacation or because you live / own / lease property across state lines?

RACs love to audit and you never know when they come sniffing.
Click to expand...
vacation. Just trying to have an answer for every possible reason they can try to deny me billing codes. If the latter I'd just get another license.
 
Ray D. Ayshun said:
vacation. Just trying to have an answer for every possible reason they can try to deny me billing codes. If the latter I'd just get another license.
Click to expand...
In that situation, it’s down to the state if they consider scan interpretation “practice of medicine” even if it’s for patients outside the state.

Most do since teleradiology has been for 20 years at this point.
 
maxxor said:
In that situation, it’s down to the state if they consider scan interpretation “practice of medicine” even if it’s for patients outside the state.

Most do since teleradiology has been for 20 years at this point.
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So you agree that we shouldn't approve images while away on vacation? I'm perfectly fine with it if that's what everyone is doing. But it ain't.
 
Ray D. Ayshun said:
So you agree that we shouldn't approve images while away on vacation? I'm perfectly fine with it if that's what everyone is doing. But it ain't.
Click to expand...
Personally, I have 8-10 licenses and got a Florida license because I go there fairly frequently. I don’t read for any patients in FL but I would rather pay the license fee than be nervous about doing something gray zone over $1000.
 
Worrying over CMS or an auditor trying to claw money back because, somehow, quite strangely and suspiciously, they found out that the day you were not in the office you were over the state line, in a different state, is... well, a weird worry.

Anything is possible though. Keep in mind those image checks are gonna cost (max) about $25-30 per check in 2026. Big Brother may lose interest in tracking rad oncs' comings and goings.

Working in Kansas City, MO, and living in Kansas City, KS... sounds like checking images from home would be a nightmare (w/o a Kansas license).

Fifty plus years from now our kids' kids will be checking images during their one week vacations in low earth orbit. Wonder which state license they'll need for that.
 
I'm not worried about CMS just "noticing". I'm worried about Qui Tam suits more than anything. People will rat you out. Don't give them the opportunity.

These are a legitimate worry in Radiology. Almost all the big DOJ radiology settlements are qui tam actions.
 
maxxor said:
I'm not worried about CMS just "noticing". I'm worried about Qui Tam suits more than anything. People will rat you out. Don't give them the opportunity.

These are a legitimate worry in Radiology. Almost all the big DOJ radiology settlements are qui tam actions.
Click to expand...
No one will rat anyone out for checking a few hundred images per year out of state. In other words, qui tams are really not going to be taken up by an attorney unless at least a million or more is on the line. And the DOJ won’t join the case for anything less etc.

Let’s say you treat 25 patients a day. I would guess nowadays between Medicare advantage and Medicare and private, about 33% of a rad onc’s workload will be Medicare work. (That’s the only work subject to qui tamming.) So 8 Medicare patients a day. Over a year that will be about 2000 Medicare IGRTs. If you did ALL of them illegally Medicare would reimburse $60K a year for that (come 2026). If you just did them illegally on vacation out of state 2 months a year, that’s just $10K a year.

No one is gonna get qui tammed at these levels of “fraud.”
 
maxxor said:
You do you. This is well established in Radiology billing circles. Even by the language of your post, we agree this is illegal by the laws currently in effect.
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Do not agree it’s illegal. I was tossing the word around in an absurdist kind of way. Illegal is a very strong word. “Settlement” doesn’t equal illegal, but it certainly equals problematic.

There is meager overlap between the rad onc doing IGRT and the radiologist doing diagnostic radiology. There is zero overlap between telerads and the rad onc doing an occasional IGRT sign off off-site. I honestly don’t know of any laws, or even “laws,” that say state lines come into play regarding the latter. But willing to look at them. As we have previously mentioned iirc there truly are laws where country/nation lines come into play.

Whatever any of us think, it doesn’t matter if you have a boss that thinks something different. Like when rad onc went to general supervision in hospitals. I imagine there were many rad oncs who went to their bosses when this changed, showed them the law, and admin was like I don’t care you still have to always be here no matter what… or it’s illegal!
 
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A lot of us have lived in ny, ct, pa, nj. Very much doubt that igrt 10 miles from your home is illegal. This is Soviet style show me the man, I will show you the crime. It’s even worse than cheating on a diversity module. I am sure we are all breaking law and that’s why we need to retain Ron g to stay out of Jail.
 
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This might be true, but conservative hospital companies will err on the side of easiest, which is to say, they'll not allow it as there is no risk or harm to them. This could be easily solved by having an actual document that says it's okay. One could argue there's a potential liability concern if you're practicing medicine in a state where you're not licensed. Ultimately, this is another example of having a thing we do that's poorly defined and in turn subject to loss because our professional society benefits from losing it
 
TheWallnerus said:
Didn’t you quote a document above saying it’s ok
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Kinda. It's nothing official. Also offered was the caveat that you should take into any legal issues that might vary by state. Whoever wrote that said you don't have to list your hotel as the place of service if on vacation. I can't find this anywhere in CMS docs, though, and ASTRO suggests IGRT requires direct supervision.
 
Ray D. Ayshun said:
Kinda. It's nothing official. Also offered was the caveat that you should take into any legal issues that might vary by state. Whoever wrote that said you don't have to list your hotel as the place of service if on vacation. I can't find this anywhere in CMS docs, though, and ASTRO suggests IGRT requires direct supervision.
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ASTRO’s suggestions are long in tooth, and toothless, now with all the virtual direct provisos that have been codified in the interim.
 
Ray D. Ayshun said:
not to hospital admin
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Exactly. This trumps everything. The law is clear virtual direct is legal. I won’t try to post links to all that; we all know that’s true.

I would try to get something official from the CMS website but, the Democrats.

IMG_3352.jpeg
 
Ray D. Ayshun said:
Kinda. It's nothing official. Also offered was the caveat that you should take into any legal issues that might vary by state. Whoever wrote that said you don't have to list your hotel as the place of service if on vacation. I can't find this anywhere in CMS docs, though, and ASTRO suggests IGRT requires direct supervision.
Click to expand...
Wouldn't it be nice if ASTRO would write a white paper on this very topic?

ACR has had a white paper on this since 2013 (direct link)


www.acr.org

Teleradiology

Radiology has long been at the forefront of technological innovation. This has led to the increased reliance, especially in rural areas, on telemedicine, specifically teleradiology. With this technology has come the need to better understand state and international medical and legal requirements.
www.acr.org www.acr.org


RE: "hotel"
That language used to be in the CMS claims processing manual regarding Radiology interpretation. I can't find it in the latest transmittal so it may have been removed. This is the relevant section from the ACR white paper

"Since April 1, 2004, CMS has required that physicians specify where services were provided when submitting their claims. More recently, on October 11, 2012, CMS issued Transmittal 2613, clarifying certain aspects of the rule but leaving the general requirement intact. Essentially, CMS requires teleradiologists to submit the address where they were physically located when performing their interpretations as the work address, regardless of where the TC was performed. The only exception to this is when “the professional interpretation was furnished at an unusual and infrequent location for example, a hotel, the locality of the professional interpretation is determined based on the Medicare enrolled location where the interpreting physician most commonly practices.”

In addition to identifying the teleradiologist’s work location, CMS requires that claims for the teleradiologist’s services be submitted to “the B/MAC [Part B Medicare carrier] which processes claims for the payment4 The medical director collaborates with the administrative director of the facility to devise the policies and procedures for the facility and to review them at least annually. They are responsible for ensuring that all professional and technical staff members meet the obligations set by the policies and procedures. The medical director may at times also have disciplinary responsibilities if professional or technical staff members fail to meet these obligations [38]. locality where the . . . service was furnished” (ie, the Part B Medicare carrier that has jurisdiction over the teleradiologist’s work address reported on the claim) [39].

The combination of these 2 rules has significant implications for the billing of teleradiology services to Medicare:

1. It requires teleradiologists to report the physical location where they performed their work, not simply report the address where the TC was performed (unless that is where they performed the interpretation).

2. Each teleradiologist’s work location must be separately and appropriately enrolled with the Medicare carrier that has jurisdiction over that geographic area.

3. It will frequently require teleradiologists to enroll with and submit claims to a carrier that is different from the carrier to which the TC was submitted.

4. Global billing is prohibited unless the billing entity is the same for both the PC and TC, and both components are performed within the same Medicare payment locality [39].

Requirements governing the submission of commer- cial insurance claims vary and are subject to numerous state laws, as well as the terms of the contract between insurer and provider, and are therefore too numerous to address here. However, the ACR believes that, absent state and contractual laws to the contrary, it is best practice to enroll each teleradiologist’s work location with the insurer and report the teleradiologist’s physical location when performing the interpretation as the service location on the claim form."
 
maxxor said:
Wouldn't it be nice if ASTRO would write a white paper on this very topic?

ACR has had a white paper on this since 2013 (direct link)


www.acr.org

Teleradiology

Radiology has long been at the forefront of technological innovation. This has led to the increased reliance, especially in rural areas, on telemedicine, specifically teleradiology. With this technology has come the need to better understand state and international medical and legal requirements.
www.acr.org www.acr.org


RE: "hotel"
That language used to be in the CMS claims processing manual regarding Radiology interpretation. I can't find it in the latest transmittal so it may have been removed. This is the relevant section from the ACR white paper

"Since April 1, 2004, CMS has required that physicians specify where services were provided when submitting their claims. More recently, on October 11, 2012, CMS issued Transmittal 2613, clarifying certain aspects of the rule but leaving the general requirement intact. Essentially, CMS requires teleradiologists to submit the address where they were physically located when performing their interpretations as the work address, regardless of where the TC was performed. The only exception to this is when “the professional interpretation was furnished at an unusual and infrequent location for example, a hotel, the locality of the professional interpretation is determined based on the Medicare enrolled location where the interpreting physician most commonly practices.”

In addition to identifying the teleradiologist’s work location, CMS requires that claims for the teleradiologist’s services be submitted to “the B/MAC [Part B Medicare carrier] which processes claims for the payment4 The medical director collaborates with the administrative director of the facility to devise the policies and procedures for the facility and to review them at least annually. They are responsible for ensuring that all professional and technical staff members meet the obligations set by the policies and procedures. The medical director may at times also have disciplinary responsibilities if professional or technical staff members fail to meet these obligations [38]. locality where the . . . service was furnished” (ie, the Part B Medicare carrier that has jurisdiction over the teleradiologist’s work address reported on the claim) [39].

The combination of these 2 rules has significant implications for the billing of teleradiology services to Medicare:

1. It requires teleradiologists to report the physical location where they performed their work, not simply report the address where the TC was performed (unless that is where they performed the interpretation).

2. Each teleradiologist’s work location must be separately and appropriately enrolled with the Medicare carrier that has jurisdiction over that geographic area.

3. It will frequently require teleradiologists to enroll with and submit claims to a carrier that is different from the carrier to which the TC was submitted.

4. Global billing is prohibited unless the billing entity is the same for both the PC and TC, and both components are performed within the same Medicare payment locality [39].

Requirements governing the submission of commer- cial insurance claims vary and are subject to numerous state laws, as well as the terms of the contract between insurer and provider, and are therefore too numerous to address here. However, the ACR believes that, absent state and contractual laws to the contrary, it is best practice to enroll each teleradiologist’s work location with the insurer and report the teleradiologist’s physical location when performing the interpretation as the service location on the claim form."
Click to expand...

So vacation IGRT non criminal?
 
maxxor said:
Wouldn't it be nice if ASTRO would write a white paper on this very topic?

ACR has had a white paper on this since 2013 (direct link)


www.acr.org

Teleradiology

Radiology has long been at the forefront of technological innovation. This has led to the increased reliance, especially in rural areas, on telemedicine, specifically teleradiology. With this technology has come the need to better understand state and international medical and legal requirements.
www.acr.org www.acr.org


RE: "hotel"
That language used to be in the CMS claims processing manual regarding Radiology interpretation. I can't find it in the latest transmittal so it may have been removed. This is the relevant section from the ACR white paper

"Since April 1, 2004, CMS has required that physicians specify where services were provided when submitting their claims. More recently, on October 11, 2012, CMS issued Transmittal 2613, clarifying certain aspects of the rule but leaving the general requirement intact. Essentially, CMS requires teleradiologists to submit the address where they were physically located when performing their interpretations as the work address, regardless of where the TC was performed. The only exception to this is when “the professional interpretation was furnished at an unusual and infrequent location for example, a hotel, the locality of the professional interpretation is determined based on the Medicare enrolled location where the interpreting physician most commonly practices.”

In addition to identifying the teleradiologist’s work location, CMS requires that claims for the teleradiologist’s services be submitted to “the B/MAC [Part B Medicare carrier] which processes claims for the payment4 The medical director collaborates with the administrative director of the facility to devise the policies and procedures for the facility and to review them at least annually. They are responsible for ensuring that all professional and technical staff members meet the obligations set by the policies and procedures. The medical director may at times also have disciplinary responsibilities if professional or technical staff members fail to meet these obligations [38]. locality where the . . . service was furnished” (ie, the Part B Medicare carrier that has jurisdiction over the teleradiologist’s work address reported on the claim) [39].

The combination of these 2 rules has significant implications for the billing of teleradiology services to Medicare:

1. It requires teleradiologists to report the physical location where they performed their work, not simply report the address where the TC was performed (unless that is where they performed the interpretation).

2. Each teleradiologist’s work location must be separately and appropriately enrolled with the Medicare carrier that has jurisdiction over that geographic area.

3. It will frequently require teleradiologists to enroll with and submit claims to a carrier that is different from the carrier to which the TC was submitted.

4. Global billing is prohibited unless the billing entity is the same for both the PC and TC, and both components are performed within the same Medicare payment locality [39].

Requirements governing the submission of commer- cial insurance claims vary and are subject to numerous state laws, as well as the terms of the contract between insurer and provider, and are therefore too numerous to address here. However, the ACR believes that, absent state and contractual laws to the contrary, it is best practice to enroll each teleradiologist’s work location with the insurer and report the teleradiologist’s physical location when performing the interpretation as the service location on the claim form."
Click to expand...
thanks. this is the **** I'm looking for.
 
maxxor said:
According to CMS, if it’s legitimately a hotel, it’s ok from their perspective.

The state license board may or may not have an opinion on this matter.
Click to expand...
I spoke with them too. In my state, they just want me licensed here, and they don't care what an out of state doc does to patients in his or her home state while visiting.
 
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