Rad Onc Twitter

[elementaryschooleconomics]

But...Step 2CS...?

---

Members don't see this ad.

 

[Mandelin Rain]

Seemed like everyone was on board with USC requiring proficient Korean for Korea Town location tho.....

 

[Bequerel]

New document states that IGRT requires direct supervision. Looks like legit Medicare language. Is this true? If so, then it would be very difficult to be out of a clinic for a day given amount of cbct and daily kv’s being done in a practice.

 

[Chartreuse Wombat]

New document states that IGRT requires direct supervision. Looks like legit Medicare language. Is this true? If so, then it would be very difficult to be out of a clinic for a day given amount of cbct and daily kv’s being done in a practice.

Can you provide a link to the mysterious "new document"?

 

[Bequerel]

Can you provide a link to the mysterious "new document"?

https://www.astro.org/ASTRO/media/ASTRO/Daily%20Practice/PDFs/2020SupervisionGuidance.pdf?utm_source=MagnetMail&utm_medium=email&[email protected]&utm_content=ASTROgram%5F2520%5FB&utm_campaign=ASTRO%20releases%20revised%20supervision%20guidance%2C%20H%26N%20adv%20reg%20ends%20today%2C%20NRC%20updates

 

[PhotonBomb]

oh wow. that seems like a big deal/reversal essentially.

good for the job market maybe, bad for the PP docs for whom this was going to be potentially good for the bottom line?

 

[deleted573262]

oh wow. that seems like a big deal/reversal essentially.

good for the job market maybe, bad for the PP docs for whom this was going to be potentially good for the bottom line?

and the sky continues to fall /s

 

[PhotonBomb]

and the sky continues to fall

?

 

[deleted941485]

oh wow. that seems like a big deal/reversal essentially.

good for the job market maybe, bad for the PP docs for whom this was going to be potentially good for the bottom line?

Meh...bigger things to worry about than tinkering like this.

 

[Bequerel]

I’ve been looking into it for past few hours since reading and my take away is that ASTRO assigned their recommended cpt codes with each of the 3 defined supervision codes and that It’s just an ASTRO recommendation and not a CMS rule? Is this the right interpretation. I think I hate ASTRO!

 

[Mandelin Rain]

Search the Physician Fee Schedule | CMS

Downloads Physician Fee Schedule Guide (PDF)

www.cms.gov

New NGS Medicare - NGSMEDICARE

www.ngsmedicare.com

Relevant pages. Under the stereoscopic guidance code, the physician supervision requirement is 09, which equals "concept does not apply". A 02 would equal "direct supervision". 09 does not equal 02.

Good try ASTRO. Admire the hustle.

 

[Reaganite]

Search the Physician Fee Schedule | CMS

Downloads Physician Fee Schedule Guide (PDF)

www.cms.gov

New NGS Medicare - NGSMEDICARE

www.ngsmedicare.com

Relevant pages. Under the stereoscopic guidance code, the physician supervision requirement is 09, which equals "concept does not apply". A 02 would equal "direct supervision". 09 does not equal 02.

Good try ASTRO. Admire the hustle.

What's strange is this "physician fee schedule" search tool is what we use to determine global reimbursement for freestanding facilities as well. When you plug in G6015, G6002, etc and apply the "global" indicator, it still lists the supervision requirement as 09.

 

[KeepCalmBeamOn]

https://www.astro.org/ASTRO/media/ASTRO/Daily%20Practice/PDFs/2020SupervisionGuidance.pdf?utm_source=MagnetMail&utm_medium=email&[email protected]&utm_content=ASTROgram%5F2520%5FB&utm_campaign=ASTRO%20releases%20revised%20supervision%20guidance%2C%20H%26N%20adv%20reg%20ends%20today%2C%20NRC%20updates

On page 7 of the document, it says 77417 port films require general supervision while 77014 CBCT require direct supervision. So you could just bill the kv x-rays but not CBCT with general supervision according to this document?

 

[scarbrtj]

Predictable. And Orwellian. I'm a big fan of italics, too: "members [must] understand that the supervision changes are more limited than they appear."* Like: "You think you can read and understand things but sorry you really can't."

They start this massive apologia with: "On Friday, November 1, 2019 the Centers for Medicare and Medicaid Services (CMS) issued the 2020 Hospital Outpatient Prospective Payment System final rule lowering the supervision level required for hospital-based therapeutic services, including radiation therapy services, from direct to general supervision." Fair enough. But for the whole rest of the bulletin they then proceed to twist into verbal pretzel knots to convince us: 1) image guided radiation therapy is not therapy, it's a diagnostic X-ray (which seems pretty dishonest on its face... it's literally not diagnostic at all), and 2) so somehow anything that's IGRT is not a "radiation therapy service" (what?), and 3) I guess this is why they almost never utter "image guided radiation therapy" the rest of the write-up and use instead the more chicanerously anodyne "image guidance" phrase instead, dropping the "therapy." Did I really have to go to med school to tell the difference between diagnosis and therapy? Guess so. The rest of the points like "if you bill for seeing a patient, you have to see the patient"... are pretty insulting too. Including them saying "some flexibility is necessary for those practices that deliver care to underserved populations who may experience access to care issues" over and over again. (I.e., only underserved populations deserve inferior care.) They completely whiff on such phenomenally salient points such as...
1) How can you provide direct supervision when "reading" an IGRT "film" (ie late at the end of day) when the patient is home/not in building?
2) How do radiologists read "diagnostic X-rays" (ostensibly what IGRT is right?) from home or across the country etc.?
3) All the times the technical portion of IGRT isn't being billed (I'm not an attorney but I think it's hard to supervise something that isn't being billed) in hospitals because bundling.
And many other things too. Of course.

Could comment much more, but wouldn't it all be a waste of good breath at this point? Haters gonna gate, alligators gonna alligate. Of course you guys are right about the 01, 02... 09, etc. But keep in mind: these only appear to be the correct numbers. Also, has anyone noticed some folks' responses to this have been very 5 stages of grief? Denial, anger, bargaining (seems to be where we are now), depression... and finally, acceptance.

* "ASTRO opposed such a broad reduction that could risk patient safety." Good to know that it wasn't broad and instead more limited than it appeared.

 

[RickyScott]

Predictable. And Orwellian. I'm a big fan of italics, too: "members [must] understand that the supervision changes are more limited than they appear."* Like: "You think you can read and understand things but sorry you really can't."

They start this massive apologia with: "On Friday, November 1, 2019 the Centers for Medicare and Medicaid Services (CMS) issued the 2020 Hospital Outpatient Prospective Payment System final rule lowering the supervision level required for hospital-based therapeutic services, including radiation therapy services, from direct to general supervision." Fair enough. But for the whole rest of the bulletin they then proceed to twist into verbal pretzel knots to convince us: 1) image guided radiation therapy is not therapy, it's a diagnostic X-ray (which seems pretty dishonest on its face... it's literally not diagnostic at all), and 2) so somehow anything that's IGRT is not a "radiation therapy service" (what?), and 3) I guess this is why they almost never utter "image guided radiation therapy" the rest of the write-up and use instead the more chicanerously anodyne "image guidance" phrase instead, dropping the "therapy." Did I really have to go to med school to tell the difference between diagnosis and therapy? Guess so. The rest of the points like "if you bill for seeing a patient, you have to see the patient"... are pretty insulting too. Including them saying "some flexibility is necessary for those practices that deliver care to underserved populations who may experience access to care issues" over and over again. (I.e., only underserved populations deserve inferior care.) They completely whiff on such phenomenally salient points such as...
1) How can you provide direct supervision when "reading" an IGRT "film" (ie late at the end of day) when the patient is home/not in building?
2) How do radiologists read "diagnostic X-rays" (ostensibly what IGRT is right?) from home or across the country etc.?
3) All the times the technical portion of IGRT isn't being billed (I'm not an attorney but I think it's hard to supervise something that isn't being billed) in hospitals because bundling.
And many other things too. Of course.

Could comment much more, but wouldn't it all be a waste of good breath at this point? Haters gonna gate, alligators gonna alligate. Of course you guys are right about the 01, 02... 09, etc. But keep in mind: these only appear to be the correct numbers. Also, has anyone noticed some folks' responses to this have been very 5 stages of grief? Denial, anger, bargaining (seems to be where we are now), depression... and finally, acceptance.

* "ASTRO opposed such a broad reduction that could risk patient safety." Good to know that it wasn't broad and instead more limited than it appeared.

That was my first reaction. You are reading the IGRT films at the end of the day when pt is no longer there, so how does one interpret the changes as saying that you need to be present for IGRT.

 

[Mandelin Rain]

That was my first reaction. You are reading the IGRT films at the end of the day when pt is no longer there, so how does one interpret the changes as saying that you need to be present for IGRT.

ASTRO going to ASTRO.

 

[Mandelin Rain]

That was my first reaction. You are reading the IGRT films at the end of the day when pt is no longer there, so how does one interpret the changes as saying that you need to be present for IGRT.

ASTRO is good at making things worse. CMS will get a hold of this commentary and they'll make a rule such that we have to time stamp approval of the IGRT between shooting the CBCT and beam-on leaving no uninterrupted time to see patients.

 

[metallica81788]

ASTRO is good at making things worse. CMS will get a hold of this commentary and they'll make a rule such that we have to time stamp approval of IGRT between the CBCT and beam on leaving no uninterrupted time to see patients.

This could be good for the job market - hire new grads just to man the machine checking films all day while the other MD sees patients in clinic and treatment plans. Mandates each clinic has two physicians. Jobs for everyone!

 

[OTN]

ASTRO is good at making things worse. CMS will get a hold of this commentary and they'll make a rule such that we have to time stamp approval of the IGRT between shooting the CBCT and beam-on leaving no uninterrupted time to see patients.

I knew of a radonc who interpreted the CMS regulations this exact way- she had a tablet that she carried around everywhere to make sure she could approve each CBCT as it arrived. Constantly, constantly interrupted, obviously. Recent data has shown there's no difference between IGRT shifts made by radiation therapists and radoncs, however, so there's clinically no argument to be made that it's necessary for us to review with that level of scrutiny.

 

[RickyScott]

1)At least under current administration guidance was issued to justice department that cms violations have to be clear and explicitly prohibited to take case forward, ie not open to interpretation; burden on cms.

DOJ Issues New Memo Limiting Use of Agency Guidance Documents in Civil Enforcement Cases: What It Means for Health Care Enforcement | Foley & Lardner LLP

On January 25, 2018, the U.S. Department of Justice (DOJ) issued a memorandum limiting the use of agency guidance documents in affirmative civil enforcement (ACE) cases.

www.foley.com

Cms seems to be lessening the burden not looking to raise bar. Again, in grand scheme when you can have np give chemo without physician, this seems like total bs and act of desperation by totally impotent Astro.

 

[RickyScott]

I knew of a radonc who interpreted the CMS regulations this exact way- she had a tablet that she carried around everywhere to make sure she could approve each CBCT as it arrived. Constantly, constantly interrupted, obviously. Recent data has shown there's no difference between IGRT shifts made by radiation therapists and radoncs, however, so there's clinically no argument to be made that it's necessary for us to review with that level of scrutiny.

Doc needs an intervention and psychological help.

 

[dsh]

ASTRO is good at making things worse. CMS will get a hold of this commentary and they'll make a rule such that we have to time stamp approval of the IGRT between shooting the CBCT and beam-on leaving no uninterrupted time to see patients.

My local administration requires me to do live imaging so I asked ASTRO for clarification a while back. Has not allowed me to change administration's mind unfortunately and is quite burdensome to everyone in my clinic.

Question: For 77014 and G6002, is there any distinction made between reviewing images prior to treatment and after treatment but on the same day (online vs. offline)? I feel that offline review after treatment, but on the same date of service as treatment, is compliant.

Answer: IGRT images need to be approved prior to the next treatment. This could be on the same date of service as the acquisition of the IGRT film (either online at the console or offline) or on the following day but prior to the next treatment session.

 

[evilbooyaa]

My local administration requires me to do live imaging so I asked ASTRO for clarification a while back. Has not allowed me to change administration's mind unfortunately and is quite burdensome to everyone in my clinic.

Live at-console review of EVERY CBCT, including those not being used for stereotactic treatment?

That's wayyyyyyyyyy excessive.

ASTRO can say whatever they want, and if they want to base their APeX accreditation on these rules that is their right.

*EDIT* - Reading fully through the linked post - it seems that even ASTRO admits that 77417 (Therapeutic radiology port films) are allowed under general supervision, but 77014 (computed tomography guidance for placement of radiation therapy fields) does require direct supervision (at least per ASTRO's interpretation of CMS).

If that last part is true, then perhaps you just don't do CBCT on the days the physician is not in the hospital.

 

[scarbrtj]

ASTRO is good at making things worse. CMS will get a hold of this commentary and they'll make a rule such that we have to time stamp approval of the IGRT between shooting the CBCT and beam-on leaving no uninterrupted time to see patients.

This could be good for the job market - hire new grads just to man the machine checking films all day while the other MD sees patients in clinic and treatment plans. Mandates each clinic has two physicians. Jobs for everyone!

I knew of a radonc who interpreted the CMS regulations this exact way- she had a tablet that she carried around everywhere to make sure she could approve each CBCT as it arrived. Constantly, constantly interrupted, obviously. Recent data has shown there's no difference between IGRT shifts made by radiation therapists and radoncs, however, so there's clinically no argument to be made that it's necessary for us to review with that level of scrutiny.

Fun historical fact of no particular interest to anyone anymore:
The first IGRT CPT codes appeared Jan 1 2006. However, CMS assigned level 3 personal supervision to the code. It meant you had to be in the room with the patient during the procedure. This was impossible. No one really knew this personal supervision code thing (the only code in the history of rad onc with personal supervision) and went on doing everything just direct. It helped some whistleblowers become rich until CMS changed the code back to direct supervision in July of 2009. In short IGRT has been a bit of a horror show, supervision-wise, since inception. Not to mention Kafkaesque. In summary...
800 cGy of palliative X-rays to the spine? ASTRO: MD not necessary to be present.
(CB)CT of spine giving <4 cGy? ASTRO: MD presence necessary.
CT of spine in outpatient clinic or hospital, no contrast, <4 cGy? ACR: MD presence unnecessary.*

* "If we're just doing CTs at our center, I don't have to be in the building."

 

[winstonfoot5]

If that last part is true, then perhaps you just don't do CBCT on the days the physician is not in the hospital.

*...just don't bill CBCT on the days the physicians is not in the hospital

 

[RickyScott]

*EDIT* - Reading fully through the linked post - it seems that even ASTRO admits that 77417 (Therapeutic radiology port films) are allowed under general supervision, but 77014 (computed tomography guidance for placement of radiation therapy fields) does require direct supervision (at least per ASTRO's interpretation of CMS).

If that last part is true, then perhaps you just don't do CBCT on the days the physician is not in the hospital.

Exactly,- thats their interpretation and it is almost assuredly wrong. Again justice department sent out memo about violations no longer relying on "interpretations." (whatever you feel about Trump, whistleblowing/CMS has really been curtailed) Recent anecdotal whistle blower case in my area that plaintiff attorneys refused to take because relied on interpreting CMS freestanding rule for radiation that a radonc, not a physician had to be present. And even if ASTRO was correct, just dont bill professional fee for medicare pts if doc not there that day or have all medicare cbcts in one part of the day. would have such a minor impact for most centers.

 

[Mandelin Rain]

*...just don't bill CBCT on the days the physicians is not in the hospital

From what I can tell, only the technical component of the CBCT requires direct supervision. So you can still bill the professional fee for review.

As always caveat: consult outside counsel to ensure your compliant, but that's what's listed in CMS's own rules.

 

[RickyScott]

From what I can tell, only the technical component of the CBCT requires direct supervision. So you can still bill the professional fee for review.

As always caveat: consult outside counsel to ensure your compliant, but that's what's listed on CMS's own rules.

even better, and again we are just talking medicare pts.

 

[medgator]

even better, and again we are just talking medicare pts.

Medicaid and Tricare ("CMS")

 

[RickyScott]

Medicaid and Tricare ("CMS")

Is Medicaid? but definitely tricare. For us, it would be like giving up pizza for staff lunch, or could just treat at certain times of day. Anyway, I am so confident Astro is wrong, will continue to advise billing if I am ever out of the hospital for an hour or 2.

 

[medgator]

Is Medicaid? but definitely tricare. For us, it would be like giving up pizza for staff lunch, or could just treat at certain times of day.

That's what all those qui tam doj postings seem to mention. Medicaid is still mostly funded through the federal government via CMS

 

[RickyScott]

That's what all those qui tam doj postings seem to mention. Medicaid is still mostly funded through the federal government via CMS

Lastly, you could order kvs that day! Again, totally reject silly interpretation to begin with. CMS supplied a rational to accompany why they were reducing the supervision burden, by stating that they saw no difference in quality of care between rural and urban sites etc! So you know their thinking/rational. I guess Astro is arguing that cms is trying to entrap radoncs?

“We don’t need you to be present because our analysis found no evidence that your direct supervision improves quality- but we are going to rely on this hidden Talmudic- like (but actually flat out wrong) interpretation that you actually had to be present all along for (cbct) and will try to recover 50$.

 

[elementaryschooleconomics]

"Can I have my good boy points now"

(Good Boy Points = GBPs = 0.25 wRVU)

 

[FindMeOnTheLinks]

amazing how indoctrinated many of the med students are. it is common to see them interacting quite a lot via twitter with faculty (AKA sucking up). I honestly believe it played a large role in certain match outcomes for some of the applicants in my class

 

[xrthopeful]

CARTI DONE?

 

[RadOncDoc21]

View attachment 296098

"Can I have my good boy points now"

(Good Boy Points = GBPs = 0.25 wRVU)

 

[deleted1002574]

Isn’t this clown still a resident?

View attachment 296098

"Can I have my good boy points now"

(Good Boy Points = GBPs = 0.25 wRVU)

 

[OTN]

Ha! He IS still a resident!

I like how he threw in the "work hard and bother to network at all" line, thus placing blame for lack of employment at graduation squarely at the feet of the residents. Additionally, job opportunities have never "abounded" in radonc, and certainly won't in 5 years.

Giving medical students "factually questionable" (if we're putting it gently) advice like this is immoral.

 

[deleted1002574]

Dude goes out of his way to annoy most people he comes across. Love to see the blacklist that grows ... networking - doesn’t that mean ingratiating yourself instead of making yourself poisonous?

Ha! He IS still a resident!

I like how he threw in the "work hard and bother to network at all" line, thus placing blame for lack of employment at graduation squarely at the feet of the residents. Additionally, job opportunities have never "abounded" in radonc, and certainly won't in 5 years.

Giving medical students "factually questionable" (if we're putting it gently) advice like this is immoral.

 

[Krukenberg]

Dude goes out of his way to annoy most people he comes across. Love to see the blacklist that grows ... networking - doesn’t that mean ingratiating yourself instead of making yourself poisonous?

you really have an axe to grind. Wanting to blacklist a resident because of some supportive words for a student who has already applied...

 

[evilbooyaa]

Gotta give it to him, he's a die hard. Others have shown some signs of thinking maybe SDN is right, on some issues, at least at some proportion of the time. I do love how he feels intimately qualified to discuss the topic as a junior resident who has not gone through the job search. Perhaps he will learn next year that it's not all sunshine and flowers.

 

[deleted774703]

Gotta give it to him, he's a die hard. Others have shown some signs of thinking maybe SDN is right, on some issues, at least at some proportion of the time. I do love how he feels intimately qualified to discuss the topic as a junior resident who has not gone through the job search. Perhaps he will learn next year that it's not all sunshine and flowers.

Agreed. he is def annoying online basically the resident version of Drew Moghanaki

 

[elementaryschooleconomics]

Ha! He IS still a resident!

I like how he threw in the "work hard and bother to network at all" line, thus placing blame for lack of employment at graduation squarely at the feet of the residents. Additionally, job opportunities have never "abounded" in radonc, and certainly won't in 5 years.

Giving medical students "factually questionable" (if we're putting it gently) advice like this is immoral.

I also cannot stand the advice to "network". What does that even mean? I have a version of networking that works for me based on my experiences and personality, but I wouldn't recommend it to everyone. Similarly, I've watched some of my colleagues use "networking techniques" that I have never and would never employ.

"Just network" is such a cheap response - made even cheaper by the fact that the "advice" is being given by someone who has yet to go through the job search experience.

 

[deleted1002574]

you really have an axe to grind. Wanting to blacklist a resident because of some supportive words for a student who has already applied...

No, not for that. I wouldn't blacklist someone for just giving terrible advice. Just follow his feed ... he picks fights, he's not tactful, he is more interested in being right than anything else. It's not the look I'd want at tumor board, especially in a private setting. I hope he takes a job with captive referrals.

 

[KHE88]

you really have an axe to grind. Wanting to blacklist a resident because of some supportive words for a student who has already applied...

It's unfortunately a theme with this individual...

Gotta give it to him, he's a die hard. Others have shown some signs of thinking maybe SDN is right, on some issues, at least at some proportion of the time. I do love how he feels intimately qualified to discuss the topic as a junior resident who has not gone through the job search. Perhaps he will learn next year that it's not all sunshine and flowers.

He felt intimately qualified on to come on here as a PGY-2 or 3 and tell attendings how to treat patients and laugh in the face of level 1 evidence saying it is outright wrong (PCI for LS-SCLC) based on presumably his own extensive experience treating these cases and following them.

He felt intimiately qualified to respond to questions on themednet (where people like me go to to get help from site specific academic experts on complicated cases) as a junior resident as well.

So why is this surprising?

People like this scare me. They don't know what they don't know, and they can wreak havoc their first year in practice. Saw it all the time in a prior career with the hot-shot new grad who thought they knew everything, way more than the senior guys, from their senior seminar course and that one grad level course they audited.

 

[PhotonBomb]

Agreed. he is def annoying online basically the resident version of Drew Moghanaki

Lol yep

 

[KHE88]

Agreed. he is def annoying online basically the resident version of Drew Moghanaki

Well that's the whole point of all of this Twitter posturing. Drew or a similar Twitter figure will take notice and get him a job offer. Sweet networking, bro. Lie to everybody else about how great the job market is so you can get a job. See how easy it was for me to get a job? Job market's great! Told ya so!!! If not, you suck at the important things a rad onc candidate should have, like tweetering skills.

 

[deleted774703]

It's unfortunately a theme with this individual...



He felt intimately qualified on to come on here as a PGY-2 or 3 and tell attendings how to treat patients and laugh in the face of level 1 evidence saying it is outright wrong (PCI for LS-SCLC) based on presumably his own extensive experience treating these cases and following them.

He felt intimiately qualified to respond to questions on themednet (where people like me go to to get help from site specific academic experts on complicated cases) as a junior resident as well.

So why is this surprising?

People like this scare me. They don't know what they don't know, and they can wreak havoc their first year in practice.

I’m with you for the first part.

I haven’t seen his specific mednet posts but I’m not opposed to a resident answering questions if they are correct and not a jerk about it

Well that's the whole point of all of this Twitter posturing. Drew or a similar Twitter figure will take notice and get him a job offer. Sweet networking, bro. Lie to everybody else about how great the job market is so you can get a job. See how easy it was for me to get a job? Job market's great! Told ya so!!! If not, you suck at the important things a rad onc candidate should have, like tweetering skills.

I’m with you but those guys are extra weird if that’s the criteria they use to evaluate if someone is good for a job

 

[deleted1002574]

Becoming huge @KHE88 fan. Would love to manage his money and take a cut of that sweet, sweet rural cash flow...

 

[RickyScott]

I also cannot stand the advice to "network". What does that even mean? I have a version of networking that works for me based on my experiences and personality, but I wouldn't recommend it to everyone. Similarly, I've watched some of my colleagues use "networking techniques" that I have never and would never employ.

"Just network" is such a cheap response - made even cheaper by the fact that the "advice" is being given by someone who has yet to go through the job search experience.

Love the idea that if all residents network better it will generate more jobs in totality. Maybe, he has a job lined up at UAB. Bonner was an author on that program position paper denying that there are any issues with too many residents or job market, so this probably just elevates him in his home institution.