Written report for EVERY cone beam? Seriously?

BobbyHeenan

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    In the weekly Dr. Bogardus e-mails I see this little gem.

    ========
    Question:

    Can you please let me know if the KV images taken daily, CPT 77014, is billable? The physician is putting approved with the date next to the image.


    Answer:

    KV imaging was originally reported as 77421. This year you must be using the temporary G code G6002. 77014 is a CT code and is now usable only for cone beam CT. The images must be approved by the physician prior to the next date of use or the procedure cannot be billed.A written report signed by the physician, although it may be very brief, is required. The signature on the images is not admissible evidence in the event of an audit to back up billing for this procedure.

    =====

    We have always just signed the cone beam images, but now he's saying some sort of additional "written report" is necessary. I have never heard of anyone doing a written report for every single cone beam. Is anyone out there doing this?
     
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    OTN

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      Billing consultants are just the worst, and my wife was one for awhile. I still give her a hard time, because they can (and do) come in and say anything they want, with zero consequences to them. So, of course they're going to be ultraconservative just to cover their ass, when all the incredibly irritating and worthless work falls on the shoulders of us MDs.

      The Bogardus stuff above is ridiculous. The physician signing the image is plenty of documentation that it has been reviewed. This stuff is getting way out of hand.
       

      BobbyHeenan

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        Billing consultants are just the worst, and my wife was one for awhile. I still give her a hard time, because they can (and do) come in and say anything they want, with zero consequences to them. So, of course they're going to be ultraconservative just to cover their ass, when all the incredibly irritating and worthless work falls on the shoulders of us MDs.

        The Bogardus stuff above is ridiculous. The physician signing the image is plenty of documentation that it has been reviewed. This stuff is getting way out of hand.

        Ha - that is about line-for-line what I've told my administrators. These billing consultants I swear have never seen how a busy practice actually works or ever considered work flow - they want unique dictations for every little thing.

        Me signing the CBCT image and not recommending shifts should be enough to acknowledge I've looked at these films. If these consultants had their way, I'd no exaggerration be dictating notes till 8 PM every night with only 20 patients under treatment. The recommendations given to us for what to include in a treatment planning note (recommended not to be templated, a unique dictation for every patient) were so asinine it would be a novel for every patient.
         

        seper

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          Is it true that for cone beam CT that is billed through IMRT-IGRT bundle, daily documentation of physician's review is not required, since there are no longer any separate professional or technical charges?
           

          BobbyHeenan

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            Is it true that for cone beam CT that is billed through IMRT-IGRT bundle, daily documentation of physician's review is not required, since there are no longer any separate professional or technical charges?

            *disclaimer - I'm not 100% positive about this*

            The 77014 Cone beam CT charge can still be billed professionally and I don't think it's bundled (yet). I do think that charge is now bundled into the IMRT delivery codes on the technical side though.

            As such, some people say that in the case of an audit you should have a unique document for every.single.CBCT. See the Bogardus e-mail above.

            Some clinics just copy/past a bit of text (ie "I personally reviewed this cone beam and found it appropriate for treatment delivery....etc, etc") on top of a digital screen capture of the cone beam for every one. Other clinics now still just let the physician sign the cone beam and approve it and consider it enough. I think it's crazy to think you should have to uniquely dictate or type every single cone beam note, but I can verify that for CMS audits they want some sort of document for every single 77014-26 charge. I believe auto-generated documents are sufficing, but simple signed CBCT images are not OK with CMS in the case of an audit.

            Huge PITA.
             

            BobbyHeenan

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              I'm confused. If 77014 code is no longer being used (such as in our clinic), no daily documentation for CBCT is required?

              I work in a hospital-based clinic. Our group (physicians) bill professional fees while the hospital bills the technical fees.

              For now, if billing separately, you can still bill a 77014-26 (26 is the professional fee modifier code) for daily CBCT. The facility can no longer bill for technical fees for daily CBCT, as it is lumped into their daily IMRT delivery code.

              Your clinic may bill differently, but that is how we do it as far as I know.
               

              OTN

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                but I can verify that for CMS audits they want some sort of document for every single 77014-26 charge. I believe auto-generated documents are sufficing, but simple signed CBCT images are not OK with CMS in the case of an audit.

                Huge PITA.[/QUOTE]

                Source for this?
                 

                BobbyHeenan

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                  but I can verify that for CMS audits they want some sort of document for every single 77014-26 charge. I believe auto-generated documents are sufficing, but simple signed CBCT images are not OK with CMS in the case of an audit.

                  Huge PITA.

                  Source for this?[/QUOTE]

                  Had a colleague (not my practice, though) that went through a CMS audit recently. I spoke briefly with them in conversation. So it's not high level proof or anything I guess.

                  This is what I recall from the convo: CMS requested some kind of document for each CBCT professional charge (cpt code 77014-26). They had just signed off on the images within the EMR (I believe ARIA) (like I'm sure 99% of all practices do - we do it now in PP, we did it this way in residency), but CMS wanted more. I think they came up with some auto-generated word document they use now and as I recall that was considered OK, but I'm not sure exactly how they handled it. Maybe it's as simple as a screen shot of the fused CBCT with the CT sim. I'm not sure.

                  I'm not intimately familiar with all the details, and I know they didn't have to pay back charges for not having the documents, but they did say that CMS "wanted" a document to support the charge.

                  ===

                  As an aside, in our practice we are just signing the images and still using that as proof/adequate documentation. I too think that should suffice and maybe we're playing with fire, but it's insane to me to think that my password protected signature of the actual image is not good enough and you need some kind of bozo robo-statement "I personally approved this image yada yada" to show I actually did the work I billed for.

                  That Bogardus recommendation is pretty clear though - but I think it's bogus.
                   

                  OTN

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                    Source for this?

                    Had a colleague (not my practice, though) that went through a CMS audit recently. I spoke briefly with them in conversation. So it's not high level proof or anything I guess.

                    This is what I recall from the convo: CMS requested some kind of document for each CBCT professional charge (cpt code 77014-26). They had just signed off on the images within the EMR (I believe ARIA) (like I'm sure 99% of all practices do - we do it now in PP, we did it this way in residency), but CMS wanted more. I think they came up with some auto-generated word document they use now and as I recall that was considered OK, but I'm not sure exactly how they handled it. Maybe it's as simple as a screen shot of the fused CBCT with the CT sim. I'm not sure.

                    I'm not intimately familiar with all the details, and I know they didn't have to pay back charges for not having the documents, but they did say that CMS "wanted" a document to support the charge.

                    ===

                    As an aside, in our practice we are just signing the images and still using that as proof/adequate documentation. I too think that should suffice and maybe we're playing with fire, but it's insane to me to think that my password protected signature of the actual image is not good enough and you need some kind of bozo robo-statement "I personally approved this image yada yada" to show I actually did the work I billed for.

                    That Bogardus recommendation is pretty clear though - but I think it's bogus.[/QUOTE]

                    Thanks for the info. I've just added a "CBCT images personally reviewed and approved by MD" in the "comments" section in Mosaiq. We'll see if that flies.
                     

                    scarbrtj

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                      From ASTRO's website. One can reasonably assume IMHO that this would apply to IGRT in general. Bogardus is an opinion-giver, not a determiner of the federal register.

                      Coding Question: How do you document 77421? Is it sufficient to just electronically sign off on the orthogonal images for IGRT of the prostate with fiducial markers? I have heard that a daily note is also needed? Do you write a unique daily note to support 77421?

                      Coding Response: The medical record should contain documentation of the medical necessity for the procedure, describing the medical appropriateness, the target delineation methodology, the type and frequency of imaging, acceptable parameters for shifts and information on the fusion algorithm. The images and shifts are to be reviewed and approved by the radiation oncologist prior to the patient’s next treatment. Appropriate documentation could be a note to the patient’s chart and/or a physician’s electronic signature on the shifts/images. A unique daily note is not required.

                      CPT code 77421: Stereoscopic X‐ray guidance for localization of target volume for the delivery of radiation therapy
                       
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