Improper Payment for Intensity-Modulated Radiation Therapy Planning Services

September 2019 ~

In a recent report, the Office of Inspector General (OIG) determined that payments for outpatient Intensity Modulated Radiation Therapy (IMRT) did not comply with Medicare billing requirements.

Specifically, hospitals billed separately for complex stimulations when they were performed as part of IMRT planning. Overpayments occurred because hospitals are unfamiliar with or misinterpreted CMS guidance.

According to the OIG report, overpayments primarily occurred because the hospitals appeared to be unfamiliar with or misinterpreted CMS guidance. Additionally, the report shows that claim processing edits did not prevent the overpayments because the edits applied only to services billed on the same date of service as the billing of the procedure code for the bundled payment, and the services in the sample were billed on a different date of service.

For IMRT planning services billed in the two years after the OIG audit period (CY 2016 and CY 2017), the agency identified an additional $3.7 million in potential overpayments for complex simulations and $1.7 million for other IMRT planning services. In total, Medicare overpaid hospitals as much as $5.4 million after the audit period.

In the report, the OIG recommends that CMS:

(1) implement an edit to prevent improper payments for IMRT planning services that are billed before (e.g., up to 14 days before) the procedure code for the bundled payment for IMRT planning is billed, which could have saved as much as $25.8 million during the audit period and as much as $5.4 million in the 2 years after the audit period, and

(2) work with the Medicare contractors to educate hospitals on properly billing Medicare for IMRT planning services.

CMS concurred with the OIG’s recommendations and provided the following reminder to hospitals billing for outpatient IMRT planning services to ensure that they bill correctly and avoid overpayments.

When IMRT is furnished to beneficiaries in a hospital outpatient department that is paid under the hospital OPPS, hospitals must remember that CPT codes 77014, 77280, 77285, 77290, 77295, 77306 through 77321, 77331, and 77370 are included in the Ambulatory Payment Classification (APC) payment for CPT code 77301 (IMRT planning).

CMS notes that these codes should not be reported in addition to CPT code 77301, when provided prior to, or as part of, the development of the IMRT plan.

The charges for these services should be included in the charge associated with CPT code 77301, even if the individual services associated with IMRT planning are performed on dates of service other than the date on which CPT code 77301 is reported.

CMS suggests providers and billing professionals use the following resources to bill correctly:

  • Intensity-Modulated Radiation Therapy (IMRT) Planning Services Editing – MLN Matters Article, MLN Matters Number: SE18013
  • Instruction for IMRT services coding and instructions – Update of the Hospital Outpatient Prospective Payment System MLN Matters Article
  • OIG Report – Medicare Improperly Paid Hospitals Millions of Dollars for IMRT Planning Services
  • Instructions for IMRT services coding and instructions – Medicare Claims Processing Manual, Chapter 4, Section 200.3.1
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Source(s): MLN Connects, September 19, 2019; Intensity-Modulated Radiation Therapy (IMRT) Planning Services Editing, MLN Matters Number: SE18013;