New Hospital Issues from OIG Work Plan Update

on Tuesday, 30 June 2015. All News Items | Outpatient Services | OIG | Billing

IMRT – “I am right”?

Don’t you just love to try to figure out the messages on those customized license plates? If you saw “IMRT” for example, would you think “eye-mart” or “I am right”? Well, the OIG (Office of Inspector General) would immediately think “intensity-modulated radiation therapy” since this is one of the new issues added to the mid-year update of their Work Plan.

The OIG’s mission is to “protect the integrity of HHS programs and operations and the well-being of beneficiaries by detecting and preventing fraud, waste, and abuse; identifying opportunities to improve program economy, efficiency, and effectiveness; and holding accountable those who do not meet program requirements or who violate Federal health care laws.” The OIG develops an annual work plan by assessing risks, identifying areas in need of attention and setting priorities. At the end of May this year they released an update to the FY 2015 Work Plan with some new items that have been started since October 2014. There are two new items for hospitals, the first of which is Intensity-Modulated Radiation Therapy.

Intensity-Modulated Radiation Therapy

For these reviews, the OIG will determine if Medicare outpatient payments for IMRT were made in accordance with Federal rules and regulations. A couple of the OIG’s hospital compliance reviews have already identified instances where IMRT was incorrectly billed. This often involves the separate billing of certain services that should be bundled when they are performed as part of developing an IMRT plan. Per the Medicare Claims Processing Manual, Chapter 4, section 200.3.2:

“Payment for the services identified by CPT codes 77014, 77280-77295, 77305-77321, 77331, 77336, and 77370 is included in the APC payment for IMRT planning when these services are performed as part of developing an IMRT plan that is reported using CPT code 77301. Under those circumstances, these codes should not be billed in addition to CPT code 77301 for IMRT planning.”

These “not separately reportable” services include CT guidance, simulation-aided field settings, 3-D radiotherapy plan, teletherapy and brachytherapy isodose plans, special teletherapy port plan, special dosimetry, and medical physics consultations. Bundling is effective for the same date of service or for different dates of service if the services are part of developing an IMRT plan.

Other challenges for IMRT billing for 2015 are the numerous CPT code changes for radiation therapy services and understanding the proper use of Medicare’s G codes. The CPT code changes represent significant changes in how radiation therapy services and associated image guidance are reported. Since CMS decided not to pursue proposed cuts to physician radiation oncology payments, CMS created new HCPCS codes for physicians to use in reporting services for 2015 that crosswalk from the 2014 CPT codes. These G-codes are not for hospital reporting. The HCPCS codes G6001-G6017 are assigned a status indicator of B for OPPS. Hospitals are to report the new CPT codes for radiation oncology services.

Also be careful when reporting treatment device design and construction with IMRT. From the CCI manual:

Intensity modulated treatment (IMRT) delivery (e.g., CPT code 77385 and 77386) is not normally reported with treatment device design and construction CPT codes 77332-77334. The latter codes are generally reported for treatment device(s) design and construction for external beam radiation therapy. IMRT planning (CPT code 77301) includes many treatment device(s) required for IMRT. Multi-leaf collimator (MLC) device(s) (CPT code 77338) may be reported separately once per IMRT plan. However, patients receiving IMRT occasionally require an additional treatment device at a later date due to decreased tumor volume or patient weight. This device may be reported with CPT codes 77332-77334.

The second new item in the update OIG Work Plan for hospitals is hospital preparedness and response to high-risk infectious diseases. This issue likely stems from our recent experiences with the Ebola virus. The OIG will evaluate hospitals’ efforts to prepare for the possibility of public health emergencies resulting from infectious diseases and their use of available resources for guidance and support, such as those from the Centers for Medicare and Medicaid Services (CMS), Health and Human Services (HHS), the Centers for Disease Control and Prevention (CDC), and the Office of the Assistant Secretary for Preparedness and Response (ASPR).

To review all current OIG Work Plan issues, you can read the 2015 OIG Work Plan Update here.

Article by Debbie Rubio

Debbie Rubio, BS, MT (ASCP), is the Manager of Regulatory Affairs and Compliance at Medical Management Plus, Inc. Debbie has over twenty-seven years of experience in healthcare including nine years as the Clinical Compliance Coordinator at a large multi-facility health system. In her current position, Debbie monitors, interprets and communicates current and upcoming regulatory and compliance issues as they relate to specific entities concerning Medicare and other payers. You may contact Debbie at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.

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