June 27, 2019

ACR Disagrees with OIG on Medicare Payment Policy for 3D-CRT Planning

The American College of Radiology (ACR) Economics Committee on Radiation Oncology plans to soon submit written comments describing why it disagrees with the assessment of recent report from the Health and Human Services’ Office of the Inspector General (OIG) entitled Medicare Could Have Saved Millions of Dollars in Payments for Three-Dimensional Conformal Radiation therapy planning Service (3D-CRT).

Necessary procedures for 3D-CRT involve both radiation therapy planning and treatment itself. Medicare makes a single payment to hospitals for the development of a 3D-CRT treatment plan. Automated prepayment edits generally prevent additional payments for separately billed radiation planning services if they are billed on the same date of service as the 3D-CRT treatment plan. However, Medicare billing requirements do not prohibit and system edits do not prevent additional payments if the services are billed on a different date of service from up to 14 days before therapy.

The OIG analysis recommends that CMS implement billing requirements (including, for example, a bundled payment similar to that for IMRT planning services) and system edits to prevent additional payments for 3D-CRT planning services that are billed before (for example, up to 14 days before) 3D-CRT planning CPT code 77295 (3-dimensional radiotherapy plan, including dose-volume histograms) is billed.

As of January 9, 2019, Medicare had paid $13.6 million for separately billed 3D-CRT planning services performed in calendar year 2018. The OIG office based its recommendation by matching payments for 3D-CRT planning CPT code 77295 with payments for the individual radiation planning services listed in the NCCI procedure to procedure edits on the radiation planning services.

The Centers for Medicare and Medicaid Services (CMS) concurred with the OIG recommendation in the OIG’s report and stated that it will consider whether implementing billing requirements in the future to prevent payments for additional planning services when reported with 3D-CRT would be appropriate.

The ACR and the American Society for Radiation Oncology (ASTRO) will coordinate their outreach efforts in response to the OIG’s assessment and any resulting CMS payment policy revisions. For questions and comments on this latest auditing activity, contact Alicia BlakeyACR economics and health policy analyst