Empowering Radiation Oncologists: Tools, Insights and Resources

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ACR Member Sections

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CARROS

In addition to belonging to a local state chapter, radiation oncology members also belong to the Council of Affiliated Regional Radiation Oncology Societies.

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Commissions and Committees

In addition to operational commissions, ACR offers specialty commissions and committees, including those focused on areas like Radiation Oncology.

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Radiation Oncology Webinar Series

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Join live webinars specifically designed for radiation oncologists, brought to you by ACR and the ACR Commission on Radiation Oncology Education Committee.

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Quality & Safety

Access a variety of resources designed to assist the radiation oncology community, including radiation oncologists and medical physicists, in providing quality and safety at their practices.

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Radiation Oncology Peer® Program for Maintenance of Certification

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M-P Peer™ Program for Maintenance of Certification

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Reimbursement

Get information, guidance and analysis on economic issues relevant to the practice of radiation oncology.

To meet Medicare payment conditions, procedures in hospital outpatient departments and physician offices must comply with the Centers for Medicare and Medicaid Services (CMS) physician supervision requirements, which vary by service type and setting. Code level supervision details are available in the Medicare Physician Fee Schedule RVU file or through the CMS Fee Schedule lookup tool.

In the hospital outpatient setting, radiation therapy services require direct supervision by a physician or qualified non-physician practitioner, who must be immediately available to assist and direct the procedure. They are not required to be physically present in the room. The supervising provider must have the necessary hospital privileges and comply with state scope-of-practice laws.

Although CMS doesn’t mandate that a radiation oncologist supervise radiation therapy services, the ACR recommends a board-certified/board-eligible radiation oncologist for this role. This is supported by the CRCPD's training requirements and ACR Radiation Oncology Practice Accreditation standards, which emphasize the oncologist’s availability for direct care, quality review, and urgent treatment initiation 24/7.

CMS’s 2010 HOPPS final rule allows non-physician practitioners, such as physician assistants and nurse practitioners, to supervise therapeutic services within their scope of practice and hospital privileges, whether on or off campus.

In the 2009 HOPPS final rule, CMS clarified that supervision requirements apply to Critical Access Hospitals (CAHs). In response to concerns from CAHs and small rural hospitals about meeting these requirements, CMS instructed Medicare Administrative Contractors (MACs) not to enforce physician supervision for outpatient therapeutic services at these facilities. This non-enforcement was extended through 2013 by legislative actions and has continued annually since.

In the CY 2018 HOPPS final rule, CMS reinstated non-enforcement of direct supervision for outpatient therapeutic services at CAHs and small rural hospitals with 100 or fewer beds for CY 2018-2019, allowing time for compliance and for submitting services to the Advisory Panel on Hospital Outpatient Payment for evaluation.

While non-enforcement continues for CAHs and rural hospitals, health systems in other settings have faced lawsuits under the False Claims Act, often related to failure to properly supervise radiation therapy, medical necessity issues, and billing violations. For examples of such litigation, visit the Department of Justice website.

Physician supervision of radiation therapy services in freestanding therapy centers requires direct supervision by a physician, excluding non-physician practitioners. CMS clarifies that while the physician need not be in the same room, they must be in the area and immediately available to assist and direct the procedure. The Social Security Act defines a physician as a doctor of medicine or osteopathy legally authorized to practice in the state.

Although CMS doesn’t require a radiation oncologist for supervision, the ACR recommends a board-certified/board-eligible radiation oncologist, supported by CRCPD training standards and NRC regulations. ACR Radiation Oncology Practice Accreditation also requires that a radiation oncologist be available for direct care, quality review, and urgent treatment initiation 24/7, or ensure appropriate coverage when unavailable.

With very few exceptions, diagnostic X-ray and other diagnostic tests payable under the physician fee schedule must be furnished under at least a general level of physician supervision and some require direct or personal supervision.

Under the Social Security Act, Medicare covers services furnished "incident to" a physician’s professional service, typically rendered in physicians' offices and either provided without charge or included in the physician’s bills. Therapeutic services for hospital outpatients are among these covered "incident to" services, which must be performed under direct supervision by a physician.

To be covered, "incident to" services must meet these criteria:

Integral to the patient’s treatment course.
Commonly rendered without charge.
Typically provided in a physician’s office or clinic.
Delivered at the physician's expense.

Additionally, "incident to" services must be provided in non-institutional settings to non-institutional patients. Hospitals and off-campus provider-based facilities can only offer these services in distinct, identifiable parts of the facility. The CY 2016 Medicare Physician Fee Schedule (MPFS) final rule clarified who may bill for "incident to" services; see the ACR summary for details.

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Radiation Oncology Model

The Medicare Accessibility and CHIP Reauthorization Act (MACRA) introduced several changes to the physician reimbursement framework. It replaced the Sustainable Growth Rate formula with the Quality Payment Program to provide incentives that emphasize value and quality of care over volume.

The Medicare Accessibility and CHIP Reauthorization Act (MACRA) replaced the Sustainable Growth Rate formula with the Quality Payment Program (QPP), focusing on value and quality over volume. Under the QPP, clinicians can choose between the Merit-based Incentive Payment System (MIPS) or Advanced Alternative Payment Models (APMs) to avoid payment cuts and earn potential rewards. While most clinicians are expected to start with MIPS, CMS aims for all to eventually participate in APMs.

More information on the Quality Payment Program and MIPS

An APM is a payment model that incentivizes coordinated, high-quality, efficient care. Advanced APMs take on risk tied to performance measures, electronic health records, cost reduction, and quality improvement. Clinicians in Advanced APMs who meet these criteria become Qualified Participants (QPs), eligible for a 5% Medicare incentive (2019-2024) and exemption from MIPS, based on participation levels. The ACR is monitoring the development of Advanced APMs and exploring radiology's role in these models.

ACOs are groups of doctors, hospitals and other healthcare providers who voluntarily come together to give coordinated, high-quality care to the patients they serve.

On Sept. 18, 2020, CMS released the mandatory Radiation Oncology (RO) Model final rule, requiring certain providers in selected areas to participate. The model will cover 30% of RO episodes in eligible regions and qualifies as an advanced APM under the Quality Payment Program (QPP). Participants must annually certify their use of Certified Electronic Health Record Technology (CEHRT), include quality measures in payment determinations, and assume financial risk. Providers not meeting the Qualified Participant (QP) threshold will be assigned to MIPS.

The model, originally set to begin in January 2022, was delayed by Congress and will run through Dec. 31, 2026. Medicare will make prospective, site-neutral, episode-based payments for radiation therapy services during a 90-day episode for 16 cancer types. Payments will be uniform across hospital outpatient departments and freestanding centers. The ACR continues to advocate for improvements to the payment methodology.

The Medicare Shared Savings Program (MSSP) is an alternative payment model that encourages groups of doctors, hospitals, and other healthcare providers to come together as an ACO to give coordinated, high-quality care to their Medicare beneficiaries. CMS encourages providers to participate in ACOs through the MSSP, which allows for different participation options/tracks that best fit an organization. Among these different levels and tracks, there are several of which qualify as Advanced APMs.

The BPCI Advanced Model aims to encourage clinicians to adopt best practices, reduce expenditures, and improve quality throughout a clinical episode. This model qualifies as an advanced APM, operates under a total-cost-of-care concept, and eligible inpatient clinical episodes included in the model are stroke and simple pneumonia. Learn more

List of APMs in the QPP
Center for Healthcare Quality and Payment Reform: The Payment Reform Glossary

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Contact Us

Need to reach the CAC Network? Call or email Alicia Blakey, Economics and Health Policy, 800-227-5463, ext. 5043.

ablakey@acr.org

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Radiology Coding Source

Feel secure about your coding proficiency and keep up-to-date on Medicare policies with our bimonthly newsletter for radiology coding and reimbursement news.

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Additional Resources

CMS Guidance on Billing IMRT Treatment Planning Services

CMS issued an MLN Matters article reminding hospitals how to correctly bill Medicare for outpatient Intensity-Modulated Radiation Therapy (IMRT) planning services and avoid overpayments. This follows an August 2018 OIG report recommending CMS implement an edit to prevent improper payments for IMRT planning billed before the procedure code (up to 14 days prior) and work with Medicare contractors to educate hospitals on proper billing. The ACR advises hospitals to review their billing processes to ensure compliance with CMS guidance on IMRT planning services.

Empowering Radiation Oncologists: Tools, Insights and Resources

Not an ACR member yet?

Already an ACR member?

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Essential ACR Resources

Journal Advisor

Journal of the American College of Radiology (JACR)

Education and CME

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Research

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Get Involved

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Radiation Oncology Webinar Series

Have a topic suggestion for an upcoming radiation oncology webinar?

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Stay Informed

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Quality & Safety

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Radiation Oncology Peer® Program for Maintenance of Certification

M-P Peer™ Program for Maintenance of Certification

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Reimbursement

ACR Analysis of Radiation Oncology Services, Supervision, Rules and Regulations

Supervision in the Hospital Outpatient Setting

Exceptions in Critical Access and Small and Rural Hospitals

Supervision in Freestanding Radiation Therapy Centers

Supervision of Diagnostic X-ray Tests

Supervision of “Incident To” Services

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Radiation Oncology Model

Quality Payment Program: Alternative Payment Models

What are Advanced Alternative Payment Models (APMs)

Accountable Care Organizations

Radiation Oncology Model

Medicare Shared Savings Program

Bundled Payments for Care Improvement Advanced (BPCI Advanced)

Relevant Articles

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Contact Us

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Radiology Coding Source

Additional Resources

CMS Guidance on Billing IMRT Treatment Planning Services

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Already an ACR member?

Essential ACR Resources

Journal Advisor

Journal of the American College of Radiology (JACR)

Education and CME

Get Involved

Radiation Oncology Webinar Series

Have a topic suggestion for an upcoming radiation oncology webinar?

Stay Informed

Radiation Oncology Peer® Program for Maintenance of Certification

M-P Peer™ Program for Maintenance of Certification

Reimbursement

ACR Analysis of Radiation Oncology Services, Supervision, Rules and Regulations

Supervision in the Hospital Outpatient Setting

Exceptions in Critical Access and Small and Rural Hospitals

Supervision in Freestanding Radiation Therapy Centers

Supervision of Diagnostic X-ray Tests

Supervision of “Incident To” Services

Radiation Oncology Model

Quality Payment Program: Alternative Payment Models

What are Advanced Alternative Payment Models (APMs)

Accountable Care Organizations

Radiation Oncology Model

Medicare Shared Savings Program

Bundled Payments for Care Improvement Advanced (BPCI Advanced)

Relevant Articles

Contractor Advisory Committee (CAC) Network

National Coverage Determinations

MEDCAC

Local Coverage Determinations (LCD)

Local Medicare Policies Under Development in Your State

CMS Coverage Resources

Principles for Sound Local Coverage Policies