Palmetto/CMS/LCD not covering R sided IMRT APBI

[NotMattSpraker]

I mean, again, I have to mention how petty and destructive the ASTRO Choosing Wisely, existing from 2013 to 2022, against breast IMRT was.

Choosing Wisely came in with trumpets and fanfare if you all recall. It shuffled off this mortal coil with nary a mention of its demise. Oh, it's withdrawn? Hey. No biggie. No harm, no foul, amirite guys?

"ASTRO has withdrawn...", "Mistakes were made..."... don't you love the past exonerative tense?

"Thanks, ASTRO," in both instances of Wisely's birth and death.

View attachment 381961

LOL just so remarkably unhelpful. Why not cite the evidence and link to it! It takes 2 seconds. What is wrong with these people.

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[emt409]

Here's a hot-take: Don't treat nodes in prostate cancer EVER unless they are proven to be positive by size criteria or if they are hot on PSMA PET. There has never been a proven overall survival advantage benefit of pelvic nodal radiation.

I fought this battle when I started at OSU. The number of emails and amount of drama that arose when I omitted nodes in a PSMA node neg unfav risk would astonish you.

 

[Gfunk6]

Putting something into choosing wisely is 'dictating' in my opinion. I understand its your opinion that it should be put into and that's fine, but its my opinion that it specifically should not be because it takes away from patient autonomy (same as not recommend RT to 70yr old women w/ stage I breast cancer) in regards to what's important to the patient.

Ah, I understand. I was simply responding to your post and apparently missed the broader context of the discussion of what should go into "choosing wisely."

 

[RadRadRad]

Not to be redundant, but it’s Uber frustrating to be in tumor board and hearing
“I’m choosing wisely, why aren’t you ?”
While knowing that every other specialty picked a choosing wisely metric that actually has no benefit while we picked a metric that does have a benefit. (In fact double the benefit that tamoxifen has for dcis)

 

[Gfunk6]

“I’m choosing wisely, why aren’t you ?”

 

[MidwestRadOnc]

Not to be redundant, but it’s Uber frustrating to be in tumor board and hearing
“I’m choosing wisely, why aren’t you ?”

I would literally laugh out loud at this (I have done numerous spit-takes at tumor boards before when something absurd is said, which is uhh.. often).

I fought this battle when I started at OSU. The number of emails and amount of drama that arose when I omitted nodes in a PSMA node neg unfav risk would astonish you.

Solo practice >*

I don't mind discussions with other specialists. I have zero interest in returning to our specialty's self-flagellating "peer review" and moral posturing in tumor boards. It's amazing how few rad oncs understand how off-putting it is to have public data-pissing contests and try and bully their peers into practicing algorithm-based medicine.

 

[medgator]

Not to be redundant, but it’s Uber frustrating to be in tumor board and hearing
“I’m choosing wisely, why aren’t you ?”
While knowing that every other specialty picked a choosing wisely metric that actually has no benefit while we picked a metric that does have a benefit. (In fact double the benefit that tamoxifen has for dcis)

Sounds like there is a lot of rot in your MDT that needs to be addressed

 

[evilbooyaa]

I fought this battle when I started at OSU. The number of emails and amount of drama that arose when I omitted nodes in a PSMA node neg unfav risk would astonish you.

wtf

Someone could literally never treat notes for UIR and it'd be fine (in my eyes, I know some would say never treat nodes for all rN0 patients). I take a bit more nuanced approach evaluating LN risk per MSKCC nomogram, but like 90%+ of my UIR patients don't get nodal coverage.

 

[evilbooyaa]

Not to be redundant, but it’s Uber frustrating to be in tumor board and hearing
“I’m choosing wisely, why aren’t you ?”
While knowing that every other specialty picked a choosing wisely metric that actually has no benefit while we picked a metric that does have a benefit. (In fact double the benefit that tamoxifen has for dcis)

I don't know if I would be able to stifle a laugh sufficiently if I truly heard someone say a line like that

 

[BobbyHeenan]

An update if anyone is interested.

I'm being told that the breast IMRT decision has been reversed, and OK for R sided APBI with IMRT now.

However, the IMRT for SBRT for bone mets is still an issue in, in spite of there being "carve outs" for special situations.

I treated a guy as re-irradiation for a prostate cancer bone met and was paid for the 77435 SBRT mgmt code, but IMRT device and Tx plan was denied even after appeal...in spite of it literally saying on the LCD web site that re-irradiation is an exemption for bone mets IMRT. On appeal I sent in his old treatment, my notes explaining why he needed IMRT (re-irradiation near cord, dose overlap from prior treatment, etc)...and still got a denial for payment.

So buyer beware for IMRT for bone mets, even in these cases.

 

[TheWallnerus]

It is so insane that IMRT (plans) and SBRT are allowed to toxically repel each other in the eyes of payers in this way.

So. Hate the game and not the p(l)ayer. Function as the system is dictating. Do the IMRT plan. Bill 77295. IMRT is a form of 3D after all. And bill a complex device and calc for every beam. And bill a 77290 for simulating the SBRT case.

 

[BobbyHeenan]

It is so insane that IMRT (plans) and SBRT are allowed to toxically repel each other in the eyes of payers in this way.

So. Hate the game and not the p(l)ayer. Function as the system is dictating. Do the IMRT plan. Bill 77295. IMRT is a form of 3D after all. And bill a complex device and calc for every beam. And bill a 77290 for simulating the SBRT case.

I am probably going to start doing this.
So frustrating though.
Gotta get clearance from the hospital but I think they'll be cool with that. They should still recoup better technical charges than 30/10 3D.

 

[TheWallnerus]

I am probably going to start doing this.
So frustrating though.
Gotta get clearance from the hospital but I think they'll be cool with that. They should still recoup better technical charges than 30/10 3D.

Yeah. Ultimately you’ll have two choices. Bill nothing for the plans. Or bill something. The something is arguably more accurate than the nothing.

 

[BobbyHeenan]

Yeah. Ultimately you’ll have two choices. Bill nothing for the plans. Or bill something. The something is arguably more accurate than the nothing.

That feels like the right thing to do rather than just not treat or use inferior 3D techniques for things like re-irradiation.

 

[TheWallnerus]

That feels like the right thing to do rather than just not treat or use inferior 3D techniques for things like re-irradiation.

People who talk about the illegality of “underbilling” (this is a hard to define term actually) remind me of the Pharisees who said it was a sin to pull a chair out from the kitchen table on the Sabbath as the dirt track the chair left in the floor meant you were plowing ground and “working.”

 

[BobbyHeenan]

People who talk about the illegality of “underbilling” (this is a hard to define term actually) remind me of the Pharisees who said it was a sin to pull a chair out from the kitchen table on the Sabbath as the dirt track the chair left in the floor meant you were plowing ground and “working.”

If I start my conversion and begin "underbilling" I'll just refer to myself as Paul.

 

[CaesarRO]

I have had this debate (underbilling) so many times within my practice and hit a wall every time. Doesn't help the doc most involved with the finances pushes back hard, having been through a medicare audit in their prior practice. Variation in billing for the same thing throws a red flag for that individual as much as the "down coding" does.

 

[BobbyHeenan]

I have had this debate (underbilling) so many times within my practice and hit a wall every time. Doesn't help the doc most involved with the finances pushes back hard, having been through a medicare audit in their prior practice. Variation in billing for the same thing throws a red flag for that individual as much as the "down coding" does.

We've had these discussions too which can be challenging...though I'm optimistic that in this particular case (SBRT) I can make inroads.

As noted, it is so bizarre that our LCD is paying for SBRT but not the underlying IMRT/VMAT plan.

 

[NotMattSpraker]

People who talk about the illegality of “underbilling” (this is a hard to define term actually) remind me of the Pharisees who said it was a sin to pull a chair out from the kitchen table on the Sabbath as the dirt track the chair left in the floor meant you were plowing ground and “working.”

I laughed.

But as a coping mechanism as a wrap my head around the fact that sometimes our field feels closer to a religion than a discipline of Oncology.

 

[TheWallnerus]

It's odd isn't it. For SBRT, we bill an IMRT plan... but don't bill for IMRT treatment. Is that "upcoding" the treatment? Of course not. We just try to put in the most accurate code.

I have had this debate (underbilling) so many times within my practice and hit a wall every time.

"You will never be accused of Medicaid or Medicare fraud for underbilling the government"
"'... is it true that underbilling is just as bad as overbilling? Can you be accused of fraud when you make a mistake that saves the government money?' This question comes up somewhat frequently, in part because people love to promote panic. I don’t know if such fear-mongering is an attempt to sell services by saying 'you need to hire us so that you code perfectly,' or perhaps whether it’s driven by a desire to generate an exciting topic of conversation – but either way, it is wrong."
"People cannot be charged with an offense for underbilling Medicare; it only becomes a problem when the system is overcharged.

Doesn't help the doc most involved with the finances pushes back hard, having been through a medicare audit in their prior practice.

I would be very surprised if Medicare had to pay him money back after the audit because the audit revealed he was problematically underbilling (which sometimes accurately and inaccurately gets called "downcoding," but again, hard to define if 77295 is a "downcode" from 77301).

Variation in billing for the same thing throws a red flag for that individual as much as the "down coding" does.

Theoretical (not really) question for the people throwing up the wall re: underbilling. If you had a proton unit that does pencil beam scanning, what is the planning code used for those protons... complex isodose, 3D, or IMRT? And if you were treating a stage one lung with 5 times 10 Gy of protons, which treatment code do you use: protons, or SBRT? Would it depend on the planning code used?

 

[TheWallnerus]

All the right breast ICD-10s have now been added... sometime in the recent dead of night?... to this Medicare Local Coverage Article. These were not there on Dec 3, 2023, when the article first appeared.

Denials for right breast IMRT, of any stage or fraction, should no longer happen for regular Medicare patients in GA, TN, AL, SC, NC, VA, or WV.

Article - Billing and Coding: Radiation Therapies (A59350)

Use this page to view details for the Local Coverage Article for Billing and Coding: Radiation Therapies.

www.cms.gov

 

[evilbooyaa]

It's odd isn't it. For SBRT, we bill an IMRT plan... but don't bill for IMRT treatment. Is that "upcoding" the treatment? Of course not. We just try to put in the most accurate code.

"You will never be accused of Medicaid or Medicare fraud for underbilling the government"
"'... is it true that underbilling is just as bad as overbilling? Can you be accused of fraud when you make a mistake that saves the government money?' This question comes up somewhat frequently, in part because people love to promote panic. I don’t know if such fear-mongering is an attempt to sell services by saying 'you need to hire us so that you code perfectly,' or perhaps whether it’s driven by a desire to generate an exciting topic of conversation – but either way, it is wrong."
"People cannot be charged with an offense for underbilling Medicare; it only becomes a problem when the system is overcharged.

I would be very surprised if Medicare had to pay him money back after the audit because the audit revealed he was problematically underbilling (which sometimes accurately and inaccurately gets called "downcoding," but again, hard to define if 77295 is a "downcode" from 77301).

Theoretical (not really) question for the people throwing up the wall re: underbilling. If you had a proton unit that does pencil beam scanning, what is the planning code used for those protons... complex isodose, 3D, or IMRT? And if you were treating a stage one lung with 5 times 10 Gy of protons, which treatment code do you use: protons, or SBRT? Would it depend on the planning code used?

Easy solution - proton radiation MUST be fractionated more than 5 treatments.

No proton SBRT allowed.