Gerard Walsh
Linda L. Lively
James E. Hugh III
Jennifer S. Wilson
Phillip M. Devlin
The focus of this final chapter is on the organizational aspects that are necessary for brachytherapy. Although the context for this is the United States of America in 2006, the principles herein may have more global significance. The chapter has three main parts. The first part focuses on the organizational process of preparing for brachytherapy in the context of an established external beam radiation therapy practice. The second part describes the elements of developing a business plan for the implementation of a new brachytherapy service for patients. The chapter concludes with focused attention on the complexities of reimbursement for brachytherapy services.
This chapter uses real clinical reimbursement codes and contemporary typical charges to illustrate the technical aspects of establishing a firm business plan for a clinical brachytherapy practice. However, a disclaimer is needed. Reimbursement policies vary widely from insurer to insurer and reimbursement policies for the same procedure may vary in different sections of the United States. Therefore, the information contained in this chapter (while accurate at the time of print) may not be accurate at the time of potential use. Before the submission of a claim for reimbursement, the user should contact the insurer (i.e., Medicare, Medicaid, or private payer) to verify applicable codes and reimbursement levels. The authors and the publisher can assume no responsibility for the consequences related to the use of information contained in this chapter. All codes presented in this chapter are for informational purposes only and not intended for treatment prescription guidelines. The authors also realize that there are variations between physicians and hospitals concerning the performance of procedures, depending upon physician technique and/or education/training. Diagnosis related groups (DRG) guidelines will determine inpatient reimbursement for Medicare recipients. All five-digit numeric Current Procedural Terminology (CPT) codes, descriptions, instructions, and guidelines are Copyright 2005 of the American Medical Association (AMA). All codes and descriptions are excerpted from the AMA CPT-4 Codebook, AMA case studies, and the Radiation Oncology Coding User's Guide 2005.
Planning for a Brachytherapy Service
Planning for a brachytherapy service must juxtapose an external assessment of the needs, wishes, wants, potential benefits and pitfalls of a new service line, with the internal departmental resources available and needed to perform the service. This section of the chapter will review these in some detail.
The rationale for initiating any clinical enterprise must be patient-based. An analysis of the population to be served must seek to understand unmet clinical needs. It must be based on scientific data as to the safety, efficacy, and comparative value of brachytherapy modalities. The specific needs of the community served may differ from one town or region to another. One simple approach may simply analyze what disease sites are commonly referred out for brachytherapy. Another may be to ask what the referring physicians are most often requesting or alternatively, what types of brachytherapy the other radiation oncologists in the region do not want to do. It may be important to ask what possibilities exist to expand radiation oncology services to improve the pattern of referrals to the practice. It may be important to ask if such new collaborations will lead to further increases in referral patterns, which in turn may demand that additional sites be covered by the brachytherapy service.
Understanding the market potential and identifying the target market will be some of the fundamental building blocks in formulating a financially viable brachytherapy program. In addition to determining the potential patient load and payor mix, it is crucial to understand the current reimbursement schemes and managed care competition that may enhance or restrict the development of a financially successful program.
Strategic Planning
Strategic planning is a many-layered cognitive process essential to the successful implementation of new brachytherapy services. Needs analyses can be done through oral surveys, questionnaires, and “strengths weaknesses advantages and threats” (SWAT) analysis. A SWAT analysis is a method of determining the needs of the community. Demographics and population statistics, projected case mix, referral sources, education opportunities, marketing opportunities, projected payor mix, project outline, and implementation timeline are essential to strategic planning. No less important will be experience and expertise with specific brachytherapy reimbursement issues from manufacturers and consultants.
Population
Many databases are available to determine the gross market potential based on diagnosis. Examples of this type of data can be found in the National Cancer Institute's Surveillance Epidemiology and End Results (SEER) database, which is broken down by incidence, locality, and historic trends among other cancer facts. The American Cancer Society also has excellent data to project potential volume and case mix. It will be important to identify which specific diagnoses will be potential cases for your program to determine the potential for referrals and to further identify the providers who will be able to generate those referrals. An important part of the referral process is established through the managed care system of authorized referrals.
Understanding the payor mix, and which managed care organizations will require participation to generate adequate expected reimbursement, is an integral step in the process of establishing realistic monetary projections to maintain a viable department or center. Most radiation oncology service lines involve a heavy percentage of Medicare “Fee-for-Service” reimbursement. Generally these percentages will vary from 28% to >50% depending on the locality and the specific service performed. The Medicare Advantage programs are differentiated from the traditional fee-for-service programs in that the individual insured's coverage is determined by the managed care organization, such as United Health Care, Humana, Cigna, or other insurance companies that offer added value to the insured—above the scope of the traditional Medicare Fee-for-Service. This also means that a provider would have to be enrolled in these individual plans to obtain authorization to treat patients, even though patients may otherwise be of Medicare age and eligible for benefits under the Medicare program. Income from managed care organizations will be predicated on appropriate participation in the specific programs available to the insured group. This can involve a variety of coverage options requiring participation by the provider to enable payment for services rendered. All too often, providers relinquish much revenue for services performed to insurance companies who will gladly allow their patients to be treated, but will refuse payment when the provider is “out of network”. It will be important to identify if any key payors are “closed” for providers in the specialty including the subspecialty of brachytherapy. In managed care organizations, a program can close its provider inventory and any referrals that an outsider may receive will not be paid for. Understanding the payor mix is a key element in determining projected income and the potential for a solid revenue stream.
Referring Community, Education, and Marketing
Many of the brachytherapy options for patients will not be the sole modality offered in the overall case management. The establishment of good referral patterns is an essential element in the planning process. As a simple example, if your program will include prostate seeds implants, you will want to determine the potential for urology referrals because this is often the point of entry for the patient. Choosing between the many potential treatment options may pose an enormous burden for the patient and the potential for a referral for brachytherapy services will be obviously influenced by the primary physician or the urologist's opinion. However, in these modern times of market savvy consumers armed with their internet info, patients' opinions and perceptions can play a vital role in determining which treatment options are chosen. Opportunities to educate the consumer and the referring specialties are plentiful. The marketing plan should include not only provider education but also outreach programs to inform the nonprovider of the benefits of the proposed brachytherapy services.
Competition
As is the case in any good marketing strategy, it is necessary to analyze the market forces, both external and internal. In this instance, the assessment of advantages and opportunities from within the specialty will be important to judge and, as important, are opportunities or threats from within the specialty. For example, another radiation oncology practice within the local market may see the proposed new brachytherapy service to be either an opportunity or a threat. If that practice offers only external beam therapies, then it can become an important referral source for specific types of treatments and these referrals can be cultivated. In the reverse scenario, another rival provider who is either performing similar services or who will not refer outside his/her program will cut into the potential market and revenue for an otherwise viable brachytherapy program. Similarly, the nonradiation therapy providers may control the referrals, particularly the primary care physicians who have a vested interest with their managed care plans to keep the patients “in network” or out of the hands of specialists. Understanding the importance of the referral process and the potential for obtaining referrals will be predicated on an understanding of the competition.
Resources
Resources—People
It must be emphasized how much the clinical and administrative staff are the core and necessary condition for a safe and effective practice. It practically takes a village to do good brachytherapy. Table 13.1 lists the many members needed to provide excellent brachytherapy. The heart and soul of any radiation oncology clinic are the nurses. These professional caregivers bring the traditional nursing values in new combinations of technical expertise for brachytherapy procedures. Always, they are the champions of the patients. Clinical coordinators are skilled administrative professionals who orchestrate the interactions of patients with the rest of the clinical staff, equipment, and space. The MS/PhD physicists and engineers control the set up, reproducibility and safety of the physical space, equipment, and computer interfaces required to perform complex brachytherapy.
Dedicated treatment planners, clinical dosimetrists interact dynamically with physicians, clinical images, prescription/directives to achieve treatment plans that will lead to the safe and effective delivery of ionizing radiation to patients. The knowledge base of this vital group covers physics, biology, and knowledge of normal tissue tolerance standards, advanced treatment planning software manipulation, clinical anatomy, and normal clinical practice paradigms. Radiation therapy technologists (RTTs) are licensed, trained professionals who with the authorized physicists share in the quality assurance and delivery of radiation therapy including brachytherapy. They also participate in the creation of diagnostic images in computed tomography (CT) scan, magnetic resonance imaging (MRI), and ultrasound (U/S) for treatment planning and other brachytherapy localization. Like the nurses, the RTTs also are the primary interface with patients and families for preparation, delivery, and recovery for brachytherapy. Master of business administration (MBA)/administrators play a leadership role in the interactions with hospital administration, legislative and regulatory bodies, and third-party reimbursement sources. The special business knowledge informs the clinical planning group about the financial viability of proposed brachytherapy programs. They have specialised knowledge of staffing levels and costs, capital equipment costs, and the general creation of operating budgets. The ability to monitor success in meeting of program goals are some of the more important regular tasks performed. The management of the human resources as well as the accounts of the brachytherapy practice is also essential. Clearly, the radiation oncologist practicing brachytherapy directs the care and is responsible for the success of every aspect. Trainees in the teaching hospital also share in this central responsibility under the attending Radiation Oncologist's supervision. Surgeons/interventional radiologists and cardiologists are collaborators who share inpatient selection, performance of the implant procedure and management of the patient during and after the implant. Anesthesia support is vital for anything but the most superficial brachytherapy. Whether the care is ambulatory or inpatient, this specialty's expertise to understand the potential for discomfort and to create expedient remedies using sedation and local, regional, general anesthesia is a vital and necessary component. Often implants are performed in operating rooms (ORs) with anesthesia support. The special needs of the brachytherapy patient during and after the case must be understood. Operating room technical support includes many different staffers and skills. The intraoperative support for special applicators and other equipment ensures a successful implant. This includes proper sterilization of equipment and orderly stocking of equipment, reusable and disposable. Radiation safety officers play an important and necessary role. They are the experts to ensure safety of the patient and staff during and after the procedure. Radiation safety officers and committees ensure that the regulatory aspects of the medical use of isotopes, as well as safety procedures, are followed. The radiation safety officer plays an ongoing vital role in the hospital or clinic to educate new staff and patients with regard to existing and new modalities. Regular in-service training sessions for all staff who come in contact with brachytherapy patients is a key component of their contribution to the practice of brachytherapy.
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Table 13.1 Resources: People |
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Resources—Real Estate
Brachytherapy takes up space; of that there is no doubt. Although it may be ideal to have the ability to design and build a dedicated suite without any interference with the external beam part of a practice, often this is not possible, at least at the start of building a brachytherapy service. A list of the space needs for brachytherapy is found in Table 13.2. Shielded planning space is essential to perform x-ray or CT scan based image guided treatment plans. These spaces are built with shielding compatible with the imaging energy. Most often these are already an integral part of the department of radiation oncology, or if not, images are generated in a nearby diagnostic radiology department and transferred to the treatment planning area of the radiation oncology clinic. Distinct from these needs are needs for the delivery of brachytherapy. If high dose rate (HDR) is to be delivered in the mega voltage linear accelerator vault then there is no need to worry about additional shielding, as the afterloader isotope's energy will always be an order of magnitude less. It is important to note that the regular shielding for a CT scan or fluoroscopic simulator will be inadequate for HDR. It is important to know that reshielding a room can be quite expensive, time consuming, put the room out of commission for quite some time, and also eat into the floor space significantly.
Treatment planning space requires a calm well-lit, ergonomically engineered set of workstations for the dosimetrist and physicist. Most treatment planning systems work off of desktop computers with generous screens. Light boxes, film viewers, printers, scanners, telephones, and network computers for additional communications with physicians are needed.
Clinical space is needed to prepare the patient. Most patients will need to change into a hospital gown and secure street clothes and other valuables. Adequate access to changing rooms and lockers in the vicinity of the brachytherapy procedure, simulation/planning, and treatment delivery area is needed. Space for the recovery of the patient needs to be part of the plan. Most brachytherapy will require some level of sedation or anesthesia. When general anesthesia is given, the anesthesiologist will most often want to formally have the patient recover in the hospital's postanesthesia care unit, for maximum streamlining and safety of care. When local anesthesia, with or without conscious sedation, is employed, provision must be made for adequate time, space, and staffing to get the patient to the point where it is safe to discharge to go home. Most radiation oncology clinics have a stretcher bay area to receive either inpatients or stretcher-bound frailer outpatients. This area is also often used if a patient needs intravenous infusion during the clinic visit, and will need to have some monitoring equipment for vital signs. It will also usually be located in an area close to the nursing station so that observation can be continuous. Space for family who are waiting should be considered. It is most often the case that even with local analgesia/anesthesia and conscious sedation, a patient should not be allowed to drive home independently for obvious safety reasons. This may mean a family member must wait sometimes for several hours. The waiting area of the clinic needs to be able to make some allowance for this. Television, computers, telephones, restrooms, refreshment area, and comfortable well-lit spaces are ideal. This space is best located relatively close to the procedure and treatment space so that if possible the family member can sit with the patient during waiting times between procedure, planning, and treatment. Space in close proximity to the clinic is needed to store equipment and records. Modern brachytherapy will need much more than the standard closet-like hot lab for storage of materials.
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Table 13.2 Resources: Real Estate |
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The afterloader, ultrasound unit, multiple duplicates of applicators, disposable supplies, calibration equipment, back up equipment, computers, isotopes including the swap out isotope for the afterloader will need to be stored in a secured, appropriately shielded room. Calibration chambers, radioactive seeds, and strands, will also be stored and used in the hot lab. The hot lab itself needs to be computer-linked for record keeping and communications. A telephone is also necessary.
Consultation rooms and adequate administrative and professional office space must be provided. Most often this will happen within the context of this space for the entire radiation oncology clinic and practice. As a brachytherapy practice expands, so will additional need for administrative support and other staffing. Brachytherapy is a time-intensive practice requiring much liaison with other services as well as the coordination of physician, physicist, planners, nurses, therapists, procedure room space, planning space, treatment space, and recovery space. It is important to make realistic allowances for these time, person, and space needs for best care of the patient and also so as not to unwittingly cause conflicts with existing programs, roles, and usage.
Resources—Time
People who are trained and dedicated to this work, gathered around the sick patient are the greatest resources in medicine. Brachytherapy requires significant additional training and in-servicing of all members of the team. Table 13.3 lists important time considerations. Realistic assessments of the time the staff needs to prepare, train, organize, calibrate, and quality assure, before patient care can begin is vital. Likewise, the ability to have blocks of time in the necessary planning and treatment space is a highly valuable commodity without which no therapy is possible. Careful attention to time and usage is key. Conflicts for use of procedure rooms, simulators, stretcher areas, anesthesia areas, are just some pitfalls that can inhibit or discourage brachytherapy programs. For teams starting out new brachytherapy practices, it will be most useful to set aside 1 hour a week as dedicated team discussion time. The actual format for the usage of this time will vary. Time to review initial cases in a new modality will provide excellent adjustments to refine the team's technique. Time to discuss upcoming cases and unique needs will prepare the team better. Time to allow open discussion and to get constructive feedback is essential to complex team-based medical care. Although in most centers the brachytherapy cases will be reviewed in the same chart rounds as the external beam patients, in a center with a significant brachytherapy practice, there may need to be dedicated brachytherapy chart rounds. This peer review process should involve the entire team. When incidents or errors occur, these must be reviewed in this context for best patient care and so as to minimize risking a similar future error.
Equipment must often be shared. The coordination of the use of such equipment is a necessary condition of therapy. Capital start-up budgets need to include purchasing and servicing of all equipment, computers, and software upgrades.
It cannot be overemphasized how much time must be utilized in training for the brachytherapy teams. Training and in-service updates are ongoing requirements for the entire brachytherapy team. This time must be calculated realistically. In some instances of new technology it may mean several days away from the clinic at a manufacturer's dedicated training facility, or at least protected blocks of time in the hospital with the manufacturer's technical specialist teaching there. Another important aspect of time usage is the need to have regular safety exercises. For the HDR afterloader, the emergency drill for the isotope stuck out, needs to be reviewed. The physicist will usually be the coordinator and evaluator of the responses of the team members. There may need to be additional refresher courses if performance is not perfect. New staffers will need initial orientation to the specific safety protocols of the individual clinic.
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Table 13.3 Resources: Time |
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On a daily basis, time must be realistically allocated for the preparation for the specific brachytherapy procedure. At the start of the day time will be needed to do the warm up runs on the CT scan, U/S, Simulator, and the HDR afterloader. If anesthesia is to be used, this equipment will also take some time for safety checks and other preparation. All imaging and therapeutic equipment will have daily QA checks. These checks must also be recorded in the appropriate log. All these take time. This time must be smoothly coordinated so as to allow safe care to proceed in an orderly fashion. For different disease sites and modalities of brachytherapy different anesthesia, implanting, planning, delivery, and recovery patterns will be needed. In common, each has the need to make the correct time space so that the best care is delivered, and so the members of the team have realistic work responsibilities, routine work breaks, and are not chronically overworked because of unrealistic expectations.
Resources—Equipment
Table 13.4 lists equipment resources to be considered. Applicators are essential to every kind of brachytherapy. An adequate supply to cover not only the intended caseload, but also with a margin of redundancy built in just in case unforeseen events occur, is essential. Every applicator must be certified as safe for patient care, by routine QA process appropriate for its nature and intended use. An example of this is cylinder applicators used for vaginal cuff brachytherapy. These are reusable devices. However, over time the tandems may bend or distort, the locking screws or other parts may simply wear out. A working knowledge of the length of time to get an applicator back from sterilization for reuse will also be important for knowing how many of a specific applicator to budget for. Disposable supplies must also be similarly accounted for. A sample of a batch may be tested for safety and integrity of structure. In a recent start-up program for a university hospital, the cost of equipping the service with applicators was almost equal to the cost of the new HDR afterloader itself!
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Table 13.4 Resources: Equipment |
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Afterloaders/Isotope
Each dose rate modality will have its own unique QA program. This needs to be designed with the collaboration of the manufacturer, the commissioning physicist, the radiation safety officer, and the therapist. In HDR there will be a daily QA program run. This is described in Chapter 2. Time before the therapeutic day must therefore be budgeted with the physicist and therapist participating.
Other Equipment
The operating room/procedure room equipment will need a daily QA routine. If an isotope is to be used, before any is introduced, the room must be surveyed for activity. Staff must be badged and in-serviced on as low as reasonably achievable (ALARA) principles and other safety issues. Safety equipment such as radiation detectors, door interlocks, survey meters, bail out equipment, must be in working order and checked on a daily basis. Clinical equipment such as leg stirrups, sterile set up kits, linen supplies, bandages, hazardous waste disposal, suction, tables, lights, cameras, audiovisual equipment, must all be in place and fully functional. The functionality must be documented.
Anesthesia equipment usually comes under the aegis of the anesthesia support staff. Again, this preparation and calibration time must be allowed for, before patient care can commence. Imaging modalities will need to be run through the manufacturer and radiation safety daily QA protocols ahead of patient care time. Treatment planning computers will need to be updated, in-serviced and checked against known values to ensure quality output. Computerized scheduling and billing systems will need to be in working order with appropriate IT support in place.
Interpersonal communications between the team members is crucial. Telephones, cellular telephones, pagers, email are practically essential elements. However, efficient communication is much more than the possession of these devices.
Developing a Business Plan for a Brachytherapy Service
The core group of stakeholders in the development of a brachytherapy service is listed in Table 13.1. A team approach will be the most optimal, as every participant has a necessary and complementary role to play in the planning stage. The physician will play many roles at this stage. Often the physician's understanding of the potential of a new technology and understanding of new clinical need will be the founding vision for the service. The physician may receive requests from referring sources that cannot currently be met. When the service is fully operational it will be the physician who is the clinician leading the brachytherapy team. The physicist will be the leader for the technologic aspects of the set up of the practice as well as for the regular provision of medical physics services for actual cases. The physicist brings not only scientific expertise, but also specialized understanding of the mechanics of the various imaging and treatment devices. The creation and maintenance of a safety program for brachytherapy will be lead by the physicist. The registered nurse (RN) will focus the planning process to the needs of the patient uniquely. The RN will lead the interface of the brachytherapy team with the patient for consultation, preparation, implantation, planning, and recovery. It cannot be emphasized enough that excellent brachytherapy care will require that the RN leader be fully versant in the goals of the therapy as well as potential risks. The patient's discomfort will be minimized by this attention. The certified medical dosimetrist (CMD) is the professional dedicated to computer-based brachytherapy treatment planning. This essential component must be represented in the earliest phases of planning and should not be underestimated. The clinical coordinator or manager for the service brings together the various components of the planned service. This role leads to the organization of timely patient flow, access to space, staff, and equipment. Department and hospital level administrators are the management specialists who are responsible for the development of a sound business plan, the integration of the plan into the wider strategic plan for the hospital/region, and the analysis of the financial impact of starting a service in terms of risk and return on investment. These crucial administrators also have charge of personnel issues, interactions with other departments, and interaction with state and federal regulatory agencies. Marketing strategies are also within their purview.
A model must be developed on the basis of how much needs to be done to meet the clinical needs and opportunities. A simple but effective way is to develop lists of things to be done. Another method is to develop a ramp up model to account for a growing number of cases. A timeline to assemble components of service needs to be reality based for the specific institution. The institutional administrators need to be educated about the core clinical needs as well as specific benefits and costs attributable to such new services. These important collaborators will guide the capital purchase process through the structure of the hospital. Hospital purchasing patterns will support the new service assisting in the selection of optimum equipment and service contracts.
Figure 13.1 demonstrates the projected timeline for a new program with much sequencing and overlapping of tasks.
Starting the process will involve a departmental work group to analyze in detail the patient flow for a new brachytherapy procedure. Figure 13.2 and Figure 13.3 show the detailed analysis for the initiation of a prostate seed implantation program. This will help to establish items required for preparing a pro forma income statement, determining resources required, and identifying which outside groups need to be contacted. A clinical need has been determined, but senior administration needs to be shown the financial impact of implementing a new program. Creating an income statement will include, estimating patient volume and determining resources required. Attention to detail is important to identify all billable procedures needed for the new clinical program. Table 13.5demonstrates expenses for the initiation of an HDR program. Note the gradual addition of staff to match the projected ramp up in clinical activity. Table 13.6 demonstrates a typical pro forma income statement to project income to project the financial health of the proposed program.
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Figure 13.1 Overlapping timeline chart for planning a new service. |
Items to Consider
Understanding patient volumes and how to ensure patient numbers is important. Where will the referrals come from? This may not be very different from where the external beam patient referrals will come. However, as new services may offer alternatives to the services provided by other departments, there may need to be some active strategy to announce not only that a new brachytherapy service is offered, but also how to include the referring physicians in the patient selection and enrollment process. A marketing strategy must be developed. The most important element of this strategy will be meeting with referring doctors, both internal and external to the practice. It is also advisable to meet with the hospital's marketing department for professional help in getting the news of a new program out to the community. It is also an excellent way to ensure that there are no unintended messages conflicting with the existing and ongoing marketing messages from the hospital.
Patient Type
Are these going to be new patients coming into the department for this new treatment or will they be coming from the existing patient population? For example, if a new prostate brachytherapy program is started, will this be a draw from the existing external beam patient group, or will this bring in patients who may have previously gone to surgery, or gone to brachytherapy in another clinic?
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Figure 13.2 Patient flow diagram for the interactions between the various components of the team and the patient in the time before the implant. A complete analysis of these interactions is essential for an understanding of the complexity of building a new brachytherapy service line into the clinic. PSA, prostate-specific antigen; PCP, primary care physician; CT, computed tomography; MRI, magnetic resonance imaging; EKG, electrocardiogram. |
A realistic assessment of the timing of the start of the new service will be greatly beneficial. New programs often take significant time to reach the targeted volume of cases. A ramp-up projection can help. Small initial numbers can help with the job fine tuning of brachytherapy procedures and further specify what additional resources will be needed and when.
When will staff need to be hired? This is an important question to consider. Staff hiring—even when suitable candidates are readily available—takes time. Positions must be posted, attention must be paid to existing hospital policies with regard to priorities in hiring, Equal Employment Opportunity (EEO), and so on.
Interviewing potential staff is vital to assess skills and other suitability for the positions. After a job offer is accepted, there will usually need to be a period of resignation from the previous employment and then orientation to the many aspects of the new hospital/clinic environment. How long is the training and education period? The more specialized the task the longer the education and training period is likely to be. For most clinical positions, it is optimal to bring in new staff under the watchful eye of existing experienced staff. The transition to independent practice within the brachytherapy service must be individually assessed. Resources have been listed in the preceding text. It is also important to know if recruitment of staff will be difficult? Are nurses, physicists, dosimetrists, therapists, and physicians available for recruitment? How much time and resources will such recruitments take?
Where will the procedure be performed? Capacity constraints of the procedure room and simulator and other parts of the clinic must be considered. Supporting departments must be contacted to assess the ability to support the new program, for example, how many days or hours can the anesthesia department provide regional or general anesthesia. What modifications to the procedure room need to be made to allow this type of anesthesia to be given safely? Does a supporting department need an income guarantee? There needs to be a careful consideration of what overall clinical capacity is possible. Consider who are the competitors in the market now and potentially in the future. Competition can be very good for patient care, but it also has the potential to be divisive in the community. Would such conflict have a potentially negative effect of the referral patterns to existing programs or other services in the hospital? Is the new program susceptible of being replaced with a new treatment technique in the near future (e.g., cardiovascular brachytherapy practically disappearing with the arrival of drug-eluting stent technology)? It will be important to clearly define who is expected to charge out each service performed.
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Figure 13.3 Patient flow diagram for the day of the implant and for all follow-up care. |
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Table 13.5 High Dose Rate Brachytherapy Program Expenses |
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Table 13.6 High Dose Remote Brachytherapy Program |
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There will be a need to establish internal controls (audits) to ensure charge capture as well as compliance. A meeting with the hospital Charge Master group will be needed to establish which billing codes will be used, and for appropriate fees. A knowledge of expected reimbursement changes on the horizon from Centers for Medicare and Medicaid Services (CMS) that may have a negative impact on revenue, will keep the program secure. Regulatory bodies govern all aspects of medical care. Proper safety and QA plans must be submitted to state agencies through the hospital's radiation safety officer for new brachytherapy programs. See Chapter 2 for details. Capital constraints may set tight limits on the ability to expand clinical services in a given hospital or clinic. Most hospital capital budgets are tight and a good business plan is required to obtain funding. A presentation to a capital committee might also be required. It will be important to ask whether this program will strategically fit the goals of the department and the hospital. Will this program be seen to be bringing “cutting edge” technology and therapy to the existing programs? Will this program be seen to be providing better patient care and or better coordination of patient care? Will there be the potential for competition for resources or for patients?
A good business plan is essential for the successful implementation of a new program. A good business plan will, more readily convince senior administrators to approve a new program and provide the required resources as outlined in the preceding text. It will set new and very specific targets and goals, with concrete timelines. The good business plan will reduce surprises during implementation. If volume does not meet the target the business plan can help identify the underlying reasons, and suggest corrective changes to subsequent projections to keep the practice sound.
Establish a Budget
A master budget will be needed to help organize the income and outflow of funds. Phases of investment may be tailored to match phases of anticipated increased clinical output. Realistic and conservative goals are important. Overly optimistic projections may momentarily comfort, but can turn sour quickly with lasting potential damage to the proposed program. It is very important to establish the cost of the services including the provision of any radiopharmaceuticals, payroll, and insurance costs including malpractice changes that may be required. Before executing the project, it will be necessary to determine evaluation indicators, and breakeven point financial analysis. It will be necessary to determine the repayment period to cover the cost of the start-up equipment as well as the ongoing cost of supplies. Identifying fixed costs and variable costs mapped against the potential income can do this. These figures should take into consideration whether the configuration will be a dedicated brachytherapy suite or if it is possible to use an existing external beam suite, which would assist in mitigating some of the start-up costs.
One example of simple breakeven analysis for the purposes of income projection is shown in the following four tables, which were created for a hospital to determine the costs and the eventual return on investment of providing a permanent prostate seed implant program. Table 13.7 examines the technical return on investment (ROI) for the hospital, whereas Table 13.8 assesses the ROI for the professional part. In Table 13.9, the professional ROI for the urologist's potential participation is examined. Lastly, the significant difference in billing because of global billing in the nonhospital (freestanding) setting is demonstrated in Table 13.10.
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Table 13.7 Technical return on investment for the Hospital |
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A second example of simple breakeven analysis is a hospital HDR remote afterloader program that would be utilized for many disease sites. The concise tabulation of three important elements is depicted in Figure 13.4—specifically, the payor mix and actual average percentage reimbursement achievable; the capital investment required; and a summary of potential return on this investment based on a conservative mix of procedures in the first year.
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Table 13.8 Professional Return on Investment for the Hospital-Based Radiation Oncologist |
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Table 13.9 Return on investment for Urologist's Potential Participation |
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Table 13.10 Significant Difference in Billing Because of Global Billing in the NonHospital (Freestanding Radiation Oncology Center) Settinga |
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Figure 13.4 Return on investment projection for a hypothetical hospital in Atlanta, Georgia, planning to start a high dose rate program to treat various disease sites. GPCI, Geographical Practice Cost Indices; BCBS, Blue Cross Blue Shield. |
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Establishing a Fee Schedule
Many practices attempt to determine the value of their fees by comparisons to other practices that might be willing to share their financial information. Although the current trend for health care payors is for “transparency” in pricing, sharing of fees may constitute price fixing and should be considered inappropriate. The best exercise for establishing an appropriate fee schedule might include the use of the following resources. The generation of information from national sources such as the Health Insurance Association of America is often quoted in national fee schedule resources available through national medical publishing companies. Use the CMS resource-based relative value system (RBRVS) as a baseline with percentage add-ons to value other third-party payor fee structures. Medicare does stipulate that fees for Medicare beneficiaries must be no greater than the usual and customary fees for the practice so it is important to remember to refrain from routinely charging fees that are lower than the Medicare rate to avoid having the Medicare rate itself lowered.
The RBRVS system was established in 1992 and comprises a complex formula for evaluating the value of service codes (CPT-4). The relative value unit (RVU) assigned to a service code is established by a committee, the AMA/Specialty RVU Update Committee (RUC) and is evaluated every 5 years for any necessary adjustments. The RVU contains values for the work component, practice expense component, and malpractice component for each procedure code. Additionally, another value for each of these categories is represented in the value assigned to the geographic practice cost indices (GPCI) that differentiates payment localities. Finally, the formula components are multiplied by the conversion factor (CF), which is updated annually through a complex series of congressionally mandated regulations and budget constraints and the Medical Economic Index (MEI). In addition to annual updates reflecting changes in CPT coding, Section 1848(C)2 (B) of the Omnibus Budget Reconciliation Act of 1990 requires the CMS to comprehensively review all relative values at least every 5 years and make any needed adjustments. Figure 13.5 shows a sample formula for computing the payment for a service code. Likewise, it is important to know whether a service has the potential for denial due to lack of deemed medical necessity. This is particularly prevalent with brachytherapy procedures due to the evolving nature and specialization of brachytherapy. Medicare requires an advanced beneficiary notice (ABN) when there may be coverage issues pending payment. An ABN waiver of liability explanation is shown in Table 13.11. The patient must sign a new waiver for each date of service. “Blanket” permission is not acceptable.
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Figure 13.5 Sample formula for computing the payment for a service code. CMS, Centers for Medicare and Medicaid Services; MPFS, Medical Practice Fee Schedule; RVU, relative value unit; GPCI, geographic practice cost indices; PLI, Practice Liability Indices. |
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Table 13.11 Advanced Beneficiary Notice Waiver of Liability |
Managed Care Restrictions/Negotiations
The most important component in negotiating fair payment from the managed care entity is to receive payment for the ancillary supplies and radioactive isotopes. This would include all needles and catheters used; these items may be quite expensive. Then the multiple procedures performed before, during, and after the brachytherapy procedure would be listed with well thought out payment for each type of brachytherapy performed. There are sometimes major differences and subtle differences between the various insertion procedures depending upon the disease site treated and how that disease site is treated. The time and staff involved are very important and there is no CPT or HCPCS (Healthcare Common Procedure Coding System) codes always to cover every costly event taking place. This is why it is important to analyze and make sure that the CPT/HCPCS codes have all possible dollars built into them to cover additional services not paid in the negotiations.
Site of service options are important considerations. Most brachytherapy procedures are performed in the outpatient hospital (outpatient place of service 22), inpatient hospital (IH) (IP or IH place of service 21), freestanding or office setting (place of service 11/99), or in a private ambulatory surgery center (place of service 24). Table 13.12 demonstrates the procedures codes involved in a typical procedure. Table 13.13 and Table 13.14 demonstrate typical procedures payment listed and charges for the physician for an outpatient HDR prostate procedure delivered in 3 fractions.
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Table 13.12 Codes Involved in a Typical Procedure |
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Table 13.13 Typical Physician Charges for an Outpatient High Dose Rate Prostate Procedure Delivered in Three Fractions |
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Table 13.14 Typical Hospital Charges for an Outpatient High Dose Rate Prostate Procedure Delivered in Three Fractions |
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Principles and Practice of Brachytherapy Reimbursement Charting and Documentation
National Correct Coding Initiative
Correct Coding Initiative Edits
The CMS introduced the Correct Coding Initiative (CCI) in January 1996 to prevent unbundling—a form of Medicare fraud or abuse. Congress mandated the system to prevent the billing of multiple procedure codes when a single code would be more appropriate, which was costing millions of dollars in wasted Medicare payments. The CCI edits apply only to services that are performed on the same day for the same patient and billed by the same physician. Services performed by different physicians for the same patient on the same day or different services provided for the same patient on different days are not subject to the CCI edits. CCI edits apply to all providers who bill for services on the CMS-1500 as well as outpatient hospital claims as part of the ambulatory payment classification (APC) system.
Coding policies are based on coding conventions defined in the AMA's CPT manual, in addition to national and local policies and coding guidelines developed by national professional societies and current coding practices.
Coding combinations that are bundled in CCI will generally only be reimbursed for one of the codes and generally the one with the lower value. Medicare and other third-party payers utilize various versions of the CCI coding edits, so understanding CCI and knowing which codes may or may not be billed together has coding implications for radiation oncology coders and financial implications for radiation oncology practices. The purpose of the CCI edits is to ensure that the most comprehensive groups of codes are billed rather than the component parts. Additionally, CCI edits check for mutually exclusive code pairs. These edits were implemented to ensure that only appropriate codes are grouped and priced. The unit-of-service edits determine the maximum allowed number of services for each HCPCS code. Chapter 9 covers Radiology and Radiation Oncology services. The CCI edits are updated quarterly and are now posted on the CMS Web site. You can refer to the CMS National Correct Coding Policy Manual for Part B Medicare Carriers at http://www.cms.hhs.gov/nationalcorrectcodinited/. Table 13.15 shows the code ranges for all categories of service type. Note that radiation oncology services, including brachytherapy services are found under the code range 70000 to 79999 and not under disease site types or the surgical service types.
The CMS contractor responsible for the development and implementation of the CCI edits is Correct Coding Solutions LLC. Comments can be sent to:
· National Correct Coding Initiative
· Correct Coding Solutions LLC
· P.O. Box 907
· Carmel, IN 46082-0907
Procedures should be reported with the HCPCS/CPT codes that most comprehensively describe the services performed. Unbundling occurs when multiple procedure codes are billed for a group of procedures that are covered by a single comprehensive code and by coding each component part as if it was a separate service.
Originally, the CCI edits consisted of two types of code pair combinations: “Comprehensive/Component” code pair edits and “Mutually Exclusive” code pair edits. The “Comprehensive/Component” edits identified coding combinations in which a procedure code is a “component” or integral part of a more “comprehensive” procedure code. The “Mutually Exclusive” edits list procedure code combinations that would not generally be performed together on the basis of CPT definition or standards of medical practice. For example, Table 13.16 shows that CPT code 77336 (continuing medical physics support) is mutually exclusive from CPT code 77370 (special physics consultation). The status indicator of 1 clarifies that a modifier could be used to bypass the edit if appropriate and documented in the medical record. The effective date shown as 19960101 indicates that the edit became effective on January 1, 1996.
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Table 13.15 Code Ranges for all Categories of Service Type |
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Revision to the Correct Coding Initiative Edits Table
In 2003, CMS renamed the heading for “Comprehensive/Component edits” code table to read “Column 1/Column 2” Correct Coding Edits because the table also included edits that did not involve a comprehensive/component relationship, but were codes that should not be reported together for other reasons, for example, misuse of the code. CMS changed the headings to reflect more accurately the overall category of the edits within the tables and to eliminate the confusion as a result of using the terms comprehensive and component.
Table 13.17 demonstrates that Column 1 CPT code 77778 (Interstitial complex radiation source application; complex) and column 2 CPT code 76873 (prostate volume study for brachytherapy treatment planning separate procedure) are paired because of stipulations in the Federal Register, CMS Carrier's Manual, CMS Local Coverage Determination (LCD), and/or professional associations who have input (e.g., American Society of Therapeutic Radiology and Oncology (ASTRO), the American College of Radiology (ACR)). In this example, the combination 77778/76873 is not specifically excluded according to AMA CPT, but the logic behind the edit is based on current medical standards, which suggests that the 76873 study is done as preplanning and presurgery and, therefore requires separate work at a greater value than if a patient underwent a transrectal ultrasound during the procedure (76872); therefore, the edit rules out the use of this ultrasound-guided service on the same day or during the same session. The 0 modifier is an indicator that no modifier can be used to bypass the edit. The second code pairing in the example, 77778/99245 is an example of a 9 indicator that identifies that the edit is no longer applicable with a deletion date of January 1, 1996 (19960101). An indicator of 1 clarifies that a code combination can be bypassed with an appropriate modifier.
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Table 13.16 Mutually Exclusive Editsb |
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Table 13.17 Column 1/Column 2 Editsa |
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Regulatory Requirements
Office of the Inspector General (OIG)—Program Guidance
The creation of compliance program guidance has been a major initiative of the OIG in its effort to engage the private health care community in preventing the submission of erroneous claims and in preventing fraudulent conduct. The OIG developed and issued compliance program guidance directed at a variety of segments in the health care industry. The goal of a voluntary compliance program is to provide a tool to strengthen the efforts of health care providers to prevent and reduce improper conduct and reduce the incidences of fraudulent claims. These programs can also benefit providers by helping to streamline business operations. Copies of the compliance program guidance can be found on the OIG web site at http://www.oig.hhs.gov/.
Components of an effective compliance program are listed in Table 13.18. The compliance program guidance for providers contains seven components that provide a solid basis upon which a practice can create a voluntary compliance program. During the internal audit process to demonstrate compliance with the OIG's guidelines or as an annual review tool to ensure ongoing compliance, the following comprehensive checklist should be utilized.
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Table 13.18 Components of an Effective Compliance Program |
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· Bills are accurately coded and accurately reflect the services.
· Documentation is completed correctly.
· Services or items provided are reasonable and necessary.
· Incentives for unnecessary services do not exist.
The OIG recommends that claims/services that were submitted and paid during the initial three months after implementation of an education and training program be examined to give the provider a benchmark against which to measure future compliance effectiveness. Following the baseline audit, a general recommendation is that periodic audits be conducted at least once each year to ensure that the compliance program is being followed. A random sample of claims can be audited. One method is to choose a random sample of claims from either all of the claims submitted for reimbursement or all claims from a specific payor. Another method is to identify specific risk areas or potential billing problems such as a new service line introduced by the provider (e.g., HDR remote afterloading, seed implant program, etc.) These risk areas may be the focus of an internal review to determine if the standards and procedures/policies are being followed. The OIG recommends that the practice evaluate claims selected to determine if the codes billed and reimbursed were accurately ordered, performed, and reasonable and necessary for the treatment of the patient. An important component of a successful compliance audit program is an appropriate and timely response when the practice identifies a problem. Corrective action should be taken as soon as possible after a problem is identified.
Centers for Medicare and Medicaid Services
President Lyndon B. Johnson signed the Medicare and Medicaid programs into law on July 30, 1965. Since 1965, a number of changes have been made to the CMS programs. The Balanced Budget Act (BBA) of 1997 modified how payment is made for Medicare skilled nursing facility (SNF) services. One of the most significant legislative changes to Medicare since its inception is the Medicare Modernization Act (MMA) that was signed into law by President George W. Bush, on December 8, 2003. A controversial aspect of the MMA is the provision of coverage for prescription drugs to Medicare beneficiaries.
Medicare is a health insurance program for:
· People aged 65 or older
· People younger than age 65 with certain disabilities
· People of all ages with end-stage renal disease (permanent kidney failure requiring dialysis or a kidney transplant)
Funding for the Medicare program is projected to be $340 billion in 2006. Medicare consists of four parts:
1. Part A (Hospital Insurance): Most people will not need to pay a premium for Part A because they or their spouse are already entitled as a result of payroll tax deductions employed. Medicare Part A (Hospital Insurance) provides coverage for inpatient care in hospitals, including critical access hospitals, and skilled nursing facilities. Medicare does not cover custodial or long-term care. It does cover some home health and hospice care. Beneficiaries must meet certain conditions to get these benefits.
2. Part B (Medical Insurance): Beneficiaries generally pay a monthly premium for Part B coverage. Medicare Part B provides coverage for physician services and outpatient care. It also covers some other medical services such as physical and occupational therapy, some home health care and supplies when they are medically necessary.
3. Part C (Medicare Advantage): Part C finances the full Medicare benefit through private plans. In 2006, 16% of beneficiaries are expected to be enrolled in Medicare Advantage plans, and by 2009; this number is projected to increase to 24%.
4. Part D (Prescription Drug Coverage): Effective January 1, 2006, the new Medicare prescription drug benefit became available to everyone with Medicare. This coverage was designed to lower the prescription drug costs and help protect against higher costs in the future. Medicare Prescription Drug Coverage is insurance and requires a benefit premium. Private companies provide the coverage and beneficiaries choose their plan and pay a monthly premium.
Approximately, 42 million Americans have Medicare coverage according to the CMS. Estimates are that Medicare enrollment is expected to reach 77 million by 2031, when the Baby Boom generation is fully enrolled.
Medicare processes over one billion fee-for-service claims per year making it the nation's largest purchaser of managed care. In 2003, Medicare accounted for almost 13% of the entire Federal Budget and is projected to balloon to 14% by 2007. On the basis of the CMS projections, 33 cents of every dollar spent on health care in the United States is paid by Medicare and Medicaid; 61 cents of every dollar spent on nursing homes, 47 cents of every dollar paid to hospitals, and 27 cents of every dollar spent on physician services. Table 13.19 demonstrates the percentage distribution of government expenditures for the 2007 financial year.
Although Radiation Oncology practices have traditionally been weighted heavily with Medicare beneficiaries, the introduction of managed care plans for seniors and the intensity of specific service lines can affect the payor mix. For example, a typical practice today will experience approximately 30% to 35% Medicare for the overall practice but may have a significant variation in the mix when focused on brachytherapy procedures that may be targeted for a younger patient population. High dose remote afterloader procedures frequently fall into this category.
Stark—Joint ventures
Legal analysis of a physician-hospital joint venture should include a review of the Stark law, the federal antikickback statute and Internal Revenue Service rules and regulations. Under the Stark law, a physician may not refer Medicare or Medicaid patients to a provider for the provision of “designated health services” when the physician has a direct or indirect financial relationship with the provider unless there is an applicable Stark law exception. If an arrangement complies with the Stark law, there may still be areas of concern in complying with the antikickback statute. That law prohibits individuals or entities from “knowingly and willfully” offering or accepting remuneration “in cash or in kind” in exchange for referrals or to induce referrals. The OIG has issued safe harbors that describe arrangements that are exempt. If an arrangement does not fall within a safe harbor, the arrangement is not necessarily illegal but the proposed arrangement should be evaluated under the statute to determine if the parties could be construed as “knowingly and willfully” intending to induce referrals through the joint venture arrangement. It is always in the best interest of the practice to engage the services of a qualified health care legal advisor to provide guidance when embarking on such a venture.
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Table 13.19 Government Spending by Category as a Percentage of the Financial Year 2007 Annual Budgeta |
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Health Insurance Portability and Accountability Act, Protected Health Information, Business Associates, Security
The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act (HIPAA) of 1996 require the Department of Health and Human Services (HHS) to establish national standards for electronic health care transactions and national identifiers for providers (NPI), health plans, and employers. It also addresses the security and privacy of health data. Developing standards will improve the efficiency of the nation's health care system by encouraging widespread use of electronic data interchange in health care.
Significant changes have taken place since the Department of HHS first introduced HIPAA in 1996. Regulations have been modified, compliance deadlines have passed, and organizations have implemented compliance programs and put them into action. Some of the operational aspects affected by these regulations include patient privacy through the rules governing protected health information (PHI), Business Associate Agreements between qualifying providers and third parties who share PHI, and security and integrity of stored data that references patient care and protected patient health information. For further guidance and more information on this topic, please refer to the CMS web site at http://www.cms.hhs.gov/.
Operational Issues
Denial Management
Denial management is a crucial monitoring tool. A good compliance program will incorporate a review of comparative values to focus on specific risk areas identified through this process. The denials not only impact the coding process but are also the financial indicators for potential lost revenue. Denials should be monitored by category/CPT code, (e.g., brachytherapy services), by payor, and/or by provider to evaluate risk areas that may require further education or process improvement. Figure 13.6 shows an illustrative graph comparing denials in comparative fiscal years.
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Figure 13.6 Comparison of denials in different fiscal years. |
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Table 13.20 Benchmarks/Expectations by Employee and Department by Function |
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Benchmarking of Clinical revenue, Accounts Receivable, Days in Accounts Receivable, Collection Ratios
An understanding of the operational expectations is crucial to the success of any brachytherapy program. Dissemination of the targets to the staff will enhance the probability that the goals will be met. Table 13.20 demonstrates some general operational guidelines.
Key Financial Indicators and Definitions
Standard Definitions are shown in Table 13.21. The days in accounts receivable (A/R) is a performance measurement for the collection of outstanding accounts receivable. Days in A/R are a key financial indicator. The goal is to move the charges from the A/R to the collected column as soon as possible. Tracking A/R days over time suggests the effectiveness of the billing and collections process. Generally a practice reporting a lower number of days in A/R will have a higher collection ratio than one with higher A/R days. Creating targets and benchmarks provides comparative data to analyze performance within a practice by department, for specific employees or comparison to other “best” practices of different sizes and productivity.
Figure 13.7 shows a target value of 48.7 days tracked over the course of 12 months by the employee responsible and by the facility. Facilities B and C are reporting relatively stable numbers and are well within the target benchmark of 48.7. Facilities A and D are well above the target with A showing progress by trending downward each month, whereas facility D is worsening. Target numbers will vary by payor mix and contract types. Note that capitated contracts, large discounts and write offs will lower the A/R days and may give a false financial picture. Specific analyses of aging accounts will lead to administrative review and corrective planning.
An accounts receivable aging summary is a useful tool for analyzing the makeup of the accounts receivable balance. This is a periodic report showing outstanding balances due, expressed as a percentage of the total A/R over time and categorized in ranges from current 0 to 30, 60, 90, 120, and >120. In Figure 13.8, benchmarks have been aggressively set with 68% of charges being targeted for resolution within the first 30 days (52% + 16%) with 10% allocated to each of the 60 and 90 day levels; 12% at the 120 day category and nothing at all over 120 days. For the 3 months reported in this example, the practice is well outside the benchmarks set for the >120 day category (set to -0-) but is showing some improvement with the downward trend from 57% to 51%.
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Table 13.21 Key Financial Indicators and Definitions |
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Figure 13.7 Days in accounts receivable (AR) summary. |
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Figure 13.8 Accounts receivable aging summary. |
Net charges are gross charges minus total adjustments. Net collections are payments received minus refunds and returned checks. Discounts are amounts that the practice does not expect to collect. For example, this may be the difference between the usual and customary charge and the contracted (discounted) charge or the Medicare allowable. Average daily charges are the average monthly gross charges divided by the number of calendar days in the reporting period; it is best to use 6-month to 12-month moving averages. Gross charges are the full dollar value of all services rendered to patients. Gross collection percentage is the unadjusted revenue collected divided by gross charges, multiplied by 100. Write offs and bad debt are amounts that the practice expected to collect but did not.
Coding and Reimbursement for Common Brachytherapy Procedures
Delivery of Radiation Codes
The code for the delivery of the radiation is selected on the basis of whether the catheter is intracavitary or interstitial and the complexity of the procedure, which is based on the number of sources. The procedure codes for each type of delivery are delineated in Tables 13.22, 13.23, 13.24, 13.25, 13.26, 13.27, 13.28, 13.29 and 13.30:
Intracavitary
The intracavitary codes 77761 to 77763 are utilized when placing sources into natural existing orifices such as rectum, nose, mouth, and vagina. These procedures utilize low dose sources. See Table 13.22 for details.
Interstitial
The interstitial codes 77776 to 77778 are utilized when inserting radioactive sources through the skin or “invasive” procedures. Some typical examples are prostate, head and neck, breast, sarcoma, and so on. These procedures utilize low dose rate radioactive, mostly iridium and iodine, source. See Table 13.23 for details.
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Table 13.22 Procedure Codes for Intracavity Delivery of Radiation |
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Table 13.23 Procedure Codes for Interstitial Delivery of Radiation |
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Table 13.24 Procedure Codes for High Dose Rate Delivery of Radiationa |
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Table 13.25 Procedure Codes for Other Types of Delivery |
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High Dose Rate
HDR codes 77781 to 77784 are used when placing HDR sources into any area of the body. Some examples are breast, gynecologic, prostate, head and neck, endovascular, and so on. This would include intracavitary and interstitial cases. See Table 13.24 for details.
Other Delivery Codes
Other types of delivery are for infusion of a solution 77750 or surface application 77789, for procedures in metastatic bone disease and pterygium respectively. See Table 13.25 for details.
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Table 13.26 Procedure Codes for Ancillary Procedures |
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Table 13.27 Procedure Codes for Physics Services |
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Ancillary Codes
When performing these procedures there are other ancillary procedures that are performed in addition to the delivery codes. The first of these codes are for verification of the position of the source into the body. For initial verification when inserting the needles, catheters, or sources, code 77290 complex simulation would be used. In these interstitial cases when the needles and catheters remain in the body throughout treatment, the subsequent verifications to determine that the needles, catheters, and sources are still in position are considered simple. In some gynecologic insertions that are repeated over a period of days, where the insertion procedure would be charged each time and only one physics plan charged, the simple simulation code would be used. In intracavitary insertions such as lung and esophagus and some gynecologic insertions, where the physics plan changes for each insertion, a complex simulation would be charged. See Table 13.26 for details.
Physics Services
See Table 13.27 for details.
Needle and Catheter Insertion Codes
See Table 13.28 for details.
Supplies Used in the Hospital
See Table 13.29 for details.
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Table 13.28 Procedure Codes for Needle and Catheter Insertion |
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Table 13.29 Procedure Codes for Supplies Used in Hospitals |
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Table 13.30 Procedure Codes for Supplies Used in the (Freestanding) Office |
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Supplies Used in the Office (Freestanding)
Note that devices are not considered to be needles or catheters, as these are supply items. See Table 13.30 for details.
The application of the radioactive source in brachytherapy has been utilized since the turn of the century. The actual definition of the codes from element to source has allowed the addition of machine-generated radioactivity as well as artificial and natural radioactive sources. However, CMS has made a statement in 2006 that only radioactive isotopes will be reimbursed and that machine-made devices will not be eligible for “source reimbursement”. CPT codes 77761, 77776, 77789, and 77790 were revised to include “radiation source” to update current terminology. Continual changes in technology have led to ambiguity in the proper coding for radiation therapy procedures. This clarification will aid coding for new external and internal radiation sources as the modes of radiation therapy administration continue to evolve. These codes are not to be utilized for insertion or needles, catheters or applicators.
Modifiers are an important part of the coding process and may affect the payment level for a code or bypass edits to allow for payment when multiple services are performed on the same date of service. National modifiers are published and maintained by the AMA. Individual third-party payers may establish local modifiers also.
Centers for Medicare and Medicaid Services Discussion
· If an edit allows use of NCCI-associated modifiers, the two procedure codes may be reported together if the two procedures are performed at different anatomic sites or different patient encounters.
· Carrier processing systems utilize modifiers to allow payment of both codes of an edit.
· Modifier-59 and other NCCI-associated modifiers should NOT be used to bypass an NCCI edit unless the proper criteria for use of the modifier are met.
· Documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier used.
Note: The CMS encourage carriers to conduct prepayment and postpayment reviews of the use of modifier 59. For additional information on CMS, you can refer to www.cms.hhs.gov/NationalCorrectCodInitEd. Common current modifiers are listed in Appendix 1.
Conclusion
In this chapter the basic organizational elements to establish a healthy and viable brachytherapy service have been outlined. From needs assessment, to the assembling of the building blocks of the service, to the creation of a business plan with a ramp-up model, to staffing and allocation of time and space, the team approach is necessary. It has been demonstrated how complex and potentially variable the reimbursement protocols may be. The most common methods to stay abreast of this complexity have been reviewed. USA health care reimbursement is a coherent pattern of codes and protocols to ensure that health care funds are spent appropriately. Some of the changes over time to this system are relatively straight forward, but most are not. They often represent the struggle of the Congress to meet the competing calls for the government's funds. Organized medicine, including that for radiation oncology, the American College of Radiology, the ASTRO, the American Brachytherapy Society, the AMA, the States Medical Societies, conduct significant ongoing monitoring and advocacy efforts for the appropriate reimbursements for an ever increasingly technologic environment for contemporary health care, and to keep caregivers and health care institutions informed about changes. Ever increasingly, more necessary professional adjuncts to this whole process are the medical accounting professions. These groups serve individual health care givers, groups, health care institutions, professional bodies, and government agencies, as experts in the technical elements of health care billing, compliance, and reimbursement. The creation and maintenance of a fiscally stable modern practice of brachytherapy within the larger context of radiation oncology continues to depend greatly on this additional technical expertise.
