The OIG audit found that hospitals received $25.8 million in payments for IMRT planning that didn't comply with Medicare billing requirements, primarily by billing separately for complex simulations along with the original bundled treatment plans. The agency recommended several steps to prevent overpayments in the future.
The OIG's August report notes that IMRT is an advanced type of radiation oncology designed to treat hard-to-reach tumors, and computer simulation plays a large role in planning IMRT sessions. The U.S. Centers for Medicare and Medicaid Services (CMS) typically makes a bundled payment for IMRT that is intended to include both the planning and actual treatment sessions.
However, previous reports by the OIG have shown that some hospitals are billing separately for planning sessions in addition to the bundled payment. The office decided to investigate to find out how widespread the phenomenon is.
The agency audited Medicare claims made by hospitals for IMRT services from 2013 to 2015. Medicare's manual states that hospitals must use current procedural terminology (CPT) code 77301 to bill for IMRT planning; the manual describes services that may not be billed separately, regardless of whether they are billed on the same or a different date of service.
For the audit period, Medicare paid 1,193 hospitals $109.2 million in bundled payments for CPT code 77301, with investigators tagging $25.8 million of that figure as overpayments for separately billed outpatient IMRT planning services.
Of the overpayments, 84% ($21.5 million) consisted of payments for complex simulations under CPT code 77290. Other services made up the rest of the overpayments.
The agency further focused on overpayments for code 77290, picking a random sample of 100 line items that were reviewed by a billing contractor to determine how well they complied with Medicare guidelines. In all 100 cases, the hospitals separately billed for complex simulations, as they appeared to be unfamiliar with CMS guidance on IMRT billing.
The office continued monitoring payments for two years after the audit period. It found an additional $3.7 million in overpayments for complex simulations and $1.7 million in overpayments for other services, for total overpayments of $5.4 million.
The OIG report recommended that CMS implement an edit to prevent overpayments for IMRT services that are billed up to 14 days before CPT code 77301 is billed. The agency should also work with Medicare contractors to educate hospitals on proper billing for IMRT planning services.
CMS concurred with the recommendations and has informed the OIG of the steps it plans to take. The report is available by clicking here.
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