PPS Exempt? Cha-ching. MDACC? CHA-CHING!

[Irradi8or]

We are still in a PHE. And lots of patients aren't vaxed. This is not my practice but I can't find fault with it

Not sure I agree,; based on CMS description, its in the context of the PHE and to mitigate exposure risk when appropriate. That isn't the case for every patient and there are times where it's appropriate and isn't. Having a blanket statement that all OTVs can be routinely done remotely doesn't seem right, but perhaps open to interpretation based on others on this forum.

Many private payers in my area don't pay for 77427 remotely now either (like when addending a -GT modifier or similar to it). CY 2021 telehealth services in CMS-1734-F places 77427 in Category 3, which according to them is "Services we are not adding to the Medicare telehealth list either permanently or temporarily." See the table below.

Anecdotally - we used 77427 remotely when COVID spiked a couple of times in our area and based on patient risk (vaccination status, comorbidities, COVID burden in our clinic, when we had a physician out sick with covid and otherwise couldn't deliver the OTV service, etc) but not routinely.

(https://www.cms.gov/files/document/12120-pfs-final-rule.pdf)

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Members don't see this ad.

 

[TheWallnerus]

Not sure I agree,; based on CMS description, its in the context of the PHE and to mitigate exposure risk when appropriate. That isn't the case for every patient and there are times where it's appropriate and isn't. Having a blanket statement that all OTVs can be routinely done remotely doesn't seem right, but perhaps open to interpretation based on others on this forum.

Many private payers in my area don't pay for 77427 remotely now either (like when addending a -GT modifier or similar to it). CY 2021 telehealth services in CMS-1734-F places 77427 in Category 3, which according to them is "Services we are not adding to the Medicare telehealth list either permanently or temporarily." See the table below.

Anecdotally - we used 77427 remotely when COVID spiked a couple of times in our area and based on patient risk (vaccination status, comorbidities, COVID burden in our clinic, when we had a physician out sick with covid and otherwise couldn't deliver the OTV service, etc) but not routinely.

View attachment 345840

(https://www.cms.gov/files/document/12120-pfs-final-rule.pdf)

It appears the first link you gave

List of Telehealth Services | CMS

List of services payable under the Medicare Physician Fee Schedule when furnished via telehealth.List of Telehealth Services for Calendar Year 2024 (ZIP) - Updated 11/13/2023

www.cms.gov

is for 2022, and 77427 is on the list.

It appears the second link discussing category 3 is from 11/27/2020.

Here is the 2022 final rule: https://public-inspection.federalregister.gov/2021-23972.pdf

Again, TBD: whether all of radiation, essentially, can be done remotely, forever.

 

[TheWallnerus]

Who made this graphic? Its dumb as hell.

The parts in red are intended to trigger those with zero imagination. It worked.

 

[evilbooyaa]

Who made this graphic? Its dumb as hell. Does SBRT quadruple the incidence of prostate cancer?

No, obviously not, but it does lead to aggressive marketing with the goal to shuttle patients from their local facilities to large academic motherships.

If the machine was filled with on treatment patients, maybe they wouldn't feel the need to do that as much.

 

[elementaryschooleconomics]

The parts in red are intended to trigger those with zero imagination. It worked.

Also, I don't think anyone is implying that "SBRT increases the incidence of prostate cancer", or whatever strawman could be invoked.

I think people in academia are used to a high overhead/surplus capacity environment. Obviously, it doesn't apply to everyone/everywhere, but I definitely know places with decent volume but 10-15 patients per linac because they have 3-5 machines.

My (community) department is fairly busy, and I have two linacs. While we can move heaven and earth for emergencies/diseases where total treatment time matters, I definitely have to consider available machine timeslots for new patients, and can't always start someone exactly on the day I want. Shorter treatment regimens means higher throughput of patients, for me and everyone else. I am, of course, limited by disease incidence and referrals.

However, I'm not at a tertiary (PPS-exempt) center with a marketing budget to rival the NFL. If you build up a cultural zeitgeist of "more fractions bad, less fractions good", and create a "destination treatment center"...you don't need the incidence of prostate cancer (or any cancer) to change in the population, because you're capturing more of those patients who would go elsewhere.

Currently, I would say ~30% of my patients get second opinions at regional PPS-exempt centers. I honestly don't have a sense if this is high, low, or normal. 90% of them stay with me because I can usually offer the same treatments...except for protons. Again, I don't know if my retention is good, bad, or normal.

But considering these factors - high negotiated reimbursement for SBRT, drilling into everyone's head that shorter is better (and "cheaper"), advertising your treatments, and getting patients in and out quickly - while the graphic is an extreme version of what could happen, it illustrates economic forces which already exist.

 

[Irradi8or]

It appears the first link you gave

List of Telehealth Services | CMS

List of services payable under the Medicare Physician Fee Schedule when furnished via telehealth.List of Telehealth Services for Calendar Year 2024 (ZIP) - Updated 11/13/2023

www.cms.gov

is for 2022, and 77427 is on the list.

It appears the second link discussing category 3 is from 11/27/2020.

Here is the 2022 final rule: https://public-inspection.federalregister.gov/2021-23972.pdf

Again, TBD: whether all of radiation, essentially, can be done remotely, forever.

Yea, that first link is for current telehealth, but 77427 is listed as a temporary addition for the PHE for the COVID-19 pandemic. 77427 is still cat 3 in the final rules.