ROCR

[elementaryschooleconomics]

true, but he is by far the worst. He once claimed it is fraud if you bill for a cbct at a satellite (covered by another doctor) when you review the film remotely.

So Ron et al had a brief moment in the sun with the 3 month window between the start of the new general supervision rules on January 1st 2020 and the start of the PHE. We barely had time to argue about that because it was more about APM at the time.

Then, with virtual direct supervision...even if you want to claim IGRT is diagnostic requiring direct supervision, it doesn't matter - we all have the ability to engage in virtual supervision. Side note, outside of Ron and ASTRO, the only other place you can find "IGRT is a diagnostic test" is from a single MAC (Palmetto) and not even an LCD, just an article (LCA) - and even then the LCA gets real cute with using the word "physician" not "Radiation Oncologist", though they make sure to specify "Radiation Oncologist" for 77427/OTV.

Virtual supervision, barring some random craziness, will likely become permanent. Which means...what else can they cling to for this?

The current flavor of "saber rattling" is this - site of service. They acknowledge the supervision rules apply to the technical component, and in hospital outpatient departments, billing technical under general is OK (per CMS guidelines, obviously individual hospitals or practices or various accreditations or whatnot might not, but that's an individual thing).

They are no longer flat out saying general supervision for IGRT is wrong, they're saying that you need to bill the professional component using the address where the service was provided.

The unspoken leaps of logic there being if you approve IGRT images remotely, from home for example, and your practice bills CMS using the hospital address on line 31 of the 1500 form or whatever, you're committing fraud.

Small problem...what about that entire industry of Teleradiology that has existed forever?

Long story short, CMS cares about zip code (for MAC jurisdiction) as well as facility vs non-facility for fee scheduled. The "default" recommendation is to bill the professional using the same address as the technical, with the example CMS gives being a scenario where a doctor orders a knee MRI, patient has it done at a hospital closer to home, ordering doctor interprets the test in their office.

Some same zip code, same fee schedule - CMS gets what they need if the address on the 1500 is the hospital where the MRI was performed.

There's other nuances and allowances for this of course. But I know a lot of people will spend all day at their clinic and then catch up on work at night, including offline review.

If Ron and friends are correct, they're opening up the dumbest version of Pandora's Box they possibly could.

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[sirspamalot]

They are no longer flat out saying general supervision for IGRT is wrong, they're saying that you need to bill the professional component using the address where the service was provided.

Where something is "billed from" and where something is done is not the same thing. Nobody knows nothing until qui tam, and even then, its never been tested post 2020.

And, since PC IGRT is minimal, it would take quite a lot of effort to create enough $ to make it worth the trouble to set aside litigation when there is much lower hanging big juicy fruit on the tree. As in 5 days a week a guy does IGRT from the Bahamas while an NP runs the practice.

Hmmm.. smells like BO in here..

 

[RickyScott]

Our MRI and CTs are often read from a different location than where they were performed and often the radiologist is working from home. This is the norm at most hospitals.

 

[BobbyHeenan]

There's other nuances and allowances for this of course. But I know a lot of people will spend all day at their clinic and then catch up on work at night, including offline review.

If Ron and friends are correct, they're opening up the dumbest version of Pandora's Box they possibly could.

I do this quite a bit. I would miss so many kid soccer games, dance, practice etc when I need to leave at 4:00 but still have images to review or plans to sign or contours to do. QoL for me would absolutely TANK.

Being able to do a little work late at night or in down times on weekends from home is a necessity for me.

 

[sirspamalot]

"Everyone does it" - will be the defense when/if the case comes to the front of the pile.

 

[elementaryschooleconomics]

I do this quite a bit. I would miss so many kid soccer games, dance, practice etc when I need to leave at 4:00 but still have images to review or plans to sign or contours to do. QoL for me would absolutely TANK.

Being able to do a little work late at night or in down times on weekends from home is a necessity for me.

Sorry to tell you this but YOU'RE A DIRTY CRIMINAL WHO SHOULD BE HUNG BY THE ANKLES.

(we all do the exact same, good luck with this line of logic Ron)

 

[deleted1168505]

Pro-tip. If you are doing hour long consults you are doing it wrong. Plenty of time throughout the day to check images as they come up if you're not in a clinic room all day trying to explain the nuance of studies with 0.056 p-values to patients. Takes a few seconds each. Sucks leaving them all at the end of the day especially if it's some kind of compliance thing (it's not).

 

[communitydoc13]

"Everyone does it" - will be the defense when/if the case comes to the front of the pile.

That's the standard of reasonableness. It's kind of the ultimate standard in medicine.

I review from home. Not worried about it.

Telerads will get licenses in 30 states for real diagnostic studies. Docs are everywhere. Company probably has a Delaware address.

 

[TheWallnerus]

Tons of billing stuff is murky. if you're worried, post about it here, see what others are doing, and make sure you're not the outlier. Boom, I just saved you and your clinic work flow and six figures.

Around 12-15 years ago (?maybe longer than that, it's blurry to me?) one of those companies (I can't remember if it was Bogardus or *trigger warning* Cyndi Parham) told us we needed to DICTATE a unique note for every single CBCT we billed for. We couldn't just approve it in mosaiq or aria, we have to generate a unique note. Could it be auto-generated by a physics/Word document and put in the chart? No, that wasn't ideal. Well maybe they said. They STRONGLY recommended we literally dictate a note every.single.fraction.

F THAT.

Thats what my current location requires - a note is 'generated' and I have to sign it. Every. Single. Day. Its nuts.

I've never seen this before: at every other place I've worked, I simply 'checked' (e-signed) the image itself, not another page with a template report and snapshot pic.

What a waste of time. Good thing its the # lyfe and I'm not that busy.

yes, we did that for a while but eventually went back to just approving images.

Physics had written a script that auto populated everything for us to sign for each image. Insane to me.

I agree billing and coding is murky. Of course I agree.

But, like in sirspam's case, if you have a biller/coder in your department saying to do something ("do a daily CBCT note" e.g.), you must do it. There can be discussion, but their determination stands. Do not agitate them. Do not try to "prove" them wrong (beyond a certain point). And no way in hell do you do what you want if they don't want it done. It doesn't matter if you're the doctor... right and wrong flows through the department billers and coders. It does not flow through anyone else. If they are Ron believers, sorry, I feel for ya, but that's just what you got. At best, you can hope to get them replaced. But play it cool until you do.

 

[NotMattSpraker]

Around 12-15 years ago (?maybe longer than that, it's blurry to me?) one of those companies (I can't remember if it was Bogardus or *trigger warning* Cyndi Parham) told us we needed to DICTATE a unique note for every single CBCT we billed for. We couldn't just approve it in mosaiq or aria, we have to generate a unique note. Could it be auto-generated by a physics/Word document and put in the chart? No, that wasn't ideal. Well maybe they said. They STRONGLY recommended we literally dictate a note every.single.fraction.

F THAT.

Haha, we are working on automating the CTP note and one of our internal billing people floated an ominous idea at the end of a recent meeting.

“You aren’t supposed to use templates in clinical documentation”

I literally laughed out loud on the meeting then felt kind of bad. But yea, how ridiculous.

 

[sirspamalot]

These same people look the other way when you point out that Cerner/Epic/WhateverBS system you're currently using in the hospital DOES NOTHING BUT THIS and that the notes it generates are garbage.

 

[elementaryschooleconomics]

I agree billing and coding is murky. Of course I agree.

But, like in sirspam's case, if you have a biller/coder in your department saying to do something ("do a daily CBCT note" e.g.), you must do it. There can be discussion, but their determination stands. Do not agitate them. Do not try to "prove" them wrong (beyond a certain point). And no way in hell do you do what you want if they don't want it done. It doesn't matter if you're the doctor... right and wrong flows through the department billers and coders. It does not flow through anyone else. If they are Ron believers, sorry, I feel for ya, but that's just what you got. At best, you can hope to get them replaced. But play it cool until you do.

One of my absolute favorite parts of coming to my current job was the sheer ignorance around RadOnc billing.

Not only that - there was no ego around it, meaning they owned their ignorance.

I have been able to - wait for it - get everyone on the same page (my page) by showing them documentation and resources.

Can you believe it?

I almost can't. It's surreal.

Now, every other place I've ever worked or trained had super headstrong billers and coders and spit in the face of logic. That's the baseline.

This is one of the only times I've been able to watch people accept evidence-based policies. It's like capturing a unicorn.

 

[deleted1168505]

Basically. Lets throw a fit about nuances in your notes so they can bill 99205 for every consult even though half should rightfully be 99204, but then lets totally screw up a bunch of rad onc TC charges. Hospital gonna hospital.

Coding your own clinical visits is so much better.

 

[NotMattSpraker]

These same people look the other way when you point out that Cerner/Epic/WhateverBS system you're currently using in the hospital DOES NOTHING BUT THIS and that the notes it generates are garbage.

Yea we could talk for an hour how, specifically, for the clinical treatment planning note, banning a template makes no sense.

She did ultimately concede. I just said look, if there is an audit, Im happy to talk about why we use a template to describe the process that is the same for each patient based on their disease and stage, otherwise known as a standard treatment pathway.

if you have a biller/coder in your department saying to do something ("do a daily CBCT note" e.g.), you must do it. There can be discussion, but their determination stands.

I agree. Ours have been great in showing their sources and explaining why they make directives. Often leads me to be pissed at ASTRO and their codebook

 

[sirspamalot]

FASTRO?

HELL NO

F ASTRO!

 

[BobbyHeenan]

Yea we could talk for an hour how, specifically, for the clinical treatment planning note, banning a template makes no sense.

She did ultimately concede. I just said look, if there is an audit, Im happy to talk about why we use a template to describe the process that is the same for each patient based on their disease and stage, otherwise known as a standard treatment pathway.


I agree. Ours have been great in showing their sources and explaining why they make directives. Often leads me to be pissed at ASTRO and their codebook

One of the benefits of billing your own pro fees.

If the hospital wants to do stupid **** like technical fee bill a 3D plan for lung SBRT ("it's like the gamma knife, right?!?"), they can do that. This was years ago but absolutely was happening.

 

[grenz]

https://x.com/nickva1/status/1701347616204763494?s=46&t=fKzMHGgUK_jttOaYQYJXrQ

The writing is on the wall. Some kind of case based reimbursement reform is needed

 

[BobbyHeenan]

https://x.com/nickva1/status/1701347616204763494?s=46&t=fKzMHGgUK_jttOaYQYJXrQ

The writing is on the wall. Some kind of case based reimbursement reform is needed

Get ready to see slightly worse toxicity ignored. “Comparable toxicity profile”

I’m fine with prostate SBRT, but the way we explain away slightly worse toxicity to get to less fractions is always something to see.

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Aside - the Dr Bekta podcast on ROCR is great. Quick like 20-30 minute listen with fantastic takes from someone that understands challenges out in the community.

 

[deleted1111261]

Get ready to see slightly worse toxicity ignored. “Comparable toxicity profile”

I’m fine with prostate SBRT, but the way we explain away slightly worse toxicity to get to less fractions is always something to see.

====

Aside - the Dr Bekta podcast on ROCR is great. Quick like 20-30 minute listen with fantastic takes from someone that understands challenges out in the community.

Agree. If more toxicity, then conventional / mod hypo should remain a standard

What about if the toxicity is the same?

 

[BobbyHeenan]

Agree. If more toxicity, then conventional / mod hypo should remain a standard

What about if the toxicity is the same?

If the same then surely it'll become a stronger option. I was just predicting it may be slightly worse.

As I recall, at 2 year results (I think cumulative toxicity of Grade 2 or worse GU was 19.8% in standard/hypofrac, 32.3% in SBRT arm at 2 years, p=0.0001) there is worse toxicity. Maybe at 5 they level out. We'll see.

 

[communitydoc13]

What about if the toxicity is the same?

It's always a tough thing to study. For higher grade toxicity (like airplane crashes) you need to look at the raw data.

 

[deleted1111261]

We are so fooked

 

[Ray D. Ayshun]

We've already accepted as a field that 5 fraction whole breast is equally toxic despite the trial showing the opposite. That was also published in the lancet. This isn't exactly a shock.

 

[BobbyHeenan]

We've already accepted as a field that 5 fraction whole breast is equally toxic despite the trial showing the opposite. That was also published in the lancet. This isn't exactly a shock.

I offer that to elderly patients but if any hint of a cosmetic concern from patient I'm still 15-16 fractions. It does not sit right to me that just 1 more Gy in the Rx changes the cosmesis. Heck, if you just sign a slightly hotter plan that could be the same as 1 more Gy (27/5) that had worse cosmesis on that trial.

 

[thecarbonionangle]

Would it be a plenary if the results are going to be spun as SBRT is more toxic? Could happen but doubtful. It will probably be 5 fraction prostate is SOC and media will run with it. Your 20 fx prostate will be seen as “greedy”

 

[Ray D. Ayshun]

I offer that to elderly patients but if any hint of a cosmetic concern from patient I'm still 15-16 fractions. It does not sit right to me that just 1 more Gy in the Rx changes the cosmesis. Heck, if you just sign a slightly hotter plan that could be the same as 1 more Gy (27/5) that had worse cosmesis on that trial.

"Across all clinician assessments from 1–5 years, odds ratios versus 40 Gy in 15 fractions were 1·55 (95% CI 1·32 to 1·83, p<0·0001) for 27 Gy in five fractions and 1·12 (0·94 to 1·34, p=0·20) for 26 Gy in five fractions." Even 26/5 was numerically more toxic in a trial not powered to eval toxicity.

 

[thesauce]

Get ready to see slightly worse toxicity ignored. “Comparable toxicity profile”

Literally there can be 10 times more toxicity compared with standard frac and the authors will say that it is “well tolerated.”

 

[BobbyHeenan]

Would it be a plenary if the results are going to be spun as SBRT is more toxic? Could happen but doubtful. It will probably be 5 fraction prostate is SOC and media will run with it. Your 20 fx prostate will be seen as “greedy”

You're probably right but hte ASTRO plenaries have been progressively less impactful studies as compared to 10 years ago. THe game changers seem to get presented at ASCO or somewhere else now.

 

[taserlaser]

Literally there can be 10 times more toxicity compared with standard frac and the authors will say that it is “well tolerated.”

Digging this up from the archives