Study shows nearly 10% improper payment rate for radiation oncology

Radiation oncology services billed to CMS had a 9.6% improper payment rate in 2015, leading to Medicare improperly paying $137 million for these services, according to a study reported in the January 2016 Medicare Quarterly Compliance Newsletter.

Radiation therapy is used to treat many types of tumors, may shrink tumors before a patient has surgery, may be used on tumors that cannot be removed with surgery or can relieve symptoms caused by tumors, according to the newsletter. HCPCS codes reviewed for the study included:

• 77300, basic radiation dosimetry calculation, central axis depth dose calculation, TDF, NSD, gap calculation, off-axis factor, tissue inhomogeneity factors, calculation of non-ionizing radiation surface and depth dose, as required during course of treatment, only when prescribed by the treating physician
• 77301, intensity modulated radiotherapy (IMRT) plan, including dose-volume histograms for target and critical structure partial tolerance specifications

Code 77301 requires a computerized plan developed by the physician, medical physicist, and dosimetrist and is required for the delivery of IMRT, according to CMS. One of the leading causes of improper payment for these services was lack of documentation, including the radiation therapy plan. Other items missing from the medical record included:

• A physician’s signature
• A signature log or attestation for an illegible signature
• The correct date of service
• The documentation submitted did not adequately describe the service defined by the HCPCS code

For more information, see the Medicare Claims Processing Manual or read the Medicare Quarterly Compliance Newsletter for an example and more CMS resources.