Don’t Get Burned: Prepare for Superficial Radiation Therapy Claims
With each passing year, the number of individuals diagnosed with skin cancer continues to escalate at an alarming rate. According to available estimates, approximately 5.4 million individuals are diagnosed with basal cell (BCC) or squamous cell (SCC) skin cancers annually, which gravely impacts the lives of around 3.3 million Americans. It is widely recognized that excessive sun exposure is a primary factor responsible for the development of these skin cancers, which are the most prevalent forms of skin cancer. Although basal and squamous cell skin cancers often do not result in fatalities, except in conditions of detection being too late, the precise rate of occurrence and number of deaths are not explicitly known. Notably, cancer registries have not been keeping track of these specific cancer types, as affirmed by the American Cancer Society.
These types of skin cancer are easily diagnosed and treated. To diagnose skin cancer a physician, usually, a dermatologist, will take a biopsy of the lesion(s) and send it to the pathology laboratory for a definitive diagnosis.
Treatment options vary but the most common is excision of the abnormal tissue, more commonly known as Mohs surgery, which is a topic we covered in our November 2021 alert. This alert will be focused on a new trend in some of our client’s data, Superficial Radiation Therapy (SRT), performed in the office setting, administered, and billed by Dermatologists.
Procedure codes for SRT
Table 1 contains the four procedure codes billed together frequently and the most frequent combination occurred with CPT codes 77401, 77280, and HCPCS code G6001. For the full list of codes please refer to your CPT (Current Procedural Terminology) Manual and/or policy.
Table 1. CPT/HCPCS codes for Superficial Radiation Therapy procedures
|77401||Radiation treatment delivery, superficial and/or ortho voltage, per day|
|G6001||Ultrasonic guidance for placement of radiation therapy fields|
|77280||Therapeutic radiology simulation-aided field setting; simple|
|77427||Radiation treatment management, 5 treatments|
The American Academy of Dermatology published that “based on current evidence, surgical management remains the most effective treatment of BCC and SCC, providing the highest cure rates. The Academy supports consideration of superficial radiation therapy as a secondary option for the BCC and SCC, for use in special circumstances, such as when surgical intervention is contraindicated or refused and after the benefits and risks of treatment alternatives have been discussed with the patient.”
“Further, the utilization of CPT codes related to superficial radiation therapy has been rapidly increasing. The Academy is concerned that a continued rapid increase in utilization of this service has drawn scrutiny from private payers, federal agencies, including the Centers for Medicare and Medicaid Services (CMS), Members of Congress, and federal watchdogs.”
“As a consequence of increased utilization of superficial radiation therapy, the CPT Editorial Panel has revised the codes and definitions for superficial radiation therapies, disallowing the use of a number of other codes in conjunction with the radiation therapy codes. Some Medicare contractors have responded to utilization increases by proposing restrictive Local Coverage Determinations (LCDs). Further CPT code revisions as well as coverage restrictions by insurers may be forthcoming.”
The American Academy of Dermatology also had this notation on their website under the title of Basic Cell Carcinoma (BCC) Diagnosis and Treatment.
“Radiation treatments: If this is prescribed to treat basal cell carcinoma, you will need to go to a hospital or treatment center for radiation treatments. These are usually given over several weeks. For some patients, radiation may be the only treatment given. Radiation can also be used as a follow-up treatment for an aggressive basal cell carcinoma to help destroy cancer cells. Radiation is typically only used to treat this skin cancer in people who are 60 years of age or older.”
According to the CMS, payment for SRT is limited to services furnished in the office (POS 11), inpatient hospital (POS 21), and outpatient hospital (POS 22). A freestanding radiation oncology center is considered, for billing purposes, an office.
Given the rise in SRT claims, many of which occur in the office setting, Codoxo recommends payers review their policies to confirm the allowable procedure codes and code combinations, the appropriate place of service for the SRT procedures, and other guidelines that would affect payments.
How can Fraud Scope identify SRT procedures and provider of interest?
We recommend Codoxo users start their review in Schemes (Professional, Rendering) to identify the detectors and providers linked to SRT procedures.
- Add “dermatology” into the search bar for the Top Specialties widget, click Search, then highlight the specialty row, and click the Codes button.
- Click on the drop-down under the Code column, add this code string to the Search bar, 77401 OR G6001 OR 77280 OR 77427, and click Apply.
- When the results return, click the selection box to the left of each code and then select Providers on the right to view a list of rendering providers with AI detector results associated with SRT procedures.
- If your plan allows dermatologists to submit procedures for SRT that are different from those provided in Table 1, please add the codes applicable to your plan policies.
- American Academy of Dermatology Position Statement on Superficial Radiation Therapy
- American Academy of Dermatology- Basal Cell Carcinoma (BCC) Diagnosis and Treatment
- CMS LCD-L34652