OIG Audits
The letter and completed appeal form, along with any evidence to support your appeal, should be sent together to the Medicare Administrative Contractor (MAC) that handles Medicare Parts A and B claims in your jurisdiction. The address for your MAC can be found on the “Medicare Summary Notice” you received listing the 77336 claims denied. More information can be found here. Before submitting your letter, be sure that all highlighted text is edited or removed. Download the form letter.
[Practice Name and Address]
Date
[Payer Name and Address]
Re: Plan ID #:
Claim #:
Dear Sir/Madam:
Enclosed, please find a completed and signed “Medicare Redetermination Request Form” appealing payment denials for CPT code 77336, Continuing Medical Physics Consultation, to the 1st level of appeal.
These denials are improper and should be reversed for a number of reasons. Claim denials of Continuing Medical Physics Consultation are occurring when billed as part of the delivery of IMRT and when billed within 30 days prior to the service date of CPT code 77301. These denials appear to stem from incorrect information in a 2018 Office of the Inspector General (OIG) audit that is contrary to Medicare Claims Processing Manual guidance effective during the applicable time period. [NOTE: Insert additional basis for overturning the denials here, if applicable.]
Timeframes for Contractor Initiated Reopenings [NOTE: Only use the following argument if the claims are more than four years old.]
Medicare regulations and guidance limit a contractor’s authority to reopen and revise an initial payment determination. A contractor may not reopen or revise an initial payment determination on its own motion after 4 years from the date of the initial determination, except (1) if there exists reliable evidence that the initial determination was procured by fraud or similar fault; (2) if the initial determination is unfavorable to the party thereto; or (3) to effectuate a decision issued under the coverage appeals process. 42 CFR § 405.980. These three exceptions do not apply here with respect to CPT code 77336 initial determinations; [INSERT CONTRACTOR NAME] is acting outside of its legal authority by reopening and revising initial determinations outside of the 4-year reopening period. Therefore, these denials should be reversed on that basis.
Medicare Claims Processing Manual
Language found in the Medicare Claims Processing Manual includes guidance regarding IMRT planning and delivery. This guidance was effective beginning January 1, 2008 through June 5, 2015and states the following:
200.3.1 - Billing for IMRT Planning and Delivery
(Rev. 1445, Issued: 02-08-08; Effective: 01-01-08; Implementation: 03-10-08)
Effective for services furnished on or after April 1, 2002, HCPCS codes G0174 (IMRT delivery) and G0178 (IMRT planning) are no longer valid codes. HCPCS code G0174 has been replaced with CPT codes 77418 and 0073T for IMRT delivery and HCPCS code G0178 with CPT code 77301. Therefore, hospitals must use CPT codes 77418 or 0073T for IMRT delivery and CPT code 77301 for IMRT planning. Any of the CPT codes 77401 through 77416 or 77418 may be reported on the same day as long as the services are furnished at separate treatment sessions. In these cases, modifier -59 must be appended to the appropriate codes. Additionally, in the context of billing 77301, regardless of the same or different dates of service, CPT codes 77014, 77280-77295, 77305-77321, 77331, 77336, and 77370 may only be billed in addition to 77301 if they are not provided as part of developing the IMRT treatment plan.
200.3.2 - Additional Billing Instructions for IMRT Planning
(Rev. 1445, Issued: 02-08-08; Effective: 01-01-08; Implementation: 03-10-08)
Payment for the services identified by CPT codes 77014, 77280-77295, 77305-77321, 77331, 77336, and 77370 is included in the APC payment for IMRT planning when these services are performed as part of developing an IMRT plan that is reported using CPT
code 77301. Under those circumstances, these codes should not be billed in addition to CPT code 77301 for IMRT planning.
Contrary to the OIG audit report, this language clearly states that it is acceptable to bill CPT code 77336 both as part of the broader course of IMRT treatment delivery and prior to the service date for CPT code 77301, so long as CPT code 77336 is not provided “as part of developing the IMRT treatment plan.”
Claims [PROVIDER: LIST APPLICABLE CLAIMS NUMBERS HERE] were either billed before or after the service date for CPT code 77301 and were not provided as part of developing an IMRT treatment plan. Therefore, any claim denials for CPT code 77336 should be reversed.
Additional Appeal Arguments
[PROVIDER: INSERT ANY ADDITIONAL ARGUMENTS SUPPORTING THE APPEAL OF 77336 CLAIMS DENIALS YOU MAY HAVE.]
The following information is provided to clarify the appropriate use of CPT code 77336, Continuing medical physics consultation, with the delivery of Intensity Modulated Radiation Therapy (IMRT).
Continuing Medical Physics Consultation
In the radiation oncology process of care, after the work of CPT code 77301 is completed, the patient begins receiving radiation treatments. During the treatment delivery phase, 77336 is appropriately used to record the work of continuing medical physics consultation, which includes the following work:
These essential actions occur once treatment delivery is underway. If this work is not performed, and appropriate modifications to the treatment regime are not instituted, the patient may be seriously harmed because of the irreversible nature of radiation treatment delivery. The patient’s health is safeguarded by the medical physicist’s analysis and involvement.
The American Society for Radiation Oncology (ASTRO) has been working with the OIG and the Centers for Medicaid and Medicare Services (CMS) for several years on issues related to billing services associated with IMRT Treatment Planning. In March 2019, ASTRO met with both the OIG and the CMS Office of Financial Management. During these meetings, ASTRO was told to inform radiation oncologists to appeal errantly denied claims containing CPT code 77336 Continuing Medical Physics and IMRT Treatment Planning.
In light of the above, I urge [Payer Name] to reverse these claim denials and remit payment for this/these claims.
Thank you for your prompt attention to this matter. Please contact [staff name] at [telephone number] in our office should you have any questions.
Sincerely,
[Physician Name]
CC: American Society for Radiation Oncology
Enclosed: [Claims]
[Payer Policy]
[Practice Name and Address]
Date
[Payer Name and Address]
Re: Plan ID #:
Claim #:
Dear Sir/Madam:
Enclosed, please find a completed and signed “Medicare Redetermination Request Form” appealing payment denials for CPT code 77336, Continuing Medical Physics Consultation, to the 1st level of appeal.
These denials are improper and should be reversed for a number of reasons. Claim denials of Continuing Medical Physics Consultation are occurring when billed as part of the delivery of IMRT and when billed within 30 days prior to the service date of CPT code 77301. These denials appear to stem from incorrect information in a 2018 Office of the Inspector General (OIG) audit that is contrary to Medicare Claims Processing Manual guidance effective during the applicable time period. [NOTE: Insert additional basis for overturning the denials here, if applicable.]
Timeframes for Contractor Initiated Reopenings [NOTE: Only use the following argument if the claims are more than four years old.]
Medicare regulations and guidance limit a contractor’s authority to reopen and revise an initial payment determination. A contractor may not reopen or revise an initial payment determination on its own motion after 4 years from the date of the initial determination, except (1) if there exists reliable evidence that the initial determination was procured by fraud or similar fault; (2) if the initial determination is unfavorable to the party thereto; or (3) to effectuate a decision issued under the coverage appeals process. 42 CFR § 405.980. These three exceptions do not apply here with respect to CPT code 77336 initial determinations; [INSERT CONTRACTOR NAME] is acting outside of its legal authority by reopening and revising initial determinations outside of the 4-year reopening period. Therefore, these denials should be reversed on that basis.
Medicare Claims Processing Manual
Language found in the Medicare Claims Processing Manual includes guidance regarding IMRT planning and delivery. This guidance was effective beginning January 1, 2008 through June 5, 2015and states the following:
200.3.1 - Billing for IMRT Planning and Delivery
(Rev. 1445, Issued: 02-08-08; Effective: 01-01-08; Implementation: 03-10-08)
Effective for services furnished on or after April 1, 2002, HCPCS codes G0174 (IMRT delivery) and G0178 (IMRT planning) are no longer valid codes. HCPCS code G0174 has been replaced with CPT codes 77418 and 0073T for IMRT delivery and HCPCS code G0178 with CPT code 77301. Therefore, hospitals must use CPT codes 77418 or 0073T for IMRT delivery and CPT code 77301 for IMRT planning. Any of the CPT codes 77401 through 77416 or 77418 may be reported on the same day as long as the services are furnished at separate treatment sessions. In these cases, modifier -59 must be appended to the appropriate codes. Additionally, in the context of billing 77301, regardless of the same or different dates of service, CPT codes 77014, 77280-77295, 77305-77321, 77331, 77336, and 77370 may only be billed in addition to 77301 if they are not provided as part of developing the IMRT treatment plan.
200.3.2 - Additional Billing Instructions for IMRT Planning
(Rev. 1445, Issued: 02-08-08; Effective: 01-01-08; Implementation: 03-10-08)
Payment for the services identified by CPT codes 77014, 77280-77295, 77305-77321, 77331, 77336, and 77370 is included in the APC payment for IMRT planning when these services are performed as part of developing an IMRT plan that is reported using CPT
code 77301. Under those circumstances, these codes should not be billed in addition to CPT code 77301 for IMRT planning.
Contrary to the OIG audit report, this language clearly states that it is acceptable to bill CPT code 77336 both as part of the broader course of IMRT treatment delivery and prior to the service date for CPT code 77301, so long as CPT code 77336 is not provided “as part of developing the IMRT treatment plan.”
Claims [PROVIDER: LIST APPLICABLE CLAIMS NUMBERS HERE] were either billed before or after the service date for CPT code 77301 and were not provided as part of developing an IMRT treatment plan. Therefore, any claim denials for CPT code 77336 should be reversed.
Additional Appeal Arguments
[PROVIDER: INSERT ANY ADDITIONAL ARGUMENTS SUPPORTING THE APPEAL OF 77336 CLAIMS DENIALS YOU MAY HAVE.]
The following information is provided to clarify the appropriate use of CPT code 77336, Continuing medical physics consultation, with the delivery of Intensity Modulated Radiation Therapy (IMRT).
Continuing Medical Physics Consultation
In the radiation oncology process of care, after the work of CPT code 77301 is completed, the patient begins receiving radiation treatments. During the treatment delivery phase, 77336 is appropriately used to record the work of continuing medical physics consultation, which includes the following work:
- Weekly chart review by the medical physicist;
- Review and analysis of medical physics aspects of changes to the treatment regime;
- Consultation on patient setup and treatment modifications;
- Verification of cumulative dose calculation data;
- Reviewing accuracy of the current data record, including review of patient-specific therapist treatment and technical notes;
- Assuring the proper operation of the delivery system for the patient; and
- Patient radiation safety.
These essential actions occur once treatment delivery is underway. If this work is not performed, and appropriate modifications to the treatment regime are not instituted, the patient may be seriously harmed because of the irreversible nature of radiation treatment delivery. The patient’s health is safeguarded by the medical physicist’s analysis and involvement.
The American Society for Radiation Oncology (ASTRO) has been working with the OIG and the Centers for Medicaid and Medicare Services (CMS) for several years on issues related to billing services associated with IMRT Treatment Planning. In March 2019, ASTRO met with both the OIG and the CMS Office of Financial Management. During these meetings, ASTRO was told to inform radiation oncologists to appeal errantly denied claims containing CPT code 77336 Continuing Medical Physics and IMRT Treatment Planning.
In light of the above, I urge [Payer Name] to reverse these claim denials and remit payment for this/these claims.
Thank you for your prompt attention to this matter. Please contact [staff name] at [telephone number] in our office should you have any questions.
Sincerely,
[Physician Name]
CC: American Society for Radiation Oncology
Enclosed: [Claims]
[Payer Policy]
