ASTRO’s Supervision Work Group, which included volunteers from academic and private practices, rural and urban settings, and with diverse practice patterns and perspectives, was created to inform ASTRO’s position in response to changes to the Centers for Medicare and Medicaid Services’ (CMS) supervision policies. It met throughout May and June and submitted its recommendations to the ASTRO Board of Directors for consideration at its June Meeting.

The following recommendations were approved by the Board on June 28.

Note: The Medicare Physician Fee Schedule proposed rule is expected to be released around July 4 and may address supervision. ASTRO will analyze any proposed policies associated with supervision and utilize the Work Group’s recommendations to inform ASTRO’s comments to the Agency.

Recommendation for Supervision for Radiation Therapy Services

The work group acknowledges the need for:

1. Direct supervision or more personal involvement by a radiation oncologist of selected therapeutic services, including simulations, stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT).
2. Physical presence of the radiation oncologist at procedures using radioactive materials, including brachytherapy and Gamma Knife stereotactic therapy, as required by the Nuclear Regulatory Commission.
3. Personal performance of radiation treatment management professional services by a radiation oncologist.

However, the work group unanimously recommends that general supervision be the standard for other radiation therapy procedures, including routine linear accelerator treatments and all forms of image guided radiation therapy (IGRT). In the instance where the level of supervision and/or physical presence required for the procedure cannot be met, the respective code should not be billed.

These recommendations are intended to serve as minimum requirements, and practices and accrediting bodies may set requirements that exceed these recommendations. Radiation oncology practices should have a clear protocol for situations where the radiation oncologist's immediate presence is required during a procedure typically overseen with general supervision.

Meeting direct supervision requirements is one of the most challenging problems faced by rural and small radiation oncology practices across the country, and there is little evidence of benefit to the patient. Onerous direct supervision requirements have resulted in access to care issues for patients living in remote areas. Adopting general supervision for those procedures that do not require face-to-face interaction between the patient and the radiation oncologist strikes a balance between patient safety and the practicality of supervision requirements in real-world practice settings. Additionally, the application of general supervision policies will make radiation therapy more accessible to remote patient populations.

Recommendation for Telehealth Flexibilities for 77427, Radiation Treatment Management

The work group also provided a recommendation for whether CPT Code 77427, Radiation treatment management 5 treatments, should remain on the Medicare Telehealth List after COVID-19 PHE flexibilities expire at the end of 2024.

The work group determined and the Board approved that, at a minimum, the on-treatment visit (OTV) component of radiation treatment management for radiation oncology patients (CPT Code 77427) must be conducted in person by a radiation oncologist. All other aspects of weekly management may be done remotely. In the instance when the radiation oncologist cannot be on site to provide an in-person OTV, the work group recommends not billing the management code. This protects patients, the involved practices and the specialty.

In addition to the physical examination, radiation treatment management encompasses reviewing treatment plans, port films and other technical aspects requiring the specialized knowledge of a radiation oncologist. In-person radiation treatment management by a radiation oncologist allows for the following benefits:

• Comprehensive Physical Examinations: In-person visits enable thorough physical examinations, which are crucial for effective treatment planning and monitoring.
• Enhanced Quality of Care: Face-to-face interaction fosters stronger patient-provider relationships and facilitates a holistic approach to care in which patient concerns are effectively addressed.
• Patient Safety: In-person observation allows for prompt identification and mitigation of potential complications arising from treatment.
• Streamlined Care Coordination: In-person visits are essential for seamless coordination of care, especially when multiple specialists are involved.

By prioritizing in-person treatment management without exceptions, we can ensure the highest standard of care, patient safety and effective utilization of health care resources.