Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/masshealth MassHealth Radiation Oncology Center Bulletin 1 June 2009 TO: Radiation Oncology Centers Eligible to Participate in MassHealth FROM: Tom Dehner, Medicaid Director RE: New MassHealth Provider Type Background MassHealth has established a new radiation oncology center (ROC) provider type to recognize facilities that provide radiation oncology services effective with dates of service on or after August 1, 2009. Providers who wish to enroll as a ROC must meet the following eligibility criteria and must contact MassHealth Customer Service to request an enrollment package for clinic providers. Eligibility Criteria To be eligible to participate as a MassHealth ROC provider, the facility must meet the following requirements: 1. be located and doing business in the Commonwealth of Massachusetts or meet the requirements of 130 CMR 450.109; 2. operate under a clinic license issued by the Massachusetts Department of Public Health (DPH), in accordance with DPH regulations at 105 CMR 140.000. (Providers that are operating as a satellite location under a Massachusetts DPH hospital license, or otherwise have medicare provider-based status under 42 CFR 413.65 do not meet this requirement.); 3. obtain a current determination of need or acceptable substitute, such as a physician’s exemption letter issued by DPH, to provide radiation therapy services; 4. employ to perform, oversee and/or direct all care at the center, one or more supervising physicians currently licensed by the Commonwealth of Massachusetts as a radiation oncologist, nuclear medicine provider, or radiologist; 5. ensure non-physician technicians providing services are licensed by the Commonwealth of Massachusetts to perform such services in accordance with DPH regulations at 105 CMR 120.000; and 6. participate in the Medicare program as a radiation therapy provider. Physician Supervision Radiation oncology centers must provide the appropriate level of physician supervision for each procedure in accordance with Medicare requirements of 42 CFR 410.323(b)(3). (continued on next page) Provider Enrollment Providers who wish to participate as a MassHealth ROC must complete a clinic provider application. Applicants should contact MassHealth Customer Service at 1-800-841-2900 or providersupport@mahealth.net to request an enrollment application package or additional information about the MassHealth enrollment process. Accreditation Radiation oncology centers are strongly encouraged to obtain accreditation from a nationally recognized review board to perform radiation oncology services such as the American College of Radiation Oncology or the American College of Radiology. Although accreditation is not currently a prerequisite of enrollment, MassHealth may require accreditation in the future. Radiation Oncology The following services are payable for ROC providers for dates of service Center Service Codes on or after August 1, 2009. MassHealth pays for the services listed below, in effect at the time of service subject to all conditions and limitations in MassHealth regulations at 130 CMR 450.000. A provider may request prior authorization for any medically necessary service reimbursable under the federal Medicaid Act in accordance with 130 CMR 450.144, 42 U.S.C. 1396d(a), and 42 U.S.C. 1396d(r)(5) for a MassHealth Standard or CommonHealth member younger than 21 years of age, even if it is not designated as covered or payable in the list below. Service Service Code Description 77261 Therapeutic radiology treatment planning; simple 77262 intermediate 77263 complex 77280 Therapeutic radiology simulation-aided field setting; simple 77285 intermediate 77290 complex 77295 3-dimensional 77299 Unlisted procedure, therapeutic radiology clinical treatment planning 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 plan, including dose-volume histograms for target and critical structure partial tolerance specifications 77305 Teletherapy, isodose plan (whether hand or computer calculated); simple (1 or 2 parallel opposed unmodified ports directed to a single area of interest) 77310 intermediate (3 or more treatment ports directed to a single area of interest) (continued on next page) Radiation Oncology Service Service Center Service Codes Code Description (cont.) 77315 complex (mantle or inverted Y, tangential ports, the use of wedges, compensators, complex blocking, rotational beam, or special beam considerations 77321 Special teletherapy port plan, particles, hemibody, total body 77326 Brachytherapy isodose plan; simple (calculation made from single plane, 1 to 4 sources/ribbon application, remote after loading brachytherapy, 1 to 8 sources) 77327 intermediate (multiplane dosage calculations, application involving 5 to 10 sources/ribbons used, remote afterloading brachytherapy, 9 to12 sources) 77328 complex (multiplane isodose plan, volume implant calculations, over 10 sources/ribbons used, special spatial reconstruction, remote afterloading bracytherapy, over 12 sources) 77331 Special dosimetry (e.g., TLD, microdosimetry) (specify), only when prescribed by the treating physician 77332 Treatment devices, design and construction; simple (simple block, simple bolus) 77333 intermediate (multiple blocks, stents, bite blocks, special bolus) 77334 complex (irregular blocks, special shields, compensators, wedges, molds or casts) 77336 Continuing medical physics consultation, including assessment of treatment parameters, quality assurance of dose delivery, and review of patient treatment documentation in support of the radiation oncologist, reported per week of therapy 77370 Special medical radiation physics consultation 77371 Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based 77372 linear accelerator based 77373 Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions 77399 Unlisted procedure, medical radiation physics, dosimetry and treatment devices, and special services (I.C.) 77401 Radiation treatment delivery, superficial and/or ortho voltage 77402 Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks; up to 5 MeV 77403 6-10 MeV 77404 11-19 MeV 77406 20 MeV or greater 77407 Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks; up to 5 MeV 77408 6-10 MeV 77409 11-19 MeV 77411 20 MeV or greater (continued on next page) Radiation Oncology Service Service Center Service Codes Code Description (cont.) 77412 Radiation treatment delivery, 3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; up to 5 MeV 77413 6-10 MeV 77414 11-19 MeV 77416 20 MeV or greater 77417 Therapeutic radiology port film(s) 77418 Intensity modulated treatment delivery, single or multiple fields/arcs, via narrow spatially and temporally modulated beams, binary, dynamic MLC, per treatment session 77421 Stereoscopic X-ray guidance for localization of target volume for the delivery of radiation therapy 77422 High energy neutron radiation treatment delivery; single treatment area using a single port or parallel-opposed ports with no blocks or simple blocking 77423 1 or more isocenter(s) with coplanar or non-coplanar geometry with blocking and/or wedge, and/or compensator(s) 77427 Radiation treatment management, 5 treatments 77431 Radiation therapy management with complete course of therapy consisting of 1 or 2 fractions only 77432 Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session) 77435 Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions 77470 Special treatment procedure (e.g., total body irradiation, hemibody radiation, per oral, endocavitary or intraoperative cone irradiation) 77499 Unlisted procedure, therapeutic radiology treatment management (I.C.) 77600 Hyperthermia, externally generated; superficial (i.e., heating to a depth of 4 cm or less) 77605 deep (i.e., heating to depths greater than 4 cm) 77610 Hyperthermia generated by interstitial probe(s); 5 or fewer interstitial applicators 77615 more than 5 interstitial applicators 77620 Hyperthermia generated by intracavitary probe(s) 77750 Infusion or instillation of radioelement solution (includes 3 month follow-up care) 77761 Intracavitary radiation source application; simple 77762 intermediate 77763 complex 77776 Interstitial radiation source application; simple 77777 intermediate 77778 complex 77785 Remote afterloading high dose rate radionuclide brachytherapy; 1 channel 77786 2-12 channels 77787 over 12 channels (continued on next page) Radiation Oncology Service Service Center Service Codes Code Description (cont.) 77789 Surface application of radiation source 77799 Unlisted procedure, clinical brachytherapy 99241 Office consultation for a new or established patient, which requires these 3 key components: * A problem focused history; * A problem focused examination; and * Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 15 minutes face-to-face with the patient and/or family 99242 Office consultation for a new or established patient, which requires these 3 key components: * An expanded problem-focused history; * An expanded problem-focused examination; and * Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family 99243 Office consultation for a new or established patient, which requires these 3 key components: * A detailed history; * A detailed examination; and * Medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family. 99244 Office consultation for a new or established patient, which requires these 3 key components: * A comprehensive history; * A comprehensive examination; and * Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 60 minutes face-to-face with the patient and/or family. (continued on next page) Radiation Oncology Service Service Center Service Codes Code Description (cont.) 99245 Office consultation for a new or established patient, which requires these 3 key components: * A comprehensive history; * A comprehensive examination; and * Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 80 minutes face-to-face with the patient and/or family. Member Eligibility Providers are responsible for verifying their patients’ MassHealth eligibility before delivering services. Providers must also ensure that the services provided are covered under their patients’ MassHealth coverage type before service delivery. Information relating to member eligibility checks and coverage types is available on the MassHealth Web site at www.mass.gov/masshealth. Click on Information for MassHealth Providers. Billing Instructions A copy of this bulletin, MassHealth companion guides for electronic transactions, and paper claim billing guides are all available on the MassHealth Web site at www.mass.gov/masshealth. Click on the link to MassHealth Regulations and Other Publications, and then on Provider Library. Recordkeeping The ROC is responsible for ensuring the medical necessity of the services it provides and maintaining the respective results in the member’s medical record. A medical-record system promoting quality and confidential member care must be maintained in accordance with Massachusetts DPH regulations at 105 CMR 140.000 in addition to MassHealth regulations at 130 CMR 450.205. The system must collect and retain data in a comprehensive and efficient manner permitting the prompt retrieval of information. Accurate and complete medical records must be maintained for each member receiving services from the center. The data maintained in the member’s medical record must also be sufficient to justify any further diagnostic or treatment procedures. The medical record must be clear and legible, and readily accessible to health-care practitioners, MassHealth, and the Massachusetts Medicaid Fraud Control Unit. The center must maintain a medical record for each member for a period of at least as long as the minimum period required by 130 CMR 450.205(F), or any successor regulation. (continued on next page) Recordkeeping The medical record must, at a minimum, include the following information: (cont.) 1. the member’s name, address, telephone number, date of birth, and MassHealth identification number; 2 the date of service; 3 the name, title, and signature of the referring clinician; 4 a written order for the tests and/or treatment to be performed; 5 the name, title, and signature of the person performing the service; 6 the name of the supervising physician; 7 pertinent findings on examination; and 8 the tests and treatment performed and the respective results. Fee Schedule The fees for the services listed above are available in the Division of Health Care Finance and Policy regulations for medicine (114.3 CMR 17.00) and radiology services (144.3 CMR 18.00). If you wish to obtain a fee schedule, you may download the Division of Health Care Finance and Policy (DHCFP) regulations for free at www.mass.gov/dhcfp. You may also purchase a paper copy of the regulations from either the Massachusetts State Bookstore or from DHCFP (see addresses and telephone numbers below). You must contact them first to find out the price of the publication. Massachusetts State Bookstore Division of Health Care Finance State House, Room 116 and Policy Boston, MA 02133 Two Boylston Street Telephone: 617-727-2834 Boston, MA 02116 www.mass.gov/cer/spr Telephone: 617-988-3100 www.mass.gov/dhcfp Questions If you have any questions about the information in this bulletin, please contact MassHealth Customer Service at 1-800-841-2900, e-mail your inquiry to providersupport@mahealth.net, or fax your inquiry to 617-988-8974. MassHealth Radiation Oncology Center Bulletin 1 June 2009 Page 7