Skip to main content

How to prepare: Radiation Oncology Model billing guidelines

Commonly asked questions about the Medicare Radiation Oncology Model billing guidelines

What are the billing guidelines for the Radiation Oncology Model?

RO Model participants must submit claims under the existing Medicare claims system according to the RO Model billing instructions described in the CMS final rule. In addition, RO participants must submit “no-pay” claims for all radiation therapy services furnished in the episode.

What are the approved cancer types?

The RO Model covers 15 cancer types. These cancer types are commonly treated with radiation therapy under nationally recognized, evidence-based guidelines and are associated with ICD-10 codes that have demonstrated pricing stability.

What are the approved modalities of treatment?

Modalities covered under the RO Model include three-dimensional conformal radiotherapy, intensity-modulated radiotherapy, stereotactic radiosurgery, stereotactic body radiotherapy, proton beam therapy and image-guided radiation therapy.

What services are not covered?

Services not covered include initial consultation, experimental and low volume treatments, general imaging not related to radiation prep, radiation therapy furnished in any setting other than a hospital outpatient department or freestanding radiation therapy center, radiopharmaceuticals, intraoperative radiation therapy and brachytherapy services. These services should be billed as fee for service.

What is the billing process?

RO Model episodes will initiate on the day of the beneficiary’s initial treatment planning service. The beneficiary must receive technical radiation therapy services within 28 days of the initial treatment planning service for the episode to trigger.

RO Model participants must generate start of episode claims when the episode initiates and end of episode claims within 89 days after the initial treatment planning service. These claims are separate for the professional and technical components of the episode and will be specific to the included cancer type targeted by the radiation therapy services.

What are the new required billing codes?

RO Model participants should use RO Model-specific HCPCS codes when billing for the professional and technical components of RO Model episodes. The V1 modifier code should be used to indicate the start of an episode and the V2 modifier code should be used to indicate the end of an episode.

Need help with preparing for the Radiation Oncology Model?

Watch our webinar, Are you ready for the NEW Radiation Oncology Model?, to hear from healthcare data analytics and policy experts on what your practice needs to know and how to prepare for this new alternative payment model.


Popular posts from this blog

BPCI Advanced – take advantage of the model extension now

The Bundled Payment for Care Improvement (BPCI) Advanced Model is now open for applications until May 31, 2023. This model provides a unique opportunity to acute care hospitals and physician group practices who are looking to: evaluate their bundle performance; rejoin if they have previously dropped out due to being under a convener; or take advantage of the changes to the model. With a small window to sign the participation agreement, you’ll need experts to process data quickly and accurately for evaluation. BPCI Advanced Program Details The Centers for Medicare & Medicaid Services (CMS) announced in October 2022 that this program will extend from January 2024 to December 2025. Data used for evaluation will be taken from the baseline period between October 2018 and September 2022. A participation agreement will be sent out in September 2023 and needs to be signed by October 2023 in order to participate. Those who apply before the May 31 deadline will benefit

You’ve been accepted to the Enhancing Oncology Model. Now what?

The Centers for Medicare and Medicaid Services Innovation Center recently announced approved applicants for the new Enhancing Oncology Model. If your facility has been selected by CMS, are you still weighing your options during the current baseline evaluation period?  Two deciding factors may include the program data that CMS provides and whether EOM is enough of an improvement over the prior Oncology Care Model to make your investment worthwhile. Another factor to consider: Will you have the resources in place to conduct a baseline evaluation before EOM’s program start on July 1, 2023? How EOM differs from OCM EOM aims to improve the coordination of oncology care, drive practice transformation and reduce Medicare fee-for-service spending through episode-based payment. It includes three major updates: Fewer cancer types. Compared with OCM’s 21, EOM will be limited to seven common cancer types: breast, prostate, lung, small intestine/colorectal, multiple myeloma, lymphoma and chronic le

3 Major Areas to Focus on After Receiving NCQA PCMH Recognition

First off, congratulations to you and your practice for achieving National Committee for Quality Assurance Patient-Centered Medical Home recognition! Gaining NCQA PCMH status is a big accomplishment for which you should be very proud. Now that you’ve completed the necessary steps to implement changes and earn recognition, you may be wondering what’s next. In this guide, we’ll navigate what to do next, PCMH standards and guidelines to follow and 2024 annual reporting requirements to focus on. Let’s get into it! What to do after earning NCQA PCMH recognition Before you’re ready to start earning the great benefits of PCMH recognition , you need to plan what actions you’ll take to maintain your status. Remember, PCMH is not a project, but a continual progression of the way care is delivered to patients, meeting them where they are. So, if you’re a practice that wishes to keep its PCMH, you’ll need to be accountable for each criterion you achieved when initially receiving PCMH recognition.