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.