Some hospitals billed Medicare for intensity-modulated radiation therapy (IMRT) simulations that should have been included in IMRT planning, partly because a CMS edit prevented overpayments only when the services were performed on the same day and perhaps because some local coverage determinations (LCDs) are silent about the timing.

A new report from the HHS Office of Inspector General (OIG) found that hospitals across the country overbilled for as much as $25.8 million in IMRT planning services between 2013 and 2015. CMS put a stop to separate billing for simulations performed before or during the development of the IMRT plan in 2014, but apparently it has continued.

“These are complicated services and there are so many moving parts,” says Joli Fitzgibbons, a senior manager at SunStone Consulting in Harrisburg, Pennsylvania. “There are a lot of requirements from a documentation standpoint that have to be in place to bill IMRT services.” Hospitals may have been distracted from the date of service because LCDs have precise IMRT clinical and documentation requirements, although the Medicare Claims Processing Manual, which requires bundling, takes precedence. They may have to pay more attention to the date of service because an expansive edit probably is coming. The edit was recommended by OIG to prevent future payments for simulation that’s billed separately from IMRT planning, regardless of the date of service, and CMS agreed to it. “Even if an edit is in place, the charge capture process at hospitals should be reviewed and a mechanism imposed to prevent those charges from being separately reported,” says Cathy Archuleta, a manager with SunStone.