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The irony is it’s a virtual direct town hall.I love that ASTRO is so scummy that they have re-defined the term town hall in their own image.
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The irony is it’s a virtual direct town hall.I love that ASTRO is so scummy that they have re-defined the term town hall in their own image.
Academic radoncs really should be doing academic stuff. There has always been a relatively small minority of academic docs who were essentially clinical only...and liked it, but this was not the bill of goods we were sold when applying 10-20 years ago. In my limited experience at a couple institutions, the clinical docs were clearly not perceived as equivalent to the docs doing research.I guess I'd just say there are important parallels in our field, and a lot of academic radiation oncologists reach out to tell me they feel over worked/under paid/not on mission.
ROhub is getting interesting!
"ASTRO has rightly been shamed for their preposterous February 26th letter to CMS. Their attempts at mea culpa will fail unless they admit they were wrong and actively support rational, reasonable supervision requirements. #NoBabysitting"
There is no good data from basically anything involving the pandemic. Just emotions, politics, and pearl clutching. This is no different.Is there data showing that the virtual supervision during the pandemic resulted in greater incidents as compared to pre-pandemic? In my opinion, requiring direct supervision for routine treatments (non-SBRT, non-SRS, non-HDR) is not necessary as we and many others have demonstrated with virtual supervision during the pandemic.
love the rest of that line..... probably what will happen to ASTRO finances after membership reacts to all of thisThe only advice I can offer ASTRO at this time is best delivered by Ice Cube.
LOL, good luck with that. Even if you have an ASTRO membership you would probably have an easier time finding the CIA intranet than that abomination of a message board.who has a link to ROHUB and can I read it even though im not a member?
My ASTRO membership JUST expired. So sad, just in time for me to miss out on all the fireworksIs this what it took for our specialty to grow some balls?
Either way I'm here for it and appreciate
Wonder if my ASTRO membership has lapsed already or if I can go on ROhub for a few more days...
And a commitment to include the interest of small community rad oncs in their mission.
I can't tell if our leaders are just that stupid or that arrogant?
There is no path forward for JM. Resignation in shame and going away is the only solution. People will take their rightful anger out on him for his stupid letter but also for all the blood bath washu stuff. i agree dude is more toasted than the grill at waffle house. This is a deeply unserious person.
Grab your popcorn and pitchfork.i call for a vote of no confidence!
wish sir spam was here to see thisI think Michalski is toast. Guy will go down like William Henry Harrison. Like a fool in the cold.
Some say that each year, if you go outside near midnight on the winter solstice to look up at the stars, if you're really lucky and happen to be standing in some ultra-rural location, 200 miles from the nearest Walmart, you can hear the faint echo of what sounds like a scream...wish sir spam was here to see this
Rumor is sir spam, KHE, and scarb went in partners and started a life insurance company in Stevens Point, WisconsinSome say that each year, if you go outside near midnight on the winter solstice to look up at the stars, if you're really lucky and happen to be standing in some ultra-rural location, 200 miles from the nearest Walmart, you can hear the faint echo of what sounds like a scream...
"750 or GTFO"
Every time someone speaks ill of jm, a single seat prop plane gets its wings.Some say that each year, if you go outside near midnight on the winter solstice to look up at the stars, if you're really lucky and happen to be standing in some ultra-rural location, 200 miles from the nearest Walmart, you can hear the faint echo of what sounds like a scream...
"750 or GTFO"
He went a little off the rails in the sociopolitical part of SDN.What happened to spam?
i have heard some stories from residents that trained thereEvery time someone speaks ill of jm, a single seat prop plane gets its wings.
Supervision Policy Discussion is still up and active on ROHUB, now with 30 responses.LOL, good luck with that. Even if you have an ASTRO membership you would probably have an easier time finding the CIA intranet than that abomination of a message board.
Is anyone commenting in favor of what Astro did? Is Astro trying to defend themselves at all? Is this just another fake gesture by Astro?Supervision Policy Discussion is still up and active on ROHUB, now with 30 responses.
I wouldn't be shocked if it's because the staffer that knew the admin account login information rage quit last year and ASTRO just realized they never had anyone write it down.Supervision Policy Discussion is still up and active on ROHUB, now with 30 responses.
This feels right (and gross…)I believe I saw on linked in one of the attendings of NY proton as “co-founder” of Bridge
Just looked again i was correct, Dr. AC. I picture a future where they win that virtual suppervision lawsuit then can funnel tons of patients to get protons in the surrounding areas. This is the way.This feels right (and gross…)
Of course this is the way it’s going to play out. Very reasonable allowances via general supervision for rural hospitals to have a single rad onc on site 3-4 days a week are going to be blown up by vultures like Jordan johnson trying to get a cut as a middleman having a rad onc there twice a month.
Ridiculous
I'm not an ASTRO shill but blanket virtual supervision (seemingly advocated by many on this thread) would spell disaster for our specialty.
Now ASTRO bungled the letter and the response (to absolutely no one's surprise) but I believe allowing virtual supervision across the board for all practice settings would have an extremely detrimental impact to employment opportunities and income.
The biggest employers of RO in the modern era are hospitals either offering direct employment (community or academic) or a PSA-type arrangements. Let's say CMS decides virtual supervision is good enough... do you think your hospital will continue to offer a $60/RVU production deal on your PSA when you can be there 3 days a week instead of 5?
The argument that we should 'trust rad oncs' to decide how to manage their practice pattern is well intentioned, and I think most docs would not take advantage of this rule change. But that assumes the docs are in charge -- and we aren't. Hospital c-suites (either community or academic) would look for opportunities to 'increase efficiencies' and 'decrease overhead'...
I don't know much about Bridge Oncology <website here> but it seems their model is an APP on-site for most stuff, and the RO comes in weekly/twice monthly. Consults, follow ups, and OTVs could all be virtual. All this in exchange for a cut of the global (again, I'm not clear on the details). I've heard there is private equity money behind this guy (Jordan Johnson) and this seems like every community hospital's dream. Outsource everything, keep most of the money, worry about fewer details. The only catch is, that one doctor could be covering 2 or 3 or 4 hospitals. Great for him/her, not great for whoever is working that job now. (Also, I think it's not great for patients to mostly see APPs but that's just my own opinion and I know people who are big believers in virtual everything... just not me.)
There is a place for virtual supervision but we need to be very careful about how it's implemented...
I hate to keep bringing up facts, but much of the above glosses over some important facts.Very reasonable allowances via general supervision for rural hospitals to have a single rad onc
I can understand the concerns regarding the job market, but it's not the job of cms to protect that. As long as far more acutely toxic treatments such as chemo, dialysis. Etc do not require direct supervision and as long as serious medical illnesses continue to be managed via virtual care across the country, how can ASTRO make a legitimate clinical argument for onsite supervision of igrt or for excluding radiation management services from telehealth? Not to mention direct supervision doesn't even exist in other xrt centers across the world. Again, I understand people's concern regarding the job market, but as someone who worked in the heyday of draconian supervision rules and opportunistic therapists reporting you for going to tumor boards, I'll let JJ have his rural centers all day, every day.
We need to cut residency spots and people need to stop applying to the field. Medical students who continue to apply to this dumpster fire are, sorry, stupid. Like you people realize you're never getting a job on the coasts or any desirable market, right? You will be stuck treating patients in middle America in perpetuity....or maybe u won't have a job at all once Jordan's side wins.
There was an astro document that may still be in circulation stating general supervision in hospitals actually does not apply to igrt. 😆I hate to keep bringing up facts, but much of the above glosses over some important facts.
Most importantly, general supervision of radiation therapy (including SBRT and all the other buzz words) is permanent for hospital outpatient. This happened in 2020 and had zero to do with COVID. IGRT, which happens to be a diagnostic test, was made permanent by CMS to be (directly) supervisable by APPs in hospital outpatient departments in 2021 (and also had zero to do with COVID). Again, these two things are permanent rules. Virtual supervision is on the same tier as direct supervision, so virtual supervision would be a higher supervision than general.
We know ASTRO said "direct supervision for all sites of service." But this is a fantasy. CMS will not roll back its permanent rules because of one tiny society's protestations. CMS has never and will not ever apply direct supervision to rural hospitals.
At best, CMS might make virtual direct go away...
but this will only affect freestanding centers.
This is the most important point.I can understand the concerns regarding the job market, but it's not the job of CMS to protect that.
Yeah this was from 2019, there's a reason that argument was abandoned (notice it doesn't show up in Jeff's letter).There was an astro document that may still be in circulation stating general supervision in hospitals actually does not apply to igrt. 😆
Not to mention diagnostic devices need fda clearance as such. If a radiologist billed cms for a diagnostic report based on cbct, they would go after him for fraud.Yeah this was from 2019, there's a reason that argument was abandoned (notice it doesn't show up in Jeff's letter).
IGRT is not a diagnostic test. Just because something emits x-rays doesn't automatically make it a diagnostic test. That was the whole argument for IGRT.
Also, to those that have heard this argument from Ron - no, you do not have to be physically on site to approve IGRT either.
If that were true, the entire industry of telerads would disappear literally overnight.
Please explain. If CMS rolls backs rules to 2020 precovid, how is igrt and sbrt general in a hospital so that you don’t have to be there?I hate to keep bringing up facts, but much of the above glosses over some important facts.
Most importantly, general supervision of radiation therapy (including SBRT and all the other buzz words) is permanent for hospital outpatient. This happened in 2020 and had zero to do with COVID. IGRT, which happens to be a diagnostic test, was made permanent by CMS to be (directly) supervisable by APPs in hospital outpatient departments in 2021 (and also had zero to do with COVID). Again, these two things are permanent rules. Virtual supervision is on the same tier as direct supervision, so virtual supervision would be a higher supervision than general.
We know ASTRO said "direct supervision for all sites of service." But this is a fantasy. CMS will not roll back its permanent rules because of one tiny society's protestations. CMS has never and will not ever apply direct supervision to rural hospitals.
At best, CMS might make virtual direct go away...
but this will only affect freestanding centers.
During Covid, Ron's group was telling people they still had to be on site to check films, even though they didn't have to be there to actually supervise the IGRT portion. (They wouldn't even admit to the latter actually, but when pressed they said "probably" ok). Imagine that--you don't have to be there to oversee the procedure, but you have to be on site to check a film after the fact. The crazy thing is one could actually interpret billing rules to support that stance. Technically, if you are doing telerads you are supposed to register your home address as a site of service if you do it more than "occasionally." That's how crazy supervision had gotten prior to COVID. I can just imagine these meetings with CMS. Well-intentioned folks trying to improve access to care during a worldwide pandemic, releasing clear rules regarding supervision only to have ASTRO and Ron telling them their own rules don't actually mean what they think they mean.Yeah this was from 2019, there's a reason that argument was abandoned (notice it doesn't show up in Jeff's letter).
IGRT is not a diagnostic test. Just because something emits x-rays doesn't automatically make it a diagnostic test. That was the whole argument for IGRT.
Also, to those that have heard this argument from Ron - no, you do not have to be physically on site to approve IGRT either.
If that were true, the entire industry of telerads would disappear literally overnight.
True. (I won't debate... for now... if IGRT is actually a diagnostic test; let's just assume it is for sake of argument.)There was an astro document that may still be in circulation stating general supervision in hospitals actually does not apply to igrt. 😆
Here is my best answer on this. It is a tad convoluted, but here goes.Please explain. If CMS rolls backs rules to 2020 precovid, ?
If igrt is and always was direct then how is it ok for us to work from home and check images at the end of the day? Don’t you have to be immediately available while images are acquired?
I answered IGRT above. For SBRT, CPT 77373, the supervision level is "9" and it is a radiation therapy and it is known and a rule that radiation therapies are general supervision in a hospital. Presence may not even be necessary in a freestanding center:how is igrt and sbrt general in a hospital so that you don’t have to be there?
Too bad a couple of insiders wrote ROCR in secret.I believe the letter to CMS may be a follow-up to the January letter sent to CMS requesting the discontinuation of telehealth as an option for 77427-weekly treatment management. Perhaps ASTRO is hedging their bets in case CMS rules against them on this issue. They may see 77427 as the one code that still requires physician presence in the clinic and should be protected at all costs - as a defeat could in theory lead to a department which is largely remotely administered by a radonc any distance away.
Alternatively - and ironically -the letter’s request to reinstate direct supervision may be part of the ROCR initiative. ROCR’s case rate plan eliminates the need to bill for 77427 - weekly treatment management and the required in-person evaluation by the radiation oncologist (and only the radiation oncologist). Direct supervision fills this hole in ROCR. Ultimately, all of this is meant to “fix” the manpower issue by increasing demand for linac babysitters while reducing salaries and maintaining the current output of new graduates. It’s ludicrous solution which ignores the real issue and a ridiculous overreach by a society that has always ignored the impact of their previous dictates on small/solo practices.
Here is my best answer on this. It is a tad convoluted, but here goes.
1) Checking images is a physician professional service (-26 modifier), while the taking of images is a technical service (-TC modifier).
2) Look in the physician fee schedule to determine the supervision level of each and every CPT code: Search the Physician Fee Schedule | CMS
3) Here is what you'll find for 77014:
View attachment 384156
4) Then cross-reference this with the supervision levels from Medicare: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2018downloads/R251BP.pdf
View attachment 384157
5) You may ask what if you bill the 77014 globally, i.e. with no modifier in a freestanding setting? Freestanding has its own supervision level specifically for X-ray therapy (and diagnostic tests!) as a carve out in the Social Security Act, and it's always direct. Freestanding centers would have more gray zone issues with remote image checking, but knowing that (freestanding imaging center) radiologists do this, it is probably OK to perform the professional service... professionally/personally (don't conflate "personally" with level 3 personal supervision here... you can't personally supervise yourself!)... at any place you want. Although, again, it's a gray zone (if billing globally in freestanding).
6) HOSPITAL (probably freestanding too): So you have to be present for IGRT (level 2 supv)... or an APP may be present for IGRT (level 2 supv)... but you can check images from home (level 9 supv).
I answered IGRT above. For SBRT, CPT 77373, the supervision level is "9" and it is a radiation therapy and it is known and a rule that radiation therapies are general supervision in a hospital. Presence may not even be necessary in a freestanding center:
Second, the Court rejected the relators' reliance on the LCDs for the IMRT and SBRT therapies, because they "fail[ed] to direct the Court to any requirement in the LCDs that a radiation oncologist be present at the time of treatment." Although relators had cited a separate LCD provision that did expressly require a radiation oncologist's direct supervision of a fifth type of therapy not at issue in the case, Image Guided Radiation Therapy (IGRT), the Court declined to extend this requirement to other therapies.
Prof services are submitted on a cms 1500 form, tech services are on something called a "UB". At least in my state the employed physician prof claims are still submitted separately from the tech claims. If checking films is akin to telehealth radiology (is it?), you should technically submit the professional claims under the address of the site where u made the read. I doubt cms ever thought of making this a fraud issue esp for rad onc, though. The issue was more reimbursement-related on the teleradiology side. If someone is reading out of state, their professional services may fall under a different mac jurisdiction. This really isn't happening in rad onc. People are just looking to check images from their home a few miles from the center. Also, cms allows for some radiology reads to be done off site while not requiring you to register the location (i.e. your home) as a site of service if it's not routine. But I could never find a strict definition of "not routine." Finally, for global billing there is no way to submit separate claims but per acr policy it seems to be ok to submit from the location where the imaging was performed even if read offsite as long as both services were provided in the same general geography (i.e. same MAC).What if the hospital employees the rad onc and bills globally? Then no issue to acquire images and the physician checks them from home because he is not there that day at all and providing general supervision from off site?
I do not believe a hospital outpatient setting can bill any CPT code with professional or TC modifiers without using those modifiers. That is to say, a global billing is only available to freestanding settings. Doesn’t matter if physician is employed or does his own professional billing.What if the hospital employees the rad onc and bills globally? Then no issue to acquire images and the physician checks them from home because he is not there that day at all and providing general supervision from off site?