Effective Aug. 23, 2025, intensity modulated radiation therapy (IMRT) will be added to the scope of our Post Payment Complex/Clinical Audit (PPCCA) program, supported by our vendor, Performant Recovery, Inc. (Performant).
The PPCCA program already includes several outpatient and professional services and impacts all plan types.
What do you need to do?
We ask that you respond to medical record requests from Performant in a timely manner.
What's included in Performant's review?
IMRT coding reviews align with our Radiation oncology billing policy and focus on the evaluation of coding and documentation of medical procedures and diagnoses, including:
Review of facility and professional claims
Review of medical records and corresponding codes to verify accuracy
Validation that documentation supports the codes assigned
Identification of medical coding errors or discrepancies that result in incorrect payments
Note: coding reviews don’t evaluate medical necessity.
These reviews are based on national coding conventions as defined by:
American Society for Radiation Oncology (ASTRO)
American Medical Association (AMA) Current Procedural Terminology (CPT®)
Centers for Medicare and Medicaid Services (CMS) National Correct Coding Initiative (NCCI) Policy Manual