RO Model Payment
National Base Rates
CMS defines national base rates by cancer type. This is the foundation for reimbursement. These are the base rates released with the final rule.
| RO Model M-Code | Bill Type | Cancer Type | National Base Rate |
| M1072 | Professional | Anal Cancer | $3,104.11 |
| M1073 | Technical | Anal Cancer | $16,800.83 |
| M1074 | Professional | Bladder Cancer | $2,787.24 |
| M1075 | Technical | Bladder Cancer | $13,556.06 |
| M1076 | Professional | Bone Metastases | $1,446.41 |
| M1077 | Technical | Bone Metastases | $6,194.22 |
| M1078 | Professional | Brain Metastases | $1,651.56 |
| M1079 | Technical | Brain Metastases | $9,879.40 |
| M1080 | Professional | Breast Cancer | $2,059.59 |
| M1081 | Technical | Breast Cancer | $10,001.84 |
| M1084 | Professional | CNS Tumor | $2,558.46 |
| M1085 | Technical | CNS Tumor | $14,762.37 |
| M1082 | Professional | Cervical Cancer | $3,037.12 |
| M1083 | Technical | Cervical Cancer | $13,560.15 |
| M1086 | Professional | Colorectal Cancer | $2,508.30 |
| M1087 | Technical | Colorectal Cancer | $12,200.62 |
| M1088 | Professional | Head and Neck Cancer | $3,107.95 |
| M1089 | Technical | Head and Neck Cancer | $17,497.16 |
| M1094 | Professional | Lung Cancer | $2,231.40 |
| M1095 | Technical | Lung Cancer | $12,142.39 |
| M1096 | Professional | Lymphoma | $1,724.07 |
| M1097 | Technical | Lymphoma | $7,951.09 |
| M1098 | Professional | Pancreatic Cancer | $2,480.83 |
| M1099 | Technical | Pancreatic Cancer | $13,636.95 |
| M1100 | Professional | Prostate Cancer | $3,378.09 |
| M1101 | Technical | Prostate Cancer | $20,415.97 |
| M1102 | Professional | Upper GI Cancer | $2,666.79 |
| M1103 | Technical | Upper GI Cancer | $14,622.66 |
| M1104 | Professional | Uterine Cancer | $2,737.11 |
| M1105 | Technical | Uterine Cancer | $14,156.20 |
Adjustments
Base rates are then adjusted based upon various factors. Within 30 days prior to the start of each performance year, CMS will provide each RO participant with its case mix and historical experience adjustments for both the professional component and technical component. This information can be found on the Radiation Oncology Administrative Portal (ROAP). Here are adjustment types:
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Case Mix & Historical Experience Adjustments
These adjustments are to address differences in the participant’s beneficiary population and demographics. There is one professional and/or one technical. This does not vary on the basis of cancer type. RO participants with < 60 episodes in the last 3 years of data will not receive a case mix adjustment or historical experience adjustment.
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- Historical Efficiency and Payment Blend
Historical efficiency is gauged to determine payout which is a blend of the national base rate and the participant’s historical payment average for a cancer type.
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- Historically Inefficient
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This means the provider’s payments were higher than the national average. If so, the reimbursement blend will be heavily tilted towards participant’s historical average rather than the national base rate. In year one, it will be 90% historical average and 10% base rate. In year two, it will be 85% historical average and 15% national base rate. In year three, it will be 80% historical average and 20% national base rate. And so on.
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- Historically Efficient
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This means the provider’s payments were lower than the national average. If so, the reimbursement blend is fixed at 90% of the participant’s historical average and 10% base rate.
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Trending Factors
The Trend Factor accounts for volume and payment trends of Radiation Therapy services made outside of the RO Model. It utilizes recent non participant claim data to calculate. A separate trend factor is calculated for the PC and TC of each cancer type.
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Participant Specific Adjustment: discounts and withholds
CMS will adjust payments by applying a discount factor. The discount factor is a percentage which CMS reduces an episode payment amount. A discount factor for the Professional Comonent is 3.75% and it is 4.75% for the Technical Component rate.
CMS applies withholds to account for Incorrect Payments and Quality Measures Performance. The Incorrect Payment Withhold is 1% of the PC rate and 1% of the TC rate. This withhold accounts for duplicate radiation therapy services that may have been delivered during the performance period or incomplete episodes in which the radiation therapy services were not delivered within the 28 day window from the date of the treatment planning service.
RO participants can earn back withholds based on clinical data reporting, quality measure performance and reporting and through performance consumer assessment reporting.
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Geographic Adjustment
Geographic adjustments will be applied in a similar manner to how they are currently used for fee-for-service for each RO Model participant.
