Radiation Therapy Coverage, Coding, and Reimbursement
for New Technologies
Presented by Susan Granucci,
Healthcare Reimbursement Specialist
Topics
1. Intensity Modulated Radiation Therapy (IMRT)
2. Tomotherapy
3. Image Guided Radiation Therapy (IGRT)
4. Stereotactic Radio Surgery (SRS), Stereotactic Radiation Therapy (SRT) or
Stereotactic Body Radiation Therapy (SBRT)
5. Accelerated Partial Breast Irradiation (APBI)
Susan Granucci
Healthcare Reimbursement Specialist
808 Sagebrush Ct, SE
Albuquerque, NM 87123
505--292
292--4217
Ph & Fax 505
e-mail: Snucci@aol.com
1
IMRT – Intensity Modulated Radiation Therapy
IMRT is a type of external beam radiation therapy that delivers highly conformal, 3-D
radiation treatment. It typically includes inverse planning, and features numerous
beams of radiation involving multiple targets with different doses, intended to maximize
the dose to the tumor and minimize the dose to normal tissue. The difference between
3-D and IMRT is the linear accelerator equipped with multileaf collimation (MLC) or
moving aperture which shuts down portions of the beam during each treatment to
modulate the intensity as well as conform to the shape and size of the tumor.
(Conventional therapy delivers a wide beam of radiation from just two or three
directions.)
Coverage – Medicare Code Bundling
Two codes are primarily used for reporting IMRT: 77301 for planning, and 77418 for
treatment delivery.
1. Planning code 77301 is intended to include all of the following:
All codes for
Diagnostic CT
36000 & 36410 1
76370 0
76375 0
76380 1
76950 0
77261 – 77263 0
77280-77295 0
77305-77315 0
77321 0
77326-77328 0
77331 0
77332-77334 1
All Visits &
77336 0
Psychotherapy
0
77370
***except consults
77401-77416 1
99241-99245
0
77417
may be billed
1
77431-77432
0083T 0 (sbrt tx mgt)
77470 0
77520-77525 0
Free-standing and hospital edits are different. Hospital Outpatient edits do not include 77332:
77334 tx devices.
Source CCI 4/1/05
See current CCI edit tables for additional edits.
0
Coverage not allowed if billed same day (with or without a modifier)
1
Coverage may be allowed if coded with Modifier 59 when billed on same date
as the treatment plan, and documentation supports separate service.
Certain of the above codes are acceptable on different days, such as treatment
planning 77263, devices 77332-77334, physician management 77427, and
treatment delivery 77418. Note, basic dosimetry 77300 has been removed from
the planning code edit table, and may be quantity billed as appropriate.
2
IMRT Continued
2. 77418 IMRT Treatment Delivery includes
36000 & 36410 1
61793 0
Dx ultrasound
76942 1
77261 – 77263 0
77305-77315 0
77321 0
77326-77328 0
77331 0
77401-77416
77432 1
77470 1
77520-77525 0
***All Visits & Psychotherapy 0
except consults
Hospital and Free-standing differences:
***Visits and psych not allowed with free-standing claims.
Visits and psych not on CCI bundling list for hospital claims.
:
Source CCI 4/1/05
Note, port films-77417, weekly QA-77336, treatment devices-77332-77334, and
physician weekly management have been removed from the above daily
treatment edit tables.
Commercial Insurance Coverage Limits
One insurance company's perspective:
Aetna considers intensity modulated radiation therapy (IMRT) medically necessary
for the following indications:
1. Treatment of radiosensitive tumors of the brain, head, neck, spine and paraspinal
regions; or
2. Treatment of prostate carcinoma in individuals with an intact prostate when ultra
high dose radiation (dosage of 75 Gy or more) is planned.
IMRT is considered experimental and investigational for treatment at other sites.
Aetna considers compensator-based IMRT experimental and investigational
because of a lack of evidence that it provides clinical outcomes equivalent to
collimator-based IMRT.
For these reasons, prior authorization is always recommended.
3
IMRT Coding
BAT 76950, Acculoc and Other Image Guidance
Ultrasound guidance for field placement, code 76950, is currently the code used most
often for verifying precise targeting for daily treatment. Other image guidance may
include implanted marker seeds, CT and portal imaging systems, and a variety of codes
from CT localization to simple simulation are being reported. New guidance code(s) are
in development. Additional discussion to follow.
Typical Coding for IMRT Course of Therapy
Prof
Tech
Comp Comp
9924X – Initial Consult
77263 – Physician Plan
77290 – Pretreatment Simulation
76370 – CT Guidance
77301 – IMRT Plan (after CT imaging)
77334 – Treatment Devices (after planning)
77418 – Daily Treatment Delivery
76950 – Daily Ultrasound Set Up or
77417 – Port films as needed if no other guidance
77336 – Weekly QA (after planning)
77427 – Weekly Physician Management
77470-59 – Special Treatment Procedure
Yes
Yes
Yes
No2
Yes
Yes
No
No2
No
No
Yes
Yes
No1
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Other codes may or may not apply depending on individual case,
documentation, and payer guidelines.
Use new Category III code for compensator-based IMRT: 0073T. Reimbursement
compares to 77418.
ACR suggests treatment devices be billed once for immobilization, and for each
complex IMRT field
1
2
No technical component for free-standing facilities, but there is a technical component (exam room)
for hospital based facilities.
A professional component is not expected, although there is a relative value.
4
IMRT Revenues
For IMRT, 2005 Medicare reimbursement continues to be quite favorable, more-so in
the free-standing facility at this time.
IMRT Services
9924X – Initial Consult
77263 – Physician Plan
77290 – Pretreatment Simulation
76370 – CT Guidance
77301 – IMRT Plan (after CT imaging)
77334 – Treatment Devices (after planning)
77418 – Daily Treatment Delivery
76950 – Daily Ultrasound Set Up or
77417 – Port films if no other guidance
77336 – Weekly QA (after planning)
77427 – Weekly Physician Management
77470-59 – Special Treatment Procedure
Hosp
APC
Prof
Comp
$ 79.65
$0.00
$224.07
$ 97.70
$813.57
$163.67
$309.20
$ 67.44
$ 43.87
$ 97.48
$0.00
$ 332.60
$184.56
$167.13
$81.10
$44.34
$414.98
$64.43
$0.00
$30.32
$0.00
$0.00
$172.05
$108.77
FreeStanding
TC
$0.00
$0.00
$259.98
$117.86
$1,114.57
$129.61
$687.84
$52.30
$23.88
$119.00
$0.00
$444.92
2005 Medicare fees are unadjusted for local wage or geographic cost indexes
Compare IMRT treatment delivery code 77418 at $309 - $687 to standard
external beam daily treatment delivery code 77413 fee ranges of $124 - $93 for
APC or Free Standing Facility.3
Compare IMRT planning code 77301 at $814 - $1115 to traditional simulation
and isodose codes 77290 & 77315 combined fees of fees $448 - $366.
One table of billing statistics for 2003 shows code 77418 represents 13% of
treatment delivery codes and 52% of treatment delivery revenues.
3
Compenssator based IMRT treatment delivery code 0073T is allowed at the same rates as 77418 by
Medicare for 2005.
5
TomoTherapy
TomoTherapy (brand name for TomoTherapy Hi-Art System®) takes IMRT several
steps further. It combines planning, patient positioning and treatment delivery into one
system. Radiation is delivered in a unique helical (or spiral) delivery pattern which
travels in multiple circles all the way around the gantry ring. The patient's couch also
moves, guiding the beam at slightly different planes during treatment.
For tumor localization, a special verification CT scan is taken just before each treatment
to verify the patient's position and position of the tumor.
Treatment delivery is via IMRT, but with a spiral delivery pattern. Computer controlled
MLC has two sets of interlaced leaves for continuous beam modulation.
Coverage, Coding and Revenues
Coverage issues are not readily found. There are no TomoTherapy references in
CMS's website, and nothing found in local Medicare or commercial insurance searches.
Coding and revenues are identical to IMRT, except:
Many providers are coding CT guidance code 76370 daily, in lieu of BAT or port
films.
Image Guidance
76370 – CT Guidance
Hosp
APC
Prof
Comp
$ 97.70
$44.34
Free
Standing
TC
$117.86
2005 Medicare fees are unadjusted for local wage or geographic cost indexes
6
Image Guided Radiation Therapy (IGRT)
To deal with tumor changes, patient changes, and variations in the targeted area of
interest such as movement caused by breathing, heart, and gastric motility, radiation
therapy is embracing image guided radiation therapy (IGRT). IGRT is typically used
with daily IMRT treatment delivery, but can also be applied to other 3-D treatments such
as stereotactic radiation therapy and accelerated partial breast irradiation. Improved
precision with IGRT sometimes results in fewer treatment fractions. Some have labeled
IGRT as a new type of radiation therapy. Based on the wide variety of equipment and
modalities available, it appears that IGRT should be considered another "tool" to
enhance precision in treatment delivery rather than the therapy itself.
IGRT may include any of the following
Fluoroscopy
Electronic portal imaging
Ultrasound
Respiratory gating technology
CT scan reconstruction
e.g., On Board Imager, used with
CyberKnife; two images beneath and two
over the table
e.g., Portal Vision, iViewGT- megavoltage xray imaging systems used for IMRT portal
imaging
BAT, SonArray - B-mode ultrasonic imaging
system for IMRT image guidance and patient
positioning on a daily basis
RPM - lightweight reflective marker and
camera track motion and breathing pattern;
correlates data with treatment plan; beam off
/ beam on signals more accurate treatment
delivery
Elekta's Synergy integrated system uses
cone beam CT for daily verification;
Tomotherapy uses sonograms to compare
CT for the current fraction to a reference
sonogram for each fraction
Partial list of manufacturers
Next generation of IGRT:
ART - Adaptive Radiation Therapy takes IGRT one step further from shifting the
patient's position to actually modifying the daily treatment. PET and MRI have also
been mentioned in connection with image guidance, but they are fairly uncommon at
this time.
7
Frequency and timing of imaging terms to know:
Inter-fraction – between fractions (weekly port films are multi-interfractional)
Intra-fraction – several times during the fraction (CyberKnife and respiratory gating
are intrafractional)
Coverage, Coding and Revenues
Technology is still relatively new, and targeted payer coverage guidelines have not yet
been established and/or published.
Coding and revenues specific to IGRT are based on the following codes, until such time
as a more specific code(s) is developed. A new code is expected in 2006.
Possible IGRT Codes
Prof Free Standing
Comp
Tech Comp
$117.86
$ 97.70 $44.34
$52.30
$79.09 $8.72
n/a
$23.88
$43.87
Hosp APC
76370 – CT Guidance
76000 – Fluoroscopy up to 1 hr
77417 – Electronic portal imag
77280 – Simple simulation (sometimes used for Acculoc)
76950 – Ultrasnd guidance (BAT)
C9722 – Stereoscopy kV imaging with
infrared tracking
N/A – Respiratory Gating
$97.48 $36.38
$138.33
$67.44 $30.32
$52.30
$75.00
n/a
n/a
n/a
n/a
n/a
2005 Medicare fees are unadjusted for local wage or geographic cost indexes
8
Stereotactic Radio Surgery (SRS)
Stereotactic Radiation Therapy (SRT)
Stereotactic Body Radiation Therapy (SBRT)
SRS – Stereotactic radiosurgery was initially used only to treat intra-cranial lesions.
Multiple beams converge on the target with 3-D planning, producing a much higher
dose, usually in one session. Treatment may be delivered via gamma ray
(GammaKnife) using a head chamber, or via a linear accelerator using a head frame
applied by a neurosurgeon, and fiducial markers for accurate delivery.
SRT & SBRT – More recent advances have allowed this technique to be applied to
many other parts of the body. Extra-cranial lesions treated with stereotactic techniques
are also known as Stereotactic Body Radiation Therapy. SRT / SBRT can be delivered
with hyperfractionation (2-5 fractions) as well as conventional fractionation. Rigid
immobilization and/or imaging guidance (IGRT) are required to assure great accuracy.
Coverage
Centers for Medicare & Medicaid Services (CMS) recognizes treatments to brain, neck,
spine, lung, pancreas, prostate, bone, and liver. It has developed different codes for
Cobalt 60, linear accelerator gantry-based systems, and linear accelerator imageguided robotic systems. One to five sessions are allowed.
Other payer policies vary and may be quite limited such as the following:
Aetna considers stereotactic radiosurgery experimental and investigational for the
following indications:
1. Stereotactic radiosurgery is considered experimental and investigational for
treatment of Parkinson's disease and epilepsy (except when associated with
treatment of AV malformations or brain tumors)
2. Fractionated stereotactic body radiosurgery is considered experimental and
investigational for treatment of cancers in extracranial sites (e.g., liver, lung,
kidney, and prostate) because definitive conclusions regarding its indications and
efficacy have not been demonstrated in large, controlled clinical trials.
3. Stereotactic body radiosurgery: Stereotactic administration of radiosurgery to
extracranial sites (e.g., liver, lung, kidney, and prostate), other than inoperable
primary CNS tumors of the spine, is considered as experimental and
investigational.
9
Coding and Reimbursement
Medicare has established unique HCPCS "G" codes for hospital outpatient claims. For
free-standing facilities, the G codes are not generally accepted. Commercial payers
should be contacted for prior authorization and coding preference.
SRT CPT Codes
if performed & documented
Hosp APC
Treatment Planning Code Choices
77295 – 3-D Plan
or
$813.57
G0242 – Cobalt 60 Plan
or
$1,450.00
G0338 – Linac plan
$1,150.00
Treatment Delivery Code Choices
77413 – Treatment Delivery or
$124.12
G0243 – Cobalt 60 Delivery 1 session only
$5,250.00
G0173 – Linac non-robotic 1 session only
$5,250.00
G0251 – Linac non-robotic, fractionated
$1,150.00
st
G0339 – Linac robotic 1 or 1 session
$5,250.00
G0340 – Linac robotic 2nd thru 5th session
$3,750.00
Additional Codes (Caution, see bundling tables below)
9924x – Initial Consult
$ 79.65
77263 – Treatment Plan
$0.00
76355 – CT Guidance SRS
$270.58
77300 – Basic Dosimetry
$97.48
77334 – Trt Device(s)
$163.67
77470 – Spec Trt Procedure
$332.60
77432 – Phys Mgt cerebral 1 session
$0.00
0083T – Phys Mgt body, per day
$0.00
Prof
Comp
Free
Standing
TC
$237.24
$0.00
$0.00
$1,114.57
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$93.23
$0.00
$0.00
$0.00
$0.00
$0.00
$184.56
$167.13
$392.24
$32.21
$64.43
$108.77
$425.59
$0.00
$0.00
$0.00
$328.95
$53.44
$129.61
$444.92
$0.00
$0.00
2005 Medicare fees are unadjusted for local wage or geographic cost indexes
Bundling (as of 4/1/2005 CCI Edit Tables)
77295 Includes:
76370-76375 guidance
77280-77290 simulation
77305-77315 isodose
77336 physics QA
And a few others
77295 is included in
77301 IMRT planning
Physician bundling
includes all E&M and
psych as well.
G planning codes include all other
radiation therapy codes from 77280
to 77470, 0083T, and most 61xxx
codes. The only exceptions are
initial plan 77263, dosimetry 77300
with mod 59, port films 77417, and
treatment device codes 7733277334.
G treatment delivery codes permit
most other 77xxx codes with
modifier 59.
10
Accelerated Partial Breast Irradiation (APBI)
APBI differs from whole breast external beam radiation therapy in several ways.
Treatment is delivered via HDR brachytherapy. The radiation targets only a segment
surrounding the tumor rather than the entire breast. Since the duration of treatment is 4
to 5 days rather than 5 to 6 weeks, radiation is delivered in fewer fractions at larger
doses per fraction. APBI features:
interstitial brachytherapy (high dose rate) via balloon catheters placed into
lumpectomy cavity usually immediately after surgery, but can follow later
the MammoSite radiation treatment system
3-D conformal planning
two treatments each day for five days (BID treatments require modifier 59)
breast conserving therapy
Coverage
Medical necessity is supported with the following criteria:
Age: Equal to or greater than 50 years old,
Diagnosis: Invasive ductal carcinoma,
Size of tumor: Less than or equal to 2cm,
Margin status: Negative - at least 2 mm in all directions,
Nodal status: Negative axillary lymph node dissection or sentinel lymph node
evaluation.
An extensive internet search did not reveal any payer guidelines other than Medicare's.
The following from Blue Cross-Blue Shield is now three years old, and although denial
is implied, it does not specifically so state. At this time, it would appear most insurers
are paying for APBI claims.
Based on the available evidence, the Blue Cross and Blue Shield Association Medical Advisory
Panel made the following judgments about whether accelerated partial breast irradiation using
brachytherapy meets the Technology Evaluation Center criteria to decrease recurrence after
breast-conserving surgery for early stage breast cancer.
Accelerated partial breast irradiation using brachytherapy as the sole radiation treatment after
breast-conserving surgery for early stage breast cancer does not meet the TEC criteria. Nov.,
2002
TEC Assessments are scientific opinions, provided solely for informational purposes. TEC
Assessments should not be construed to suggest that the Blue Cross Blue Shield Association,
Kaiser Permanente Medical Care Program or the TEC Program recommends, advocates,
requires, encourages, or discourages any particular treatment, procedure, or service; any
particular course of treatment, procedure, or service; or the payment or non-payment of the
technology or technologies evaluated.
11
APBI / MammoSite Coding and Reimbursement
Hosp
APC
Prof
Comp
Tech
Comp
$3,250.00
$2,750.00
$209.19
$95.88
na
na
US guidance for rtx placement or
Echo guidance rtx interstitial
$67.44
$67.44
$30.32
$70.11
$52.30
$222.08
77263
77280
Planning
Phys rad therapy planning
Simple simulation
$0.00
$97.48
$167.13
$36.38
na
$138.33
77290
76370
77326
Complex simulation
Ct scan for therapy guide
Brachy plan, simple
$224.07
$97.70
$97.48
$81.10
$44.34
$48.51
$259.60
$117.86
$94.36
Surgery
varies
19296
19297
Radiation
76950 or
76965
Service
Lumpectomy or lesion excision +
Place catheter in breast post op
Place catheter post during lumpect
or
77295
3-D Treatment plan
$813.57
$237.24
$1,114.57
Additional Codes
77300
Basic Dosimetry
$97.48
$32.21
$53.44
77336-59 Radiation physics QA
$97.48
na
$119.00
77370-59 Spec physics consult
$97.48
na
$139.08
77427
Radiation tx management, x 5
$0.00
$172.05
na
77470
Special radiation treatment
$332.60
$108.77
$444.92
77781-59 High intensity brachytherapy – or –
$790.75
$86.03
$809.49
77782-59 High intensity brachytherapy
$790.75
$129.61
$809.49
C1717
Brachy source IR 192*
$0.00
na
$0.00
2005 Medicare fees are unadjusted for local wage or geographic cost indexes
Modifier 59 is essential to bypass the following edits:
77370 is bundled into 77336 on same day
77336 is bundled into 77326 on same day
When treatments are BID, always use mod 59 on second treatment to avoid
duplicate denial
* C1717 hospital pass through cost may be allowed by
Medicare according to the vendor
Bundling: When 3-D treatment plan code 77295 is used, it includes other plan codes
77290, 76370, and 77326 (as well as codes mentioned previously).
12
Quick Facts on Correct Coding Initiative (CCI)
Easy to use CD is available from NTIS (have your credit card ready)
www.ntis.gov/fcpc
$299 for National Correct Coding Policy Manual – fee includes quarterly
updates by CD for one year
Or download CCI free, from
http://www.cms.hhs.gov/providers/hopps/cciedits
Free of charge
Multiple files to manage, fairly difficult to navigate between files
•
•
•
•
•
•
•
Edits apply to codes on same day
Edits are different for hospitals and doctors or freestanding providers
Edits are different for mutually exclusive and column 1 & 2 files
Need to look for edits in both files (mutually exclusive or column 1 & 2 files)
Two separate files exist for each code section 10000's, 20000's, 30000's, alphas,
etc.
Edits are updated quarterly
Each code edit is followed by a suffix:
0
Coverage not allowed if billed same day (with or without a modifier)
Coverage may be allowed if coded with Modifier 59 when billed on same
date as the treatment plan, and documentation supports separate service.
1
13