Learning Objectives
New Technology
Reimbursement
• Understand the process for CPT applications
Najeeb Mohideen, MD
Co Chair Health Policy Committee ASTRO
• Introduction to how new codes are valued
Department of Radiation Oncology,
Northwest Community Hospital, Arlington Heights, IL
• Supervision requirements for RO procedures.
AAPM Annual Meeting, Houston, TX
July 27-31,2008
Projections of National Health Expenditures
and Their Share of Gross Domestic Product,
2006-2017
National Health Expenditures and Their Share of
Gross Domestic Product, 1960-2006
$2,500
$4,500
Dollars in Billions
$1,500
$1,000
714.0
$500
253.4
27.5
74.9
1960
1970
$0
1980
1990
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
NHE as a Share of GDP
5.2% 7.2%
9.1% 12.3% 13.7% 13.6% 13.6% 13.7% 13.8% 14.5% 15.3% 15.8% 15.9% 15.9% 16.0%
Source: Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at
http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; NHE summary including share of GDP, CY 1960-2006; file nhegdp06.zip).
$4,000
$3,500
$3,000
Dollars in Billions
2,105.5
1,973.3
1,852.3
1,732.4
1,603.4
1,469.6
1,353.6
1,265.6
1,190.5
1,125.3
1,068.8
$2,000
$2,500
2,245.6
2,105.5
2,394.3
2,555.1
2,725.8
2,905.1
3,097.8
3,305.0
3,523.6
3,757.0
4,277.1
4,007.8
$2,000
$1,500
$1,000
$500
$0
NHE as a %
of GDP:
2006*
16.0
2007
16.3
2008
16.6
2009
2010
2011
2012
16.9
17.1
17.4
17.7
2013
18.0
2014
18.4
2015
18.8
2016
2017
19.1
*2006 are actual data from the 2006 National Health Expenditure Accounts; 2007-2017 are projected data from the 2006 National Health
Expenditure Accounts.
Source: Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at
http://www.cms.hhs.gov/NationalHealthExpendData/03_NationalHealthAccountsProjected.asp#TopOfPage (see Projected; NHE Historical and
projections, 1965-2017, file nhe65-17.zip) and http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; NHE summary including
share of GDP, CY 1960-2006; file nhegdp06.zip).
19.5
Reasons for Rising Healthcare Costs
• Demographics
– aging population, rising obesity
• Increased use of Investigations and Imaging
– PET scans, MRI scans, Molecular testing
• Expensive Drugs
• New Technological Capabilities
– SBRT, IGRT
• Increased utilization of expensive procedures
– eg IMRT
2006
HCPCS
CPT Code
2003 OPPS+PartBTotal
*includes beneficiary
payments
Rank
77413
77418
~$380 million
~$318 million
1
2
77414
77427
77334
77295
77336
77290
~$292 million
~$226 million
3
4
5
6
7
8
77300
77263
9
10
The Medical Technology Market
OPPS+PartBTotal
*includes
beneficiarypayments
77418
~ $820 million
1
Total Market : Over $ 200 Billion annually
77413
~$260 million
2
Diagnostic Radiology: 25 Billion
77427
~$225 million
3
77414
~$210 million
4
Cardiovascular: 17 Billion
77334
5
77295
6
77336
7
77290
8
77300
9
77301
10
Orthopedics : 16 Billion
Radiotherapy and Radiosurgery : 2.5 Billion
New Technology
Reimbursement
• Most new devices launched without
dedicated codes, coverage, or payment
• Most new devices launched with little or no
published data
• It takes time, data, and a significant effort to
garner new codes, influence coverage
policies/ technology assessments, and drive
appropriate payment
Pathways For New Technology
Codes
ASTRO Priorities:
Health Policy Committee
• CPT Panel Process
Vendors
– Category I and III codes
Hospitals
Physicians
Specialty Organizations
ASTRO
•
•
Payers
•
Research Department
– NIH, NCI,
Emerging Technology Committee
– Paul Wallner, DO & Andre
Konski, MD
Health Policy Committee
• RVS Update Committee (RUC)
– Recommendations for Physician Work and PE
• CMS
– National Payment Rates
– Local Coverage Determinations
– HCPCS
Coding
• Medicare Fee Schedule
– CPT Codes – owned, updated, maintained by
the AMA
• Hospital Outpatient Prospective System:
New Technology In Medicare
Physician Fee Schedule
– G Codes – CMS controlled - for procedures applicable to physician and hospital payment
systems
– C Codes – CMS controlled - for pass through
drugs and devices - applicable to OPPS only
The MFS Reimbursement
Process
• Current Procedural Terminology codes
(CPT) eg 77427
• Codes are valued on a scale relative to
each other
• Payments are determined by resource
costs needed to provide them
The Process For New Codes:
ASTRO Code
Development
and Valuation
Subcommittee
SBRT Treatment Management
SBRT Treatment Delivery
“Typical patient” vignettes
Complete description of
the procedure,
Supporting US peerreviewed literature
CPT
Editorial
Panel
CATEGORY 1
OR
CATEGORY III
THE RUC PROCESS
CPT PANEL APPROVES
CAT I CODES
SURVEY PHYSICIANS
Physician Work
ASTRO REVIEWS
NEW CODES
PRACTICE EXPENSE
Direct Inputs
Components of RBRVS
• Physician Work (does not include support
staff)
53%
– Time
– Intensity
• Technical skill and physical effort
• Mental effort and judgment
• Stress associated with patient risk
• Direct Practice Expense
44%
• Non Physician Clinical Labor
• Equipment
• Supplies
• Professional Liability Insurance
3%
Components of RBRVS
• RO reimbursement is heavily weighted in
technical reimbursement.
• Pre IMRT: 50 - 60% technical charge
• Post IMRT: 60 -80% technical charge
Practice Expense
Clinical Labor, Supplies and Equipment
(CLSE)
Clinical Labor Staff 2008
“Top 4”
Clinical Labor Staff 2008
Staff Code
• 44 Staff Types
Description
Rate
'Medical Physicist
L152A
1.523
'Medical Dosimetrist/Medical Physicist
L107A
• Price per minute ranges from 0.23 to
1.523
1.075
'RN/OCN
L056A
0.79
'Medical Dosimetrist
L063A
0.63
Radiation Oncology Codes:
Physics Time
• 77301 Intensity modulated radiotherapy plan, including dose-volume
histograms for target and critical structure partial tolerance specifications
• 77418 Intensity modulated treatment delivery, single or multiple fields/arcs, via
narrow spatially and temporally modulated beams, binary, dynamic MLC, per
treatment session
Radiation Oncology Codes:
Physics Time
Radiation Oncology Codes:
Physics Time
• 77371 Radiation treatment delivery, stereotactic radiosurgery (SRS), complete
• 77301 Intensity modulated radiotherapy plan, including dose-volume
histograms for target and critical structure partial tolerance specifications
– Medical Dosimetrist/Medical Physicist = 45
Minutes
– Medical Physicist = 280 Minutes
• 77418 Intensity modulated treatment delivery, single or multiple fields/arcs, via
narrow spatially and temporally modulated beams, binary, dynamic MLC, per
treatment session
– Medical Physics Time = 0 Minutes
Radiation Oncology Codes:
Physics Time
• 77371 Radiation treatment delivery, stereotactic radiosurgery (SRS), complete
course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt
60 based
– Medical Physics Time = 115 minutes
• 77372 Radiation treatment delivery, stereotactic radiosurgery (SRS),
complete course of treatment of cranial lesion(s) consisting of 1 session; linear
accelerator based
– Medical Physics Time = 60 minutes
• 77373 Stereotactic body radiation therapy, treatment delivery, per fraction
to 1 or more lesions, including image guidance, entire course not to exceed 5
fractions
– Medical Physics Time = 75 minutes
course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt
60 based
• 77372 Radiation treatment delivery, stereotactic radiosurgery (SRS),
complete course of treatment of cranial lesion(s) consisting of 1 session; linear
accelerator based
• 77373 Stereotactic body radiation therapy, treatment delivery, per fraction
to 1 or more lesions, including image guidance, entire course not to exceed 5
fractions
Physics work for CPT 77373
SBRT Delivery:
• Setup DRR reference positions (20 min)
• Establish Respiratory Cycle (RC) for patient (5 min)
• Correlate RC with Target (Fiducial) position (5 min)
• Compare with ref DRR's and consult with physician (5
min)
• Treatment (30 min)
• Re-establish RC/Target position if correlation lost (5 min)
• Compare with DRR's, consult with physician (5 min)
THE RUC PROCESS
CPT PANEL APPROVES
CAT I CODES
SURVEY PHYSICIANS
Physician Work
The RBRVS equation
ASTRO REVIEWS
NEW CODES
PRACTICE EXPENSE
Direct Inputs
RECOMMEND WORK VALUES (RVW)
RUC MEETING
ASTRO RVS COMMITTEE
MEDICARE PAYMENT
SCHEDULE
CMS
New CPT Code
• CPT code assigned
• Work RVUs recommended by AMA/RUC
• Practice expense RVUs recommended by
PEAC/RUC
• New code and payment published in November
Federal Register
• Implemented following January
• Total process takes two years
Hospital Outpatient
Prospective Payment System
(HOPPS)
OPPS: Unit of Payment
• A separate payment is made for
each Ambulatory Payment
Classification (APC)
NEW TECHNOLOGY PAYMENTS
Specialty Organizations
Vendors
CMS
NEW TECHNOLOGY APC
G Codes : G 0339, G 0340
C Codes : Code for Electronic Brachytherapy
No Professional Component reimbursement
Can be used in a Hospital based setting only
CODES FOR IGRT in 2004
Examples in Radiation
Oncology:
– Ultrasound : CPT 76950
– Stereoscopic X-ray
– Computerized Tomography
– Stereotactic Body Radiotherapy:
– Other Modalities
• Respiratory Gating, 4D RT
• Tracking Systems (electromagnetic, optical)
• Fiducial Markers
CODES FOR IGRT in 2008
–
–
–
–
–
Ultrasound : CPT 76950
Stereoscopic X-ray : CPT 77421
Computerized Tomography : CPT 77014
Stereotactic Body Radiotherapy: 77435
Other Modalities
• Respiratory Gating, 4D RT
• Tracking Systems
• Fiducial Markers: 55876 for prostate
CMS Supervision Rules
Medicare Supervision Rules
Image Guided Radiation Therapy
(IGRT)
• General Supervision - means the procedure is furnished under the
physician’s overall direction and control, but the physician’s presence is not
required during the performance of the procedure. Under general
supervision, the training of the nonphysician personnel who actually
performs the diagnostic procedure and the maintenance of the necessary
equipment and supplies are the continuing responsibility of the physician.
• Direct Supervision - in the office setting means the physician must
be present in the office suite and immediately available to furnish assistance
and direction throughout the performance of the procedure. It does not
mean that the physician must be present in the room when the procedure is
performed. ( Most Radiation Oncology Procedures)
• Personal Supervision - means a physician must be in attendance
in the room during the performance of the procedure. (CPT 77421)
• All the IGRT codes are considered diagnostic tests
subject to the physician supervision requirements in the
Code of Federal Regulations at 42CFR §410.32(b)(3).
• 77% increase in Medicare Procedures for RO IGRT
Codes (76370,76950 and 77421) from 2003 to 2006
Increased Scrutiny on New
Technology Codes
Code will be reviewed in 2 years
Monitor Utilization Rates
Cost effectiveness/ Comparative
effectiveness
Does this improve outcome?
Long Term outcomes
Impact on work
Quality
What’s on the Horizon?
•
•
•
•
•
What’s on the Horizon?
Big changes for Practice Expense
Increased scrutiny on High Volume codes
Equipment Utilization Rates
Case Rates & Bundling/Pairing of Services
An aggressive 5 YEAR Review
Summary
• Appropriate Payment for New Technology
– Supporting clinical data
– Adequate Codes
– Appropriate Valuation
– Appropriate Coverage
• New Technology will need to show Comparative
efficiency to alternatives
• Increased Scrutiny of high utilization RO Codes
MOVING FORWARD:
All codes (current and future) are
vulnerable even with the smallest change