Imaging for IGRT should ideally be equivalent in quality to the best
diagnostic images
Use of the Abt survey in Technology and Manpower
Assessments – Image Guided Radiation Therapy
Michael D. Mills, Ph.D., MSPH
Associate Professor and Chief of Physics
James Graham Brown Cancer Center
Louisville, Kentucky
If you can define a target volume with millimeter accuracy, you
must be able to target your delivery to millimeter accuracy
Staffing and manpower to assure image quality and process quality
should be measured with the same precision as we measure staffing
and manpower for treatment delivery
Image guidance procedures are separate from delivery procedures
and should be reimbursed separate from delivery procedures
Historical Diagnostic Staffing
Standards
Review historical manpower and staffing estimates for imaging
physics
Estimate staffing needs for IGRT in a model radiation oncology
department
Look at the Abt II and Abt III models for IGRT manpower
How to measure Diagnostic, Nuclear Medicine and Medical Health
Physics Manpower with an Imaging Abt Study
Consider the recent CMS proposal to bundle image guidance CPT
codes with the delivery codes
THE EUROPEAN
FEDERATION
OF ORGANISATIONS FOR
MEDICAL PHYSICS, 1997
Staffing need for Diagnostic
Equipment
Equipment
FTE - AAPM Report 33
1991
FTE - AAPM ACMP
Report 1993
R/F Room (Simulator)
0.05
0.05
R/F Room (Simulator)
CT Scanner (CT Sim)
0.08
0.05
CT Scanner (CT-Sim)
Ultrasound
0.015
0.02
Ultrasound and MRI
0.1-0.25
0.1-0.3
MRI
Institute of Physics and
Engineering in Medicine –
Guidelines: The provision of a
physics service to radiotherapy,
2002
Equipment
IPEM, 2002
R/F Room (Simulator)
0.15
CT Scanner (CT Sim)
0.15
Ultrasound
0.1
MRI
Not addressed
0.13
0.13
Not addressed
Consensus Staffing for Imaging
in Radiation Oncology
Equipment
Equipment
EFOMP, 1997
Consensus
R/F Room (Simulator)
0.125
CT Scanner (CT Sim)
0.125
Ultrasound
0.025
MRI
0.25
Staffing for a Model
Radiotherapy Department
Performing IGRT
Equipment
Conventional Simulator x 2
Physics Staff Required
0.25
CT Simulator x 2
0.25
Imager for Cone Beam CT
0.125
Helical tomotherapy with MVCT
0.125
Ultrasound units x 2
0.05
MRI unit
Total
0.25
1.05 FTE
Heavily used equipment requires more physics support than lightly
used equipment
Such estimates by an expert panel might not be trusted by
administrators responsible for the position
There is no survey information to support that these
recommendations are actually common in the community
Such estimates provide no support for the future possible
development of imaging physics CPT codes
Measure the non-procedural work (not patient specific)
Measure commissioning work (annualized)
Measure annual QA work
Measure monthly and daily QA work (annualized)
Allocate the work over the annual number of procedures
Total the non-procedural work per procedure
Report for each survey respondent
Measure the procedural work (patient specific) for each respondent
Total the work per patient procedure for each survey respondent
Relate the result of this measure to staffing
Except for prostate ultrasound guidance, there was almost no image
guided therapy in radiation oncology in 2003
Since 2003, a large number of machines capable of cone-beam CT
and helical tomotherapy have been purchased
Abt III was designed to measure the additional manpower required
for QA associated with the image-guided procedures
However, the image-guided codes were not measured as part of the
Abt survey – turns out that was a good thing!
In both surveys, the manpower to perform initial commissioning
and ongoing QA of the simulator and CT simulator were allocated
equally over all of the treatment planning and calculation codes:
77295, 77300, 77301, 77305, 77310, 77315 and 77321. No patient
specific medical physics imaging services were measured in Abt II
However, in Abt III, physicist work above that included in 77301
for Image Guided Radiation Therapy was measured as a separate
special procedure for 77370
Yes, but:
There is much less time spent by imaging physicists on patient
specific procedures
There are no CPT codes specifically identified for imaging physics
services
Consequently, imaging physicists have a lower overall profile in the
healthcare system
OK, what are the totals
assuming 1000
mammography patient
procedures per year?
What are the mammography
procedure CPT Codes?
77032
Guidance for needle, breast
77051
Computer dx mammogram add-on
77052
Comp screen mammogram add-0n
77053
X-ray of mammary duct
77054
X-ray of mammary ducts
77055
Mammogram, one breast
77056
Mammogram, both breasts
77057
Mammogram, screening
Task
Hours
Annualized Hours
Commissioning
21
3
Yearly calibration
5
5
Quarterly, Monthly and
Daily QA
1 per month
12
Total annual effort
20
Non-procedural hours per
patient procedure
20 / 1000 =
0.02
Procedural hours per
patient procedure
4 / 1000 =
0.004
Total hours per patient
0.02 + 0.004 =
0.024 hours, or 4 minutes
Reconcile staffing
recommendations with
procedural work
measurements
Work estimate
Work / unit
Total Hours / (FTE)
30 mammography tubes per 0.015 FTE / Tube
year
2000 hours / (1FTE)
30 mammography tubes per 4 minutes per patient x
year
1000 patients per tube x 30
tubes
2000 hours / (1FTE)
You may estimate staffing using published expert panel results
You may measure staffing using a procedure-based study
You may measure staffing using an equipment and staffing survey
A reconciliation of the above defends the staffing for imaging
services
Such estimates may provide a rationale for physicists to have
dedicated CPT codes for their work
CMS Proposes to eliminate
image guidance codes for 2008
CPT Code and Descriptor
APC Payment
2007
Proposed APC Payment
2008
76950 – Ultrasonic
guidance placement of
radiation fields
$73.04
$0.00
76965 – Echo guidance
radiotherapy
$129.16
$0.00
77011 – CT guidance for
stereotactic localization
$250.94
$0.00
77014 - CT guidance for
placement of radiation
fields
$94.53
$0.00
77417 – Port films
$43.60
77421 - Stereoscopic x-ray
guidance
$67.45
values to include the guidance
codes
CPT Code and Descriptor
APC Payment
2007
Proposed APC Payment
2008
77418 - IMRT delivery
$336.42
$364.80
77371 - SRS treatment delivery
complete course of treatment of
cerebral lesion(s) 1 session; multisource Cobalt-60
$8510.16
$7864.15
G0173 - Linear accelerator based
stereotactic radiosurgery, complete
course of therapy in one session
$3895.59
$3918.43
G0251 – Linear accelerator based
stereotactic radiosurgery, delivery
$1249.18
$1095.47
$0.00
Go339 – Robotic linear accelerator
radiosurgery, first fraction
$3895.59
$3918.43
$0.00
G0340 – Robotic linear accelerator
radiosurgery, fractions 2-5
$2644.95
$3017.56
CMS wants to bundle the image guidance codes into the delivery
codes
It proposed to allocate the dollar value of the guidance codes over
the delivery codes in a manner that is fair and neutral to the total
dollars spent on radiation oncology
There is certainly some question that that is actually the case
CMS is very interested in containing costs for all imaging
procedures, including image guided radiotherapy
Although CMS is currently placing emphasis on “Pay for
Performance”, this decision undermines this principle by paying for
non-performance or paying for poor performance
Hospitals and clinics that purchase image guidance equipment
because it is the right thing for the patient will be penalized
However those that do not use image guidance with IMRT stand to
gain the most
This proposal may have a chilling effect on our industry
We do not have procedure-based estimates for medical physicists
performing imaging procedures in radiation oncology
Are our high
salaries making
us complacent?
Manpower to perform physics imaging QA has never been
measured, but is significant, and is essential for precision radiation
therapy
Thanks for coming
and for listening!
CMS is proposing to eliminate funding for guidance procedures
Medical physicists need to fight to maintain the guidance
procedures for radiation oncology and to measure physics
manpower for imaging procedures in an Abt type procedure-based
study for imaging medical physics
Have a safe trip
home!