Section 10
Radiation Oncology,
SRS, SBRT, Protons.
Advanced Concepts
Carl R Bogardus, Jr MD
9:00-10:00
65
031114
Revised for 4-10-14
1
Stereotactic treatment is defined
as the use of external beam
radiation therapy using
stereotactic guidance to deliver
very precise doses of radiation
to a defined tissue volume
1
STEREOTACTIC PROCEDURES
Gamma Knife (Radio surgery, SRS)
Cyber Knife (SRS, SBRT)
Conventional XRT (SRS, SBRT )
Stereotactic Procedures, SRS
• SRS, Stereotactic Radio Surgery was the
original definition of this code.
• SRS is now limited to the cranial vault, and is
limited (by reimbursement only) to one
fraction of treatment.
• Treatment may be delivered using a Gamma
Knife unit, linear accelerator, Tomotherapy
unit, Cyber Knife unit, but Protons are
excluded from SRS at this time.
1
Stereotactic Procedures, SBRT
• When the treatment is delivered to the
contents of the cranial vault, brain, and;
• Even if the treatment exceeds one fraction, it
is still considered a single SRS.
• Payment will be limited to a single fraction
reimbursement 77372. The remaining
fractions are considered bundled into the
initial treatment and are not reimbursable.
• RULE CHANGE 2014
1
Stereotactic Procedures, SBRT
1
• SBRT, Stereotactic Body Treatment may be
delivered any where in the body, and is
restricted to 1-5 fractions.
• SRS and SBRT are both calculated using
Advanced 3-D Dosimetry, 77295.
• If IMRT 77301, is used for planning,
treatment delivery should be 77418.
• Treatment may be delivered using a linear
accelerator, Tomotherapy unit, or Cyber Knife
unit, but Protons are excluded at this time.
MANAGEMENT OF CRANIAL LESIONS BY 1
STEREOTACTIC TREATMENT
•Medicare would expect to see 77432 reported one
time for management of a Gamma Knife, or X
Knife treatment course consisting of 1 treatment
only.
•If the course is to extend longer than one day, but 5
or less, then 77432, Treatment Management must
still be used.
•If the treatment extends beyond 5 fractions, 77427
must be used to report the entire course of
treatment.
•RULE CHANGE 2014
Only one of these codes may be
reported per session of
stereotactic radiation therapy.
The codes 77427, 77432, and
77435 may not be used on the
same date of service, or during
the same course of treatment.
THESE CODES ARE MUTUALY EXCLUSIVE, CANNOT BE USED SEQUENTIALLY
42
2
Gamma Knife Historical
Background
3-Dimensional simulation
(77295, not 77301) is
performed to determine the
optimal beam arrangement to
deliver treatment to a target
volume by Gamma Knife.
2
NIB
The patient is fixed into a head frame for
total accuracy of localization of the lesion
2
The head frame locks in to
the Gamma Knife unit for
absolute accuracy of set up
and treatment. Bill each
helmet as a 77334
Removal of the head Frame
2
• The code 20660 application of stereotactic frame, includes
removal (a separate process) CPT)
• This is only a neurosurgery code, in spite of what you may
have been told
• 20664 is the application of a cranial halo on the head of a
small child whose skull is unusually thin. (CPT)
• 20665 is the removal of this halo, not a stereotactic frame.
(CPT)
• The radiation oncologist should not bill 20665 for
stereotactic frame removal, if payment is received, then this
is an error in local billing as the description is a legitimist
procedure, just the wrong procedure. Any one qualified can
remove the stereotactic head frame, but there is no valid
charge today for any one. The placement by
the neurosurgeon also includes the removal.
2
GAMMA KNIFE TECHNICIAL TREATMENT
DELIVERY CODE
The code 77371 Gamma Knife one
fraction only, complete course of
therapy, is used for the technical
reimbursement.
4
Gamma knife
work page and
final narrative of
procedure
ONCOCHART
History of Dosimetry
Covered in Section 7
• Conventional Dosimetry.
• Gamma plan (original 3-D planning)
• Basic 3-D External beam planning (3-D simulation)
• Forward Planned IMRT
• Inverse planned IMRT
• Advanced 3-D planning
The use of forward planned IMRT planning
algorithms is the basis of all Advanced 3-D
Dosimetry for SRS and SBRT.
APC Rules for Gamma Knife (SRS)
Reimbursement
Hospitals must bill for Gamma Knife SRS
planning using CPT procedure code 77295
Hospital APC ~$1,036.39
Hospitals Must use 77371, 77372 for SRS
delivery.
THIS IS USUALY A NEGOTIATED RATE
Hospital APC 0067 ~$ 5,615.41
7
SRS USING A LINEAR ACCELERATOR
The use of a linear accelerator (Cyber Knife, Xknife, Tomo therapy, Peacock, Brain Lab, Etc.) for
stereotactic radiation therapy uses either an
aperture, iris, or micro MLC to collimate the x-ray
beam from the accelerator.
Please note, these rules have changed for
2014, and only the single fraction 77372
may be reported for SRS, fractions 2-5 are
now considered bundled.
8
4-5
Brain Lab Micro
Multileaf collimator
Removable head frame
5
BRAIN LAB
STEREOTACTIC
PLANING;
THIS USES
IMRT FORWARD
PLANNING
ALGORYTHM
SOFTWARE,
AND SHOULD
BE BILLIED AS
ADVANCED 3-D
77295
6
A report is absolutely required for proper
documentation of this procedure
136/216
Stereotactic treatment delivery
7
G0173--GO340 DELETED 1-1-14
77371 single session, Gamma Knife
77372 1-5 sessions, SRS, Linac, free standing
center, or hospital, Cranial only, bill one time.
77373 1-5 sessions, SBRT, Linac, free standing
center, or hospital, bill for each session as done,
Body only.
If the planning is done using IMRT planning 77301,
then treatment should be IMRT 77418 IF YOU TREAT
OVER 5 SESSIONS
NIB
I think they are going
to allow to use the G
codes, but bundle and
pay through the 77000
codes for 2014. I would
continue to bill the G
codes until they
disappear, or until
instructions are
posted. They may be
available, but paid
differently. Wish I
could be more specific.
Sidney Hayes, MD
Novitas-Solutions
.
RULES AND CODES FOR SRS
8
SRS/SRT Stereotactic Radiosurgery or Stereotactic Radiation
Therapy Treatment; Limited to Contents of the Cranial
Vault (Brain)
77371
Single Cranial treatment delivery using multisource
photon unit (Gamma Knife)
77432
Single Cranial Treatment Physician Management
77372
Single Cranial treatment delivery using a linear
accelerator unit.
This is a change from previous years
8
Stereotactic Body Radiation Therapy, SBRT.
• SBRT is utilized as the technique of stereotactly
treating small localized lesions outside of the
cranial vault, anywhere within the body.
• SBRT treatment may be delivered utilizing a
linear accelerator, Tomotherapy unit, or Cyber
knife.
• Check your LCD for specific rules
related to payment for SBRT based
on ICD 9.
SBRT, Body Only
77373 1st FX
77373 2nd FX
77373 3rd FX
77373 4th FX
77373 5th FX
9
Notice the detailed
and customized
clinical comments as
part of the statement
of medical necessity
Courtesy ONCOCHART
RULES AND CODES FOR SBRT
SBRT
9
Stereotactic Body Radiation Therapy Treatment;
Limited to the Body Below the Cranial Vault (Brain)
77373
1 – 5 treatments delivered using a linear accelerator
unit, Cyber knife, Tomotherapy unit or other x-ray
source
 If treatment extends beyond 5 fractions, Code 77373
should not be used for the case; rather 77418 (IMRT)
must be used for all fractions delivered 1-X
77373 includes all Image Guided Codes
77435
Physician treatment management 1 – 5 treatments
Includes image guidance
If treatment extends beyond 5 fractions 77435 should
not be used for the case. Management will be
considered 77427 only.
Medicare reimbursement values, 2014.
9
77371 GammaKnife, SRS, complete course of treatment of cranial
lesion(s), one session multi-sourced cobalt 60, $ negotiated value.
77372 SRS complete course of treatment of cranial lesion(s)
consisting of one session, linear accelerator $992.79.
77373 SBRT linear accelerator, 1-5 TX, stereotactic body radiation
therapy, treatment delivery, per fraction to one or more lesions,
including image guidance, entire course not to exceed 5 fractions
$1188.76.
77435 SBRT stereotactic body radiation therapy treatment
management, per treatment course, to one or more lesions,
including image guidance, entire course not to exceed 5 fractions
$601.87.
77432 SRS stereotactic radiation treatment management of
cranial lesion(s) , complete course of treatment consisting of one
session $398.41.
Stereotactic Radio Surgery
(SRS), 77432
10
What’s it for?
The physician’s clinical care during a course of 1 fraction using either the
Gamma Knife or X-Knife.
Who normally documents this code?
The physician.
When is this code normally billed?
The day of the procedure.
What Documentation is suggested for this code?
A progress procedure note outlining the course of therapy.
What is the common documentation error identified with this code?
No note being documented.
What is the common billing error identified?
Billing of this code with conventional therapy or SBRT. (only for SRS)
Stereotactic Body Radiation
therapy (SBRT) 77435
What’s it for?
The physician’s clinical care during a course up to 5 fractions using
stereotactic body treatment, including the CNS.
Who normally documents this code?
The physician.
When is this code normally billed?
At the completion of the procedure.
What Documentation is suggested for this code?
A progress/procedure note outlining the course of therapy
What is the common documentation error identified with this code?
No note being documented.
What is the common billing error identified?
Billing of this code with conventional therapy or one fraction SRS.
11
12
IGRT
IMAGE
GUIDED
RADIATION THERAPY
COMBINED CT AND LINEAR ACCELERATOR
12
THE TREATMENT IS IMRT 77418,
THE GUIDANCE IS DAILY CONE BEAM
CT IMAGING BILLED AS 77014, OR;
12
LINEAR ACCELERATOR IMRT
USING KILOVOLTAGE X-RAY
IMAGING, ON BOARD IMAGING
(OBI)
77421 STEREOSCOPIC
ADVANTAGE OF IGRT
13
• The image is directly referenced to the
treatment machine
• All machine parameters are in perfect
geometric relationship to the images
• The Physician guides the daily treatment
based on “live “images
BILLING FOR IGRT
13
• There is no code at this time for IGRT
• Without a specific code you cannot
bill for a new procedure
• The only choice is to use existing
codes
Available Codes for IGRT
•
•
•
•
13
77427 Physician treatment management
77418 IMRT treatment delivery
77421 Fiducial treatment guidance, or
77014 CT treatment guidance (2014??)
Treatment with SRS or SBRT may
still be considered IGRT, but the
guidance codes are bundled, and the
treatment cannot be IMRT, 77418
13
77421 STEREOSCOPIC GUIDANCE
• MAY USE KV OR MV 90 DEGREE X-RAYS
• REQUIRES POSITIONING OR TRACKING
SYSTEM, INFRARED OR SURFACE
ANATOMY, FIDUCIAL MARKERS, OR A
CONSISTANT DEFINABLE ANATOMIC
STRUCTURE
13
77421
STEREOSCOPIC
X-RAY GUIDANCE
FIDUCIAL MARKERS FOR
STEREOSCOPIC GUIDANCE
FORMAT OF STEREOSCOPIC
X-RAY GUIDANCE
• Locating the target volume on orthogonal XRays with Fiducial markers.
• Locating the target volume on orthogonal XRays without Fiducial markers if the target
volume or a consistent anatomic structure
can be clearly seen on the images.
• To ensure accurate treatment of the target
and spare normal tissues.
13
SIMULATION IMAGES AND ON
TREATMENT KV BEAM SET UP IMAGES
SUPERIMPOSED
168/183/216
NIB
14
DOCUMENTATION for 77421
If the physician wishes to bill for this
procedure, a report must be generated
within 24 hrs. of the next performed
procedure.
Failure to approve the images and
generate a report prior to the next
image could result in denial of payment
for the procedure
BILLING FOR STEREOSCOPIC
GUIDANCE, 77421
• The 2014 Medicare value is :
•
77421-26 about $ 19.05
•
77421-TC about $ 51.37
•
77421
about $70.43
170/216
14
14
Image Guidance of Radiation Treatment Delivery
77421
Stereotactic X-Ray Guidance for Localization of
Target Volume for the Delivery of Radiation
Therapy Treatments
May be used on a daily basis if clinically indicated
Requires the Direct supervision of a
physician.
Requires a written report.
Requires fiducial alignment using fiducial
marker(s) or definable anatomic structure(s) to
establish the Isocenter for treatment.
CONE BEAM CT
15
• GUIDANCE OF TOMOTHERAPY and OTHER IGRT
TECHNIQUES, USE CODE 77014, CT GUIDANCE
• ALL PAYMENT is Bundled with the simulation or
treatment delivery.
• No professional billing is recognized in 2014. The
professional component of the CT scan is
considered bundled into either the simulation or
the treatment delivery procedure.
15
CONE BEAM CT 77014
77014
CT Guidance of Delivery of Radiation Treatments
If used as a Guidance Code some form of treatment
machine based CT imagery system must be used.
Imaging may be done using the Mega Voltage
Treatment Beam or an on-board Kilo Voltage Cone
Beam device.
The physician must provide Direct Supervision of
this procedure. A physician must be present in the
Department when the procedure is performed and
must be available if corrective action is required. The
images may be reviewed after treatment has been
delivered; a brief report is required for each image
set reviewed.
This code is bundled into the Technical Procedure
of CT Simulation and treatment delivery and
payment is no longer recognized.
15
RESPIRATORY MOTION
MANAGEMENT
• This is 4-D
1, Vertical
2, Lateral
3, Horizontal
4, Motion is the fourth dimension
• Billing code +77293 for simulation.
• Billing code 0197T for treatment gating.
• 77290-22, (very time intensive)
16
17
Respiratory motion
causes mismatch
Respiratory gating
allows treatment
only at match time
172/183/216
2014 CPT update
17
NIB
• +77293 is a new add-on code describing the
physician work and resources involved in acquiring
a respiratory correlated 4D CT simulation study for
conformal planning.
• Professional payment $98.67
• Global payment $410.66
• Technical payment $311.99
• Add-on codes must be reported in addition to the
primary procedure, 77295 or 77301, and reported
on the same date of service.
17
T CODE FOR GATING
• 0197T category III code
• Intra fraction localization and tracking of target
or patient motion during delivery of radiation
therapy.
• 3-D positional tracking, gating, 3-D surface
tracking.
• Report each fraction of therapy
• Hospital packaged
• Physician carrier priced. Indicator C in CPT Jan 1,
2009
• Still a valid code in 2014.
• May be discontinued Jan 2015
19
PARTICLE ACCELERATORS
The concept of a Proton
radiation therapy unit
was first proposed by
physicists in 1946
Proton units in The United States, a timeline
1946-Wilson proposes using protons clinically.
1955- the 1st patient is treated at Berkeley.
1961- the Harvard cyclotron lab begins treatment.
1991-Loma Linda operates the 1st proton gantry.
2001-Harvard proton center opens.
2002- Indiana University starts proton treatment.
2006- MD Anderson, Houston.
2006-University of Florida, Jacksonville.
2009- procure Oklahoma City.
2010- procure Warrenville Illinois [Chicago].
2012- Procure Somerset New Jersey [New York City].
2013- Mevion Washington University St. Louis.
2014- At least 13 proton units proposed or under construction
this year.
20
21
Tumor
22
Prostate
dose 100%
Sharp drop off at 45% for hip joint
Pair of opposed
lateral proton
ports
Proton Cranio-spinal Irradiation
(Prone Position based)
22
NIB
PATIENT SET UP ON
TREATMENT TABLE
Ion Beam Applications (IBA) Isocentric Gantry 22
Typical IBA 3 room Proton Treatment Installation 22
fixed beam
3 gantry rooms
230 MeV
Cyclotron
MEVION (Still River) Proton
unit, Single room unit with
superconducting cyclotron
mounted on gantry,
23
Gantry rotates through a
180 degree arc, and robotic
table allows all possible
angles of therapy to be
accomplished
ESTIMATED COSTS OF A PROTON FACILITY
EQUIPMENT, FACILITY, AND START UP COST
•
•
•
•
•
•
23
Single room, single gantry system…..$36,106,125
One gantry, remote cyclotron………..$57,207,027
One gantry, one fixed beam………….$73,708,555
Two gantry, one fixed beam……...….$97,657,456
Three gantry, one fixed beam……....$121,606,359
IMPT added to any unit, added
cost...$30,000,000
Proton Beam Treatment Delivery
• 77520
• 77522
• 77523
• 77525
Proton Beam Delivery; Simple
Proton Beam Delivery; Simple, with
compensators
Proton Beam Delivery; Intermediate
Proton Beam Delivery; Complex
• 0664
• 0419
APC For 77520, 77522,
APC For 77523, 77525,
23
Proton Reimbursement
HCPCS APC Descriptor
$2014
24
$2013.00
77520
0664 Simple w/o $872.37
comp
$1136.61
77522
0664 Simple with $872.37
comp
$1136.61
77523
0667 Intermediate $1205.27 $682.36
77525
0667 Complex
$1205.27 $682.36
OTHER CHARGES WITH PROTONS
•
•
•
•
•
99205
77263-22
77290-22
77290
77300
port)
• 77334
• 77321
• 77470-22
• 77431-22
•
•
•
•
•
77427
77315
77295
77336
77370
High Intensity Consultation.
25
Complex Treatment Planning
Complex Simulation(s) at time of setup.
Simulation as done as pre-plan,
Basic Dosimetry (often multiple done per
Complex Treatment Devices, blocks,
compensators, degraders, etc
Special Beam Considerations (Protons)
Special Treatment Procedure (Protons)
Short Week of Radiation Management (Single
Fraction)
standard week(s) of therapy
Complex Isodose Plan(s) (Proton Isodose)
3-D planning
Physics Support
Special Physics Report (if documented)
END
PRINCIPLES OF
BILLING, CODING
AND COMPLIANCE IN
RADIATION
ONCOLOGY
BMSi 2014
END SECTION 10
END SECTION 10
Fractionated Stereotactic Radiation
Therapy Treatment Management
51
Medicare will not allow 77435 to follow 77432, LIMIT OF
ONE PER COURSE.
If the procedure is planned to be fractionated 2 to
5 fractions, then it should be reported
as 77435 fractionated SRS or SBRT.
Average physician payment $601.87 in 2014
All of the ancillary codes associated with either
77432 or 77435 may be reported at the time of
setup or subsequent treatment except guidance
codes with IGRT.
NIB
This puts it in perspective
Courtesy of MEVION
Still River Systems – Compact Proton Therapy
NIB
Single Room
contains all
equipment
Cyclotron mounted on
gantry
Clean clinical environment
FDA 510k cleared
NIB
This is a
big
machine,
But it still
fits in one
room.
NIB
MEVION
1) Barnes Jewish
hospital in
St. Louis, Mo.
Now operational
treating patients.
2) University of
Oklahoma in
Okla. City, OK.
MEVION is now FDA approved. The
first three units are being installed
- 250 MeV
- ~20 tons
- Very high B field: 9 T
3) Robert Wood
Johnson
University, in
New Jersey
NIB
Double Scattering, Aperture, and compensator
Two Scatterers
Rotating
Range Modulator
Second
Scatterer
Aperture & Compensator
Fixed
Scatterer
P+
Two Patient specific scattering compensators
and an aperture and compensator each of
which is billed as a 77334
Intensity Modulated Proton Beam
24
• Varian Medical Systems announced its it’s updated
ProBeam proton therapy system received FDA 510(k)
clearance.
• The IMPT system gives clinicians more options for delivering
the dose precisely in the course of proton therapy
treatments.
• The scanning beam technology enables IMPT by modulating
dose levels on a spot-by-spot basis throughout the
treatment area.
• Irradiations from multiple angles are combined in an
optimal manner to improve control of dose distributions.
• Scanning beam technology eliminates the need to
utilize external compensators for each beam angle.
NIB
Depth doses of photons, protons, and carbon
Carbon ion beam ions
Pristine (Bragg) peak: Bragg peak by a near-monoenergetic carbon ion beam
Proton Accelerator - CYCLOTRON
NIB
Cyclotron opened for maintenance
NIB
Energy Selection System
Beam Transport and Switching System
NIB
21
Proton Beam
Shaping
Milled brass
compensators
Comparison of single photon versus single proton beams
Photon Beam
TUMOR
Proton Beam
TUMOR
21
Skull base tumor, Single Proton Port
21
22
Proton treatment of rib lesion
Proton Plan for a Lung tumor
22
Fixed Beam Treatment Nozzle and Robotic Table
65
22
ProCure
23
PROTON THERAPY REMBURSEMENT
• CMS has allowed each Proton therapy center to
be priced locally, due to the small number of
operating centers.
• Hospital payment under the APC 0664, and
0667 are still locally negotiated.
• As the Conversion Factor changes, we have no
way to predict the payment system, or the
values, over the next few years, (for all
radiation therapy services)
11 In operation
9 Under construction/in
development
4 Mevion
MPRI, IN
1993-2009
890 patients
ProCure, WA
Harvard/MGH,MA
2001-2009
4270 patients
ProCure, MI
Mayo, MN
UC San Francisco, CA
1994 -2009 (Ocular Tumors)
1200 patients
McLaren, MI
UPenn
NIPTRC, IL
RWJUH, NJ
ProCure, IL
Loma Linda, CA
1990 - 2009
14000 patients
Scripps, CA
NIB
ProCure, OK
2009
47 patients
Mayo, AZ
ProCure, NJ
UMaryland, MD
WashU, MO
Hampton
OUHSC, OK
UTenn, TN
UFPTI, FL
2006-2009
1847 patients
UCSD, CA
ProCure, FL
MD Anderson, TX
2006-2009
1700 patients
Source: National association for proton therapy
WHAT ARE PROTONS?
•
•
•
•
Sub-atomic particle with a positive charge
Weigh 2000 times as much as an Electron
Building block of all atoms
All atoms must have at least one Proton
and one Electron (Hydrogen)
• As more Protons are added to the
nucleus then Neutrons are also added
which creates different elements.
20
23
Proton machines
• Fixed beam physics adapted units
• Multiple gantry physics adapted units
• Multiple gantry dedicated radiation therapy
units
• Single gantry dedicated radiation therapy
units
• Single room gantry mounted cyclotron
• Next generation IMPT machines, prototype
unit now treating patients in Germany
202/216