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
Susan Granucci
Susan Granucci
Susan Granucci
Healthcare Reimbursement Specialist Healthcare Reimbursement Specialist Healthcare Reimbursement Specialist
Healthcare Reimbursement Specialist 808 Sagebrush Ct, SE808 Sagebrush Ct, SE808 Sagebrush Ct, SE808 Sagebrush Ct, SE Albuquerque, NM 87123 Albuquerque, NM 87123 Albuquerque, NM 87123 Albuquerque, NM 87123 Ph & Fax 505 Ph & Fax 505 Ph & Fax 505 Ph & Fax 505----292292292292----4217421742174217 e-mail: [email protected]
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 77261 – 77263 0 77336 0
All Visits & Psychotherapy 36000 & 36410 1 77280-772950 77370 0 ***except consults
763700 77305-77315 0 77401-77416 1 99241-99245
763750 773210 77417 0 may be billed
763801 77326-773280 77431-77432 1 0083T 0 (sbrt tx mgt)
769500 773310 77470 0
77332-773341 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)
1Coverage 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.
IMRT Continued
2. 77418 IMRT Treatment Delivery includes 36000 & 36410 1 77305-77315 0 77432 1
61793 0 77321 0 77470 1
Dx ultrasound 77326-77328 0 77520-775250
76942 1 77331 0 ***All Visits & Psychotherapy 0
77261 – 77263 0 77401-77416 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.
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 Comp
Tech Comp
9924X – Initial Consult Yes No1
77263 – Physician Plan Yes No
77290 – Pretreatment Simulation Yes Yes
76370 – CT Guidance No2 Yes
77301 – IMRT Plan (after CT imaging) Yes Yes 77334 – Treatment Devices (after planning) Yes Yes
77418 – Daily Treatment Delivery No Yes
76950 – Daily Ultrasound Set Up or No2 Yes 77417 – Port films as needed if no other guidance No Yes 77336 – Weekly QA (after planning) No Yes 77427 – Weekly Physician Management Yes No 77470-59 – Special Treatment Procedure Yes 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
No technical component for free-standing facilities, but there is a technical component (exam room) for hospital based facilities.
2
IMRT Revenues
For IMRT, 2005 Medicare reimbursement continues to be quite favorable, more-so in the free-standing facility at this time.
IMRT Services Hosp
APC Prof Comp Free-Standing TC 9924X – Initial Consult $ 79.65 $184.56 $0.00 77263 – Physician Plan $0.00 $167.13 $0.00 77290 – Pretreatment Simulation $224.07 $81.10 $259.98 76370 – CT Guidance $ 97.70 $44.34 $117.86
77301 – IMRT Plan (after CT imaging) $813.57 $414.98 $1,114.57 77334 – Treatment Devices (after planning) $163.67 $64.43 $129.61 77418 – Daily Treatment Delivery $309.20 $0.00 $687.84 76950 – Daily Ultrasound Set Up or $ 67.44 $30.32 $52.30 77417 – Port films if no other guidance $ 43.87 $0.00 $23.88 77336 – Weekly QA (after planning) $ 97.48 $0.00 $119.00 77427 – Weekly Physician Management $0.00 $172.05 $0.00 77470-59 – Special Treatment Procedure $ 332.60 $108.77 $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.
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 Hosp APC Prof Comp Free Standing TC 76370 – CT Guidance $ 97.70 $44.34 $117.86 2005 Medicare fees are unadjusted for local wage or geographic cost indexes
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 e.g., On Board Imager, used with
CyberKnife; two images beneath and two over the table
Electronic portal imaging e.g., Portal Vision, iViewGT- megavoltage x-ray imaging systems used for IMRT portal imaging
Ultrasound BAT, SonArray - B-mode ultrasonic imaging system for IMRT image guidance and patient positioning on a daily basis
Respiratory gating technology 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
CT scan reconstruction 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.
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 Hosp APC Prof Comp
Free Standing Tech Comp
76370 – CT Guidance $ 97.70 $44.34 $117.86
76000 – Fluoroscopy up to 1 hr $79.09 $8.72 $52.30 77417 – Electronic portal imag $43.87 n/a $23.88 77280 – Simple simulation
(some-times used for Acculoc) $97.48 $36.38 $138.33 76950 – Ultrasnd guidance (BAT) $67.44 $30.32 $52.30 C9722 – Stereoscopy kV imaging with
infrared tracking $75.00 n/a n/a
N/A – Respiratory Gating n/a n/a n/a
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 image-guided 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
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
Prof Comp
Free Standing
TC
Treatment Planning Code Choices
77295 – 3-D Plan or $813.57 $237.24 $1,114.57 G0242 – Cobalt 60 Plan or $1,450.00 $0.00 $0.00
G0338 – Linac plan $1,150.00 $0.00 $0.00
Treatment Delivery Code Choices
77413 – Treatment Delivery or $124.12 $0.00 $93.23
G0243 – Cobalt 60 Delivery 1 session only $5,250.00 $0.00 $0.00 G0173 – Linac non-robotic 1 session only $5,250.00 $0.00 $0.00 G0251 – Linac non-robotic, fractionated $1,150.00 $0.00 $0.00 G0339 – Linac robotic 1 or 1st session $5,250.00 $0.00 $0.00 G0340 – Linac robotic 2nd thru 5th session $3,750.00 $0.00 $0.00
Additional Codes (Caution, see bundling tables below)
9924x – Initial Consult $ 79.65 $184.56 $0.00 77263 – Treatment Plan $0.00 $167.13 $0.00 76355 – CT Guidance SRS $270.58 $392.24 $328.95 77300 – Basic Dosimetry $97.48 $32.21 $53.44 77334 – Trt Device(s) $163.67 $64.43 $129.61 77470 – Spec Trt Procedure $332.60 $108.77 $444.92
77432 – Phys Mgt cerebral 1 session $0.00 $425.59 $0.00
0083T – Phys Mgt body, per day $0.00 $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 77332-77334.
G treatment delivery codes permit most other 77xxx codes with modifier 59.
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.
APBI / MammoSite Coding and Reimbursement Surgery Service Hosp APC Prof Comp Tech Comp varies Lumpectomy or lesion excision +
19296 Place catheter in breast post op $3,250.00 $209.19 na 19297 Place catheter post during lumpect $2,750.00 $95.88 na
Radiation
76950 or US guidance for rtx placement or $67.44 $30.32 $52.30 76965 Echo guidance rtx interstitial $67.44 $70.11 $222.08 77263 Phys rad therapy planning $0.00 $167.13 na
77280 Simple simulation $97.48 $36.38 $138.33
Planning
77290 Complex simulation $224.07 $81.10 $259.60 76370 Ct scan for therapy guide $97.70 $44.34 $117.86 77326 Brachy plan, simple $97.48 $48.51 $94.36
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
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)
1Coverage may be allowed if coded with Modifier 59 when billed on same
