Radiation Therapy Coverage, Coding, And Reimbursement

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Radiation Therapy Coverage, Coding, and Reimbursementfor New TechnologiesPresented by Susan Granucci,Healthcare Reimbursement SpecialistTopics1. Intensity Modulated Radiation Therapy (IMRT)2. Tomotherapy3. Image Guided Radiation Therapy (IGRT)4. Stereotactic Radio Surgery (SRS), Stereotactic Radiation Therapy (SRT) orStereotactic Body Radiation Therapy (SBRT)5. Accelerated Partial Breast Irradiation (APBI)Susan GranucciHealthcare Reimbursement Specialist808 Sagebrush Ct, SEAlbuquerque, NM 87123505--292292--4217Ph & Fax 505e-mail: Snucci@aol.com1

IMRT – Intensity Modulated Radiation TherapyIMRT is a type of external beam radiation therapy that delivers highly conformal, 3-Dradiation treatment. It typically includes inverse planning, and features numerousbeams of radiation involving multiple targets with different doses, intended to maximizethe dose to the tumor and minimize the dose to normal tissue. The difference between3-D and IMRT is the linear accelerator equipped with multileaf collimation (MLC) ormoving aperture which shuts down portions of the beam during each treatment tomodulate 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 threedirections.)Coverage – Medicare Code BundlingTwo codes are primarily used for reporting IMRT: 77301 for planning, and 77418 fortreatment delivery.1. Planning code 77301 is intended to include all of the following:All codes forDiagnostic CT36000 & 36410 176370 076375 076380 176950 077261 – 77263 077280-77295 077305-77315 077321 077326-77328 077331 077332-77334 1All Visits &77336 0Psychotherapy077370***except consults77401-77416 199241-99245077417may be billed177431-774320083T 0 (sbrt tx mgt)77470 077520-77525 0Free-standing and hospital edits are different. Hospital Outpatient edits do not include 77332:77334 tx devices.Source CCI 4/1/05See current CCI edit tables for additional edits.0Coverage not allowed if billed same day (with or without a modifier)1Coverage may be allowed if coded with Modifier 59 when billed on same dateas the treatment plan, and documentation supports separate service.Certain of the above codes are acceptable on different days, such as treatmentplanning 77263, devices 77332-77334, physician management 77427, andtreatment delivery 77418. Note, basic dosimetry 77300 has been removed fromthe planning code edit table, and may be quantity billed as appropriate.2

IMRT Continued2. 77418 IMRT Treatment Delivery includes36000 & 36410 161793 0Dx ultrasound76942 177261 – 77263 077305-77315 077321 077326-77328 077331 077401-7741677432 177470 177520-77525 0***All Visits & Psychotherapy 0except consultsHospital 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 4/1/05Note, port films-77417, weekly QA-77336, treatment devices-77332-77334, andphysician weekly management have been removed from the above dailytreatment edit tables.Commercial Insurance Coverage LimitsOne insurance company's perspective:Aetna considers intensity modulated radiation therapy (IMRT) medically necessaryfor the following indications:1. Treatment of radiosensitive tumors of the brain, head, neck, spine and paraspinalregions; or2. Treatment of prostate carcinoma in individuals with an intact prostate when ultrahigh 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 investigationalbecause of a lack of evidence that it provides clinical outcomes equivalent tocollimator-based IMRT.For these reasons, prior authorization is always recommended.3

IMRT CodingBAT 76950, Acculoc and Other Image GuidanceUltrasound guidance for field placement, code 76950, is currently the code used mostoften for verifying precise targeting for daily treatment. Other image guidance mayinclude implanted marker seeds, CT and portal imaging systems, and a variety of codesfrom CT localization to simple simulation are being reported. New guidance code(s) arein development. Additional discussion to follow.Typical Coding for IMRT Course of TherapyProfTechComp Comp9924X – Initial Consult77263 – Physician Plan77290 – Pretreatment Simulation76370 – CT Guidance77301 – IMRT Plan (after CT imaging)77334 – Treatment Devices (after planning)77418 – Daily Treatment Delivery76950 – Daily Ultrasound Set Up or77417 – Port films as needed if no other guidance77336 – Weekly QA (after planning)77427 – Weekly Physician Management77470-59 – Special Treatment YesYesYesYesYesYesYesNoYesOther codes may or may not apply depending on individual case,documentation, and payer guidelines.Use new Category III code for compensator-based IMRT: 0073T. Reimbursementcompares to 77418.ACR suggests treatment devices be billed once for immobilization, and for eachcomplex IMRT field12No 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 RevenuesFor IMRT, 2005 Medicare reimbursement continues to be quite favorable, more-so inthe free-standing facility at this time.IMRT Services9924X – Initial Consult77263 – Physician Plan77290 – Pretreatment Simulation76370 – CT Guidance77301 – IMRT Plan (after CT imaging)77334 – Treatment Devices (after planning)77418 – Daily Treatment Delivery76950 – Daily Ultrasound Set Up or77417 – Port films if no other guidance77336 – Weekly QA (after planning)77427 – Weekly Physician Management77470-59 – Special Treatment ProcedureHospAPCProfComp 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 0.00 172.05 108.77FreeStandingTC 0.00 0.00 259.98 117.86 1,114.57 129.61 687.84 52.30 23.88 119.00 0.00 444.922005 Medicare fees are unadjusted for local wage or geographic cost indexesCompare IMRT treatment delivery code 77418 at 309 - 687 to standardexternal beam daily treatment delivery code 77413 fee ranges of 124 - 93 forAPC or Free Standing Facility.3Compare IMRT planning code 77301 at 814 - 1115 to traditional simulationand isodose codes 77290 & 77315 combined fees of fees 448 - 366.One table of billing statistics for 2003 shows code 77418 represents 13% oftreatment delivery codes and 52% of treatment delivery revenues.3Compenssator based IMRT treatment delivery code 0073T is allowed at the same rates as 77418 byMedicare for 2005.5

TomoTherapyTomoTherapy (brand name for TomoTherapy Hi-Art System ) takes IMRT severalsteps further. It combines planning, patient positioning and treatment delivery into onesystem. Radiation is delivered in a unique helical (or spiral) delivery pattern whichtravels in multiple circles all the way around the gantry ring. The patient's couch alsomoves, guiding the beam at slightly different planes during treatment.For tumor localization, a special verification CT scan is taken just before each treatmentto verify the patient's position and position of the tumor.Treatment delivery is via IMRT, but with a spiral delivery pattern. Computer controlledMLC has two sets of interlaced leaves for continuous beam modulation.Coverage, Coding and RevenuesCoverage issues are not readily found. There are no TomoTherapy references inCMS'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 portfilms.Image Guidance76370 – CT GuidanceHospAPCProfComp 97.70 44.34FreeStandingTC 117.862005 Medicare fees are unadjusted for local wage or geographic cost indexes6

Image Guided Radiation Therapy (IGRT)To deal with tumor changes, patient changes, and variations in the targeted area ofinterest such as movement caused by breathing, heart, and gastric motility, radiationtherapy is embracing image guided radiation therapy (IGRT). IGRT is typically usedwith daily IMRT treatment delivery, but can also be applied to other 3-D treatments suchas stereotactic radiation therapy and accelerated partial breast irradiation. Improvedprecision with IGRT sometimes results in fewer treatment fractions. Some have labeledIGRT as a new type of radiation therapy. Based on the wide variety of equipment andmodalities available, it appears that IGRT should be considered another "tool" toenhance precision in treatment delivery rather than the therapy itself.IGRT may include any of the followingFluoroscopyElectronic portal imagingUltrasoundRespiratory gating technologyCT scan reconstructione.g., On Board Imager, used withCyberKnife; two images beneath and twoover the tablee.g., Portal Vision, iViewGT- megavoltage xray imaging systems used for IMRT portalimagingBAT, SonArray - B-mode ultrasonic imagingsystem for IMRT image guidance and patientpositioning on a daily basisRPM - lightweight reflective marker andcamera track motion and breathing pattern;correlates data with treatment plan; beam off/ beam on signals more accurate treatmentdeliveryElekta's Synergy integrated system usescone beam CT for daily verification;Tomotherapy uses sonograms to compareCT for the current fraction to a referencesonogram for each fractionPartial list of manufacturersNext generation of IGRT:ART - Adaptive Radiation Therapy takes IGRT one step further from shifting thepatient's position to actually modifying the daily treatment. PET and MRI have alsobeen mentioned in connection with image guidance, but they are fairly uncommon atthis 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 gatingare intrafractional)Coverage, Coding and RevenuesTechnology is still relatively new, and targeted payer coverage guidelines have not yetbeen established and/or published.Coding and revenues specific to IGRT are based on the following codes, until such timeas a more specific code(s) is developed. A new code is expected in 2006.Possible IGRT CodesProf Free StandingCompTech Comp 117.86 97.70 44.34 52.30 79.09 8.72n/a 23.88 43.87Hosp APC76370 – CT Guidance76000 – Fluoroscopy up to 1 hr77417 – Electronic portal imag77280 – Simple simulation (sometimes used for Acculoc)76950 – Ultrasnd guidance (BAT)C9722 – Stereoscopy kV imaging withinfrared trackingN/A – Respiratory Gating 97.48 36.38 138.33 67.44 30.32 52.30 75.00n/an/an/an/an/a2005 Medicare fees are unadjusted for local wage or geographic cost indexes8

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 higherdose, usually in one session. Treatment may be delivered via gamma ray(GammaKnife) using a head chamber, or via a linear accelerator using a head frameapplied by a neurosurgeon, and fiducial markers for accurate delivery.SRT & SBRT – More recent advances have allowed this technique to be applied tomany other parts of the body. Extra-cranial lesions treated with stereotactic techniquesare also known as Stereotactic Body Radiation Therapy. SRT / SBRT can be deliveredwith hyperfractionation (2-5 fractions) as well as conventional fractionation. Rigidimmobilization and/or imaging guidance (IGRT) are required to assure great accuracy.CoverageCenters for Medicare & Medicaid Services (CMS) recognizes treatments to brain, neck,spine, lung, pancreas, prostate, bone, and liver. It has developed different codes forCobalt 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 thefollowing indications:1. Stereotactic radiosurgery is considered experimental and investigational fortreatment of Parkinson's disease and epilepsy (except when associated withtreatment of AV malformations or brain tumors)2. Fractionated stereotactic body radiosurgery is considered experimental andinvestigational for treatment of cancers in extracranial sites (e.g., liver, lung,kidney, and prostate) because definitive conclusions regarding its indications andefficacy have not been demonstrated in large, controlled clinical trials.3. Stereotactic body radiosurgery: Stereotactic administration of radiosurgery toextracranial sites (e.g., liver, lung, kidney, and prostate), other than inoperableprimary CNS tumors of the spine, is considered as experimental andinvestigational.9

Coding and ReimbursementMedicare has established unique HCPCS "G" codes for hospital outpatient claims. Forfree-standing facilities, the G codes are not generally accepted. Commercial payersshould be contacted for prior authorization and coding preference.SRT CPT Codesif performed & documentedHosp APCTreatment Planning Code Choices77295 – 3-D Planor 813.57G0242 – Cobalt 60 Planor 1,450.00G0338 – Linac plan 1,150.00Treatment Delivery Code Choices77413 – Treatment Delivery or 124.12G0243 – Cobalt 60 Delivery 1 session only 5,250.00G0173 – Linac non-robotic 1 session only 5,250.00G0251 – Linac non-robotic, fractionated 1,150.00stG0339 – Linac robotic 1 or 1 session 5,250.00G0340 – Linac robotic 2nd thru 5th session 3,750.00Additional Codes (Caution, see bundling tables below)9924x – Initial Consult 79.6577263 – Treatment Plan 0.0076355 – CT Guidance SRS 270.5877300 – Basic Dosimetry 97.4877334 – Trt Device(s) 163.6777470 – Spec Trt Procedure 332.6077432 – Phys Mgt cerebral 1 session 0.000083T – Phys Mgt body, per day 0.00ProfCompFreeStandingTC 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 0.002005 Medicare fees are unadjusted for local wage or geographic cost indexesBundling (as of 4/1/2005 CCI Edit Tables)77295 Includes:76370-76375 guidance77280-77290 simulation77305-77315 isodose77336 physics QAAnd a few others77295 is included in77301 IMRT planningPhysician bundlingincludes all E&M andpsych as well.G planning codes include all otherradiation therapy codes from 77280to 77470, 0083T, and most 61xxxcodes. The only exceptions areinitial plan 77263, dosimetry 77300with mod 59, port films 77417, andtreatment device codes 7733277334.G treatment delivery codes permitmost other 77xxx codes withmodifier 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 segmentsurrounding the tumor rather than the entire breast. Since the duration of treatment is 4to 5 days rather than 5 to 6 weeks, radiation is delivered in fewer fractions at largerdoses per fraction. APBI features:interstitial brachytherapy (high dose rate) via balloon catheters placed intolumpectomy cavity usually immediately after surgery, but can follow laterthe MammoSite radiation treatment system3-D conformal planningtwo treatments each day for five days (BID treatments require modifier 59)breast conserving therapyCoverageMedical 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 nodeevaluation.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 denialis implied, it does not specifically so state. At this time, it would appear most insurersare paying for APBI claims.Based on the available evidence, the Blue Cross and Blue Shield Association Medical AdvisoryPanel made the following judgments about whether accelerated partial breast irradiation usingbrachytherapy meets the Technology Evaluation Center criteria to decrease recurrence afterbreast-conserving surgery for early stage breast cancer.Accelerated partial breast irradiation using brachytherapy as the sole radiation treatment afterbreast-conserving surgery for early stage breast cancer does not meet the TEC criteria. Nov.,2002TEC Assessments are scientific opinions, provided solely for informational purposes. TECAssessments 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; anyparticular course of treatment, procedure, or service; or the payment or non-payment of thetechnology or technologies evaluated.11

APBI / MammoSite Coding and ReimbursementHospAPCProfCompTechComp 3,250.00 2,750.00 209.19 95.88nanaUS guidance for rtx placement orEcho guidance rtx interstitial 67.44 67.44 30.32 70.11 52.30 222.087726377280PlanningPhys rad therapy planningSimple simulation 0.00 97.48 167.13 36.38na 138.33772907637077326Complex simulationCt scan for therapy guideBrachy plan, simple 224.07 97.70 97.48 81.10 44.34 48.51 259.60 117.86 94.36Surgeryvaries1929619297Radiation76950 or76965ServiceLumpectomy or lesion excision Place catheter in breast post opPlace catheter post during lumpector772953-D Treatment plan 813.57 237.24 1,114.57Additional Codes77300Basic Dosimetry 97.48 32.21 53.4477336-59 Radiation physics QA 97.48na 119.0077370-59 Spec physics consult 97.48na 139.0877427Radiation tx management, x 5 0.00 172.05na77470Special radiation treatment 332.60 108.77 444.9277781-59 High intensity brachytherapy – or – 790.75 86.03 809.4977782-59 High intensity brachytherapy 790.75 129.61 809.49C1717Brachy source IR 192* 0.00na 0.002005 Medicare fees are unadjusted for local wage or geographic cost indexesModifier 59 is essential to bypass the following edits:77370 is bundled into 77336 on same day77336 is bundled into 77326 on same dayWhen treatments are BID, always use mod 59 on second treatment to avoidduplicate denial* C1717 hospital pass through cost may be allowed byMedicare according to the vendorBundling: When 3-D treatment plan code 77295 is used, it includes other plan codes77290, 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 quarterlyupdates by CD for one yearOr download CCI free, sFree of chargeMultiple files to manage, fairly difficult to navigate between files Edits apply to codes on same dayEdits are different for hospitals and doctors or freestanding providersEdits are different for mutually exclusive and column 1 & 2 filesNeed 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 quarterlyEach code edit is followed by a suffix:0Coverage not allowed if billed same day (with or without a modifier)Coverage may be allowed if coded with Modifier 59 when billed on samedate as the treatment plan, and documentation supports separate service.113

3 IMRT Continued 2. 77418 IMRT Treatment Delivery includes 36000 & 36410 177305 -77315 0 77432 61793 0 77321 0 77470 1 Dx ultrasound 77326 -77328 0 77520 -77525 0 76942 1 77331 0 ***All Visits & Psychotherapy 0 77261 – 77263 0 77401 -77416

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