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Radiation Oncology, SRS, SBRT, Protons. Advanced Concepts Section 10 9:00-10:00 031114 Revised for 4-10-14 65 Carl R Bogardus, Jr MD.

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Presentation on theme: "Radiation Oncology, SRS, SBRT, Protons. Advanced Concepts Section 10 9:00-10:00 031114 Revised for 4-10-14 65 Carl R Bogardus, Jr MD."— Presentation transcript:

1 Radiation Oncology, SRS, SBRT, Protons. Advanced Concepts Section 10 9:00-10:00 031114 Revised for 4-10-14 65 Carl R Bogardus, Jr MD

2 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

3 STEREOTACTIC PROCEDURES Gamma Knife (Radio surgery, SRS) Cyber Knife (SRS, SBRT) Conventional XRT (SRS, SBRT ) 1

4 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

5 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

6 Stereotactic Procedures, SBRT 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. 1

7 MANAGEMENT OF CRANIAL LESIONS BY 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 1

8 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 THESE CODES ARE MUTUALY EXCLUSIVE, CANNOT BE USED SEQUENTIALLY 42 2

9 (77295, not 77301) 3-Dimensional simulation (77295, not 77301) is performed to determine the optimal beam arrangement to deliver treatment to a target volume by Gamma Knife. Gamma Knife Historical Background 2

10 The patient is fixed into a head frame for total accuracy of localization of the lesion NIB

11 The head frame locks in to the Gamma Knife unit for absolute accuracy of set up and treatment. Bill each helmet as a 77334 2

12 Removal of the head Frame 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

13 GAMMA KNIFE TECHNICIAL TREATMENT DELIVERY CODE The code 77371 Gamma Knife one fraction only, complete course of therapy, is used for the technical reimbursement. 2

14 Gamma knife work page and final narrative of procedure 4 ONCOCHART

15 History of Dosimetry 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. Covered in Section 7

16 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 APC Rules for Gamma Knife (SRS) Reimbursement 7

17 The use of a linear accelerator (Cyber Knife, X- knife, 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 SRS USING A LINEAR ACCELERATOR

18 Brain Lab Micro Multileaf collimator Removable head frame 4-5

19 BRAIN LAB STEREOTACTIC PLANING; THIS USES IMRT FORWARD PLANNING ALGORYTHM SOFTWARE, AND SHOULD BE BILLIED AS ADVANCED 3-D 77295 5

20 absolutely required A report is absolutely required for proper documentation of this procedure 6 136/216

21 G0173--GO340 DELETED 1-1-14 77371 single session,Gamma Knife 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 Stereotactic treatment delivery 7

22 . 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 NIB

23 SRS/SRT Limited to Contents of the Cranial Vault (Brain) Stereotactic Radiosurgery or Stereotactic Radiation Therapy Treatment; Limited to Contents of the Cranial Vault (Brain) 77371Single Cranial treatment delivery using multisource photon unit (Gamma Knife) 77432Single Cranial Treatment Physician Management 77372Single Cranial treatment delivery using a linear accelerator unit. RULES AND CODES FOR SRS 8 This is a change from previous years

24 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. 8

25 77373 1st FX 77373 2nd FX 77373 3rd FX 77373 4th FX 77373 5th FX SBRT, Body Only

26 Courtesy ONCOCHART Notice the detailed and customized clinical comments as part of the statement of medical necessity 9

27 SBRT Below the Cranial Vault (Brain) Stereotactic Body Radiation Therapy Treatment; Limited to the Body Below the Cranial Vault (Brain) 773731 – 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 77435Physician 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. 9 RULES AND CODES FOR SBRT

28 Medicare reimbursement values, 2014. 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. 9

29 Stereotactic Radio Surgery (SRS), 77432 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) 10

30 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

31 IMAGE GUIDED RADIATION THERAPY IGRT 12

32 COMBINED CT AND LINEAR ACCELERATOR THE TREATMENT IS IMRT 77418, THE GUIDANCE IS DAILY CONE BEAM THE GUIDANCE IS DAILY CONE BEAM CT IMAGING BILLED AS 77014, OR; 12

33 LINEAR ACCELERATOR IMRT USING KILOVOLTAGE X-RAY IMAGING, ON BOARD IMAGING (OBI) 77421 STEREOSCOPIC 12

34 ADVANTAGE OF IGRT 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 13

35 BILLING FOR IGRT 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 13

36 77427 Physician treatment management 77418 IMRT treatment delivery 77421 Fiducial treatment guidance, or 77014 CT treatment guidance (2014??) 13 Available Codes for IGRT Treatment with SRS or SBRT may still be considered IGRT, but the guidance codes are bundled, and the treatment cannot be IMRT, 77418

37 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 REQUIRES POSITIONING OR TRACKING SYSTEM, INFRARED OR SURFACE ANATOMY, FIDUCIAL MARKERS, OR A CONSISTANT DEFINABLE ANATOMIC STRUCTURE 13

38 FIDUCIAL MARKERS FOR STEREOSCOPIC GUIDANCE 13 77421 STEREOSCOPIC X-RAY GUIDANCE

39 FORMAT OF STEREOSCOPIC X-RAY GUIDANCE Locating the target volume on orthogonal X- Rays with Fiducial markers. Locating the target volume on orthogonal X- Rays 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

40 SIMULATION IMAGES AND ON TREATMENT KV BEAM SET UP IMAGES SUPERIMPOSED NIB 168/183/216

41 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 14

42 BILLING FOR STEREOSCOPIC GUIDANCE, 77421 The 2014 Medicare value is : 77421-26 about $ 19.05 77421-TC about $ 51.37 77421-TC about $ 51.37 77421 about $70.43 77421 about $70.43 14 170/216

43 Image Guidance of Radiation Treatment Delivery 77421Stereotactic 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 Direct supervision of a physician.  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. 14

44 CONE BEAM CT 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

45 CONE BEAM CT 77014 15

46 77014CT 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

47 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

48 Respiratory motion causes mismatch Respiratory gating allows treatment only at match time 17 172/183/216

49 2014 CPT update +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. NIB 17

50 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 17

51 PARTICLE ACCELERATORS 19 The concept of a Proton radiation therapy unit was first proposed by physicists in 1946

52 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

53 Tumor 21

54 22 Pair of opposed lateral proton ports Prostate dose 100% Sharp drop off at 45% for hip joints

55 Proton Cranio-spinal Irradiation (Prone Position based) 22

56 NIB PATIENT SET UP ON TREATMENT TABLE

57 Ion Beam Applications (IBA) Isocentric Gantry 22

58 Typical IBA 3 room Proton Treatment Installation 230 MeV Cyclotron 3 gantry rooms fixed beam 22

59 MEVION (Still River) Proton unit, Single room unit with superconducting cyclotron mounted on gantry, Gantry rotates through a 180 degree arc, and robotic table allows all possible angles of therapy to be accomplished 23

60 ESTIMATED COSTS OF A PROTON FACILITY EQUIPMENT, FACILITY, AND START UP COST Single room, single gantry system…..$36,106,125 Single room, single gantry system…..$36,106,125 One gantry, remote cyclotron………..$57,207,027 One gantry, remote cyclotron………..$57,207,027 One gantry, one fixed beam………….$73,708,555 One gantry, one fixed beam………….$73,708,555 Two gantry, one fixed beam……...….$97,657,456 Two gantry, one fixed beam……...….$97,657,456 Three gantry, one fixed beam……....$121,606,359 Three gantry, one fixed beam……....$121,606,359 IMPT added to any unit, added cost...$30,000,000 IMPT added to any unit, added cost...$30,000,000 23

61 Proton Beam Treatment Delivery 77520Proton Beam Delivery; Simple 77522Proton Beam Delivery; Simple, with compensators 77523Proton Beam Delivery; Intermediate 77525Proton Beam Delivery;Complex 0664APC For 77520, 77522, 0419APC For 77523, 77525, 23

62 Proton Reimbursement HCPCSAPCDescriptor$2014$2013.00 775200664Simple w/o comp $872.37 $1136.61 775220664Simple with comp $872.37 $1136.61 775230667Intermediate $1205.27 $682.36 775250667Complex $1205.27 $682.36 24

63 OTHER CHARGES WITH PROTONS 99205High Intensity Consultation. 99205High Intensity Consultation. 77263-22Complex Treatment Planning 77263-22Complex Treatment Planning 77290-22Complex Simulation(s) at time of setup. 77290-22Complex Simulation(s) at time of setup. 77290Simulation as done as pre-plan, 77290Simulation as done as pre-plan, 77300Basic Dosimetry (often multiple done per port) 77300Basic Dosimetry (often multiple done per port) 77334Complex Treatment Devices, blocks, compensators, degraders, etc 77334Complex Treatment Devices, blocks, compensators, degraders, etc 77321Special Beam Considerations (Protons) 77321Special Beam Considerations (Protons) 77470-22Special Treatment Procedure (Protons) 77470-22Special Treatment Procedure (Protons) 77431-22Short Week of Radiation Management (Single Fraction) 77431-22Short Week of Radiation Management (Single Fraction) 77427standard week(s) of therapy 77427standard week(s) of therapy 77315Complex Isodose Plan(s) (Proton Isodose) 77315Complex Isodose Plan(s) (Proton Isodose) 772953-D planning 772953-D planning 77336Physics Support 77336Physics Support 77370Special Physics Report (if documented) 77370Special Physics Report (if documented) 25 END

64 PRINCIPLES OF BILLING, CODING AND COMPLIANCE IN RADIATION ONCOLOGY BMSi 2014 END SECTION 10

65

66 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 except guidance codes with IGRT. 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. Fractionated Stereotactic Radiation Therapy Treatment Management 51

67 This puts it in perspective Courtesy of MEVION NIB

68 Cyclotron mounted on gantry Clean clinical environment Single Room contains all equipment FDA 510k cleared Still River Systems – Compact Proton Therapy NIB

69 This is a big machine, But it still fits in one room. NIB

70 -250 MeV -~20 tons - Very high B field: 9 T MEVION 1) Barnes Jewish hospital in St. Louis, Mo. Now operational treating patients. 2) University of Oklahoma in Okla. City, OK. 3) Robert Wood Johnson University, in New Jersey MEVION is now FDA approved. The first three units are being installed NIB

71 Double Scattering, Aperture, and compensator Two Scatterers Rotating Range Modulator Fixed Scatterer Aperture & Compensator Second Scatterer P+ Two Patient specific scattering compensators and an aperture and compensator each of which is billed as a 77334 NIB

72 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. Intensity Modulated Proton Beam 24

73 Depth doses of photons, protons, and carbon ions Pristine (Bragg) peak: Bragg peak by a near-monoenergetic carbon ion beam NIB Carbon ion beam

74 Proton Accelerator - CYCLOTRON NIB

75 Cyclotron opened for maintenance NIB

76 Energy Selection System Beam Transport and Switching System NIB

77 Proton Beam Shaping Milled brass compensators 21

78 Photon Beam Proton Beam Comparison of single photon versus single proton beams 21 TUMOR TUMOR

79 Skull base tumor, Single Proton Port 21

80 Proton treatment of rib lesion 22

81 Proton Plan for a Lung tumor 22

82 Fixed Beam Treatment Nozzle and Robotic Table 65 ProCure 22

83 PROTON THERAPY REMBURSEMENT CMS has allowed each Proton therapy center to be priced locally, due to the small number of operating centers. 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. 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) 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) 23

84 Harvard/MGH,MA 2001-2009 4270 patients Loma Linda, CA 1990 - 2009 14000 patients MD Anderson, TX 2006-2009 1700 patients Source: National association for proton therapy UFPTI, FL 2006-2009 1847 patients UC San Francisco, CA 1994 -2009 ( Ocular Tumors) 1200 patients ProCure, OK 2009 47 patients UPenn Hampton ProCure, WA ProCure, IL ProCure, FL MPRI, IN 1993-2009 890 patients ProCure, NJ McLaren, MI UTenn, TN Mayo, MN Mayo, AZ ProCure, MI Scripps, CA UCSD, CA OUHSC, OK WashU, MO UMaryland, MD RWJUH, NJ 9 Under construction/in development 4 Mevion NIPTRC, IL 11 In operation NIB

85 WHAT ARE PROTONS? Sub-atomic particle with a positive charge Sub-atomic particle with a positive charge Weigh 2000 times as much as an Electron Weigh 2000 times as much as an Electron Building block of all atoms Building block of all atoms All atoms must have at least one Proton and one Electron (Hydrogen) 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. As more Protons are added to the nucleus then Neutrons are also added which creates different elements. 20

86 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 23 202/216


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