4Stereotactic Procedures, SRS 1SRS, 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.
5Stereotactic Procedures, SBRT 1When 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 The remaining fractions are considered bundled into the initial treatment and are not reimbursable.RULE CHANGE 2014
6Stereotactic Procedures, SBRT 1SBRT, 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,If IMRT , is used for planning, treatment delivery should beTreatment may be delivered using a linear accelerator, Tomotherapy unit, or Cyber Knife unit, but Protons are excluded at this time.
7MANAGEMENT OF CRANIAL LESIONS BY STEREOTACTIC TREATMENT 1Medicare would expect to see 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, must be used to report the entire course of treatment.RULE CHANGE 2014
82Only one of these codes may be reported per session of stereotactic radiation therapy. The codes 77427, 77432, and 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 SEQUENTIALLY42
9Gamma Knife Historical Background 2Gamma Knife Historical Background3-Dimensional simulation (77295, not 77301) is performed to determine the optimal beam arrangement to deliver treatment to a target volume by Gamma Knife.
10NIBThe patient is fixed into a head frame for total accuracy of localization of the lesion
112The head frame locks in to the Gamma Knife unit for absolute accuracy of set up and treatment. Bill each helmet as a 77334
12Removal of the head Frame 2The code application of stereotactic frame, includes removal (a separate process) CPT)This is only a neurosurgery code, in spite of what you may have been told20664 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 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.
13GAMMA KNIFE TECHNICIAL TREATMENT DELIVERY CODE 2GAMMA KNIFE TECHNICIAL TREATMENT DELIVERY CODEThe code Gamma Knife one fraction only, complete course of therapy, is used for the technical reimbursement.
14Gamma knife work page and final narrative of procedure 4Gamma knife work page and final narrative of procedureONCOCHART
15History of Dosimetry Forward Planned IMRT Inverse planned IMRT Covered in Section 7Conventional Dosimetry.Gamma plan (original 3-D planning)Basic 3-D External beam planning (3-D simulation)Forward Planned IMRTInverse planned IMRTAdvanced 3-D planningThe use of forward planned IMRT planning algorithms is the basis of all Advanced 3-D Dosimetry for SRS and SBRT.
16Hospitals Must use 77371, 77372 for SRS delivery. APC Rules for Gamma Knife (SRS) Reimbursement7Hospitals must bill for Gamma Knife SRS planning using CPT procedure code 77295Hospital APC ~$1,036.39Hospitals Must use 77371, for SRS delivery.THIS IS USUALY A NEGOTIATED RATE Hospital APC ~$ 5,615.41
17SRS USING A LINEAR ACCELERATOR 8The 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 may be reported for SRS, fractions 2-5 are now considered bundled.
1977295 5 BRAIN LAB STEREOTACTIC PLANING; THIS USES IMRT FORWARD PLANNING ALGORYTHM SOFTWARE, AND SHOULD BE BILLIED AS ADVANCED 3-D77295
206A report is absolutely required for proper documentation of this procedure136/216
21Stereotactic treatment delivery 7G0173--GO340 DELETEDsingle session, Gamma Knifesessions, SRS, Linac, free standing center, or hospital, Cranial only, bill one time.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 IF YOU TREAT OVER 5 SESSIONS
22NIB Sidney Hayes, MD Novitas-Solutions . I think they are going to allow to use the G codes, but bundle and pay through the codes for 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, MDNovitas-Solutions
23This is a change from previous years RULES AND CODES FOR SRS8SRS/SRTStereotactic 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 Management77372Single Cranial treatment delivery using a linear accelerator unit.This is a change from previous years
248Stereotactic 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.
25SBRT, Body Only 77373 1st FX 77373 2nd FX 77373 3rd FX 77373 4th FX
269Notice the detailed and customized clinical comments as part of the statement of medical necessityCourtesy ONCOCHART
27RULES AND CODES FOR SBRT 9 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 sourceIf treatment extends beyond 5 fractions, Code should not be used for the case; rather (IMRT) must be used for all fractions delivered 1-X77373 includes all Image Guided Codes77435Physician treatment management 1 – 5 treatmentsIncludes image guidanceIf treatment extends beyond 5 fractions should not be used for the case. Management will be considered only.
28Medicare 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 $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 $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 $SRS stereotactic radiation treatment management of cranial lesion(s) , complete course of treatment consisting of one session $9
29Stereotactic Radio Surgery (SRS), 77432 10What’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)
30Stereotactic Body Radiation therapy (SBRT) 77435 11What’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 therapyWhat 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.
32THE GUIDANCE IS DAILY CONE BEAM CT IMAGING BILLED AS 77014, OR; 12COMBINED CT AND LINEAR ACCELERATORTHE TREATMENT IS IMRT 77418,THE GUIDANCE IS DAILY CONE BEAMCT IMAGING BILLED AS 77014, OR;
3312LINEAR ACCELERATOR IMRT USING KILOVOLTAGE X-RAY IMAGING, ON BOARD IMAGING (OBI)77421 STEREOSCOPIC
34ADVANTAGE OF IGRT13The image is directly referenced to the treatment machineAll machine parameters are in perfect geometric relationship to the imagesThe Physician guides the daily treatment based on “live “images
35BILLING FOR IGRT There is no code at this time for IGRT 13There is no code at this time for IGRTWithout a specific code you cannot bill for a new procedureThe only choice is to use existing codes
36Available Codes for IGRT 13Available Codes for IGRTPhysician treatment managementIMRT treatment delivery77421 Fiducial treatment guidance, or77014 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
3777421 STEREOSCOPIC GUIDANCE 1377421 STEREOSCOPIC GUIDANCEMAY USE KV OR MV 90 DEGREE X-RAYSREQUIRES POSITIONING OR TRACKING SYSTEM, INFRARED OR SURFACE ANATOMY, FIDUCIAL MARKERS, OR A CONSISTANT DEFINABLE ANATOMIC STRUCTURE
39FORMAT OF STEREOSCOPIC X-RAY GUIDANCE 13Locating 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.
40SIMULATION IMAGES AND ON TREATMENT KV BEAM SET UP IMAGES SUPERIMPOSED NIBSIMULATION IMAGES AND ON TREATMENT KV BEAM SET UP IMAGES SUPERIMPOSED168/183/216
4114DOCUMENTATION for 77421If 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
42BILLING FOR STEREOSCOPIC GUIDANCE, 77421 14BILLING FOR STEREOSCOPIC GUIDANCE, 77421The 2014 Medicare value is :about $ 19.0577421-TC about $ 51.37about $70.43170/216
43Image Guidance of Radiation Treatment Delivery 14Image Guidance of Radiation Treatment Delivery77421Stereotactic X-Ray Guidance for Localization of Target Volume for the Delivery of Radiation Therapy TreatmentsMay be used on a daily basis if clinically indicatedRequires 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.
44CONE BEAM CT15GUIDANCE OF TOMOTHERAPY and OTHER IGRT TECHNIQUES, USE CODE 77014, CT GUIDANCEALL PAYMENT is Bundled with the simulation or treatment delivery.No professional billing is recognized in The professional component of the CT scan is considered bundled into either the simulation or the treatment delivery procedure.
4615 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.
47RESPIRATORY MOTION MANAGEMENT 16This is 4-D , Vertical , Lateral , Horizontal , Motion is the fourth dimensionBilling code for simulation.Billing code 0197T for treatment gating., (very time intensive)
48Respiratory motion causes mismatch 17Respiratory motion causes mismatchRespiratory gating allows treatment only at match time172/183/216
492014 CPT update17NIBis 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 $98.67Global payment $410.66Technical payment $311.99Add-on codes must be reported in addition to the primary procedure, or 77301, and reported on the same date of service.
50T CODE FOR GATING May be discontinued Jan 2015 0197T category III code 17T CODE FOR GATING0197T category III codeIntra 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 therapyHospital packagedPhysician carrier priced. Indicator C in CPT Jan 1, 2009Still a valid code in 2014.May be discontinued Jan 2015
51PARTICLE ACCELERATORS 19PARTICLE ACCELERATORSThe concept of a Proton radiation therapy unit was first proposed by physicists in 1946
52Proton 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
59MEVION (Still River) Proton unit, Single room unit with superconducting cyclotron mounted on gantry, 23Gantry rotates through a 180 degree arc, and robotic table allows all possible angles of therapy to be accomplished
60Single room, single gantry system…..$36,106,125 23ESTIMATED COSTS OF A PROTON FACILITY EQUIPMENT, FACILITY, AND START UP COSTSingle room, single gantry system…..$36,106,125One gantry, remote cyclotron………..$57,207,027One gantry, one fixed beam………….$73,708,555Two gantry, one fixed beam……...….$97,657,456Three gantry, one fixed beam……....$121,606,359IMPT added to any unit, added cost...$30,000,000
66Fractionated Stereotactic Radiation Therapy Treatment Management 51Medicare will not allow to follow 77432, LIMIT OF ONE PER COURSE.If the procedure is planned to be fractionated 2 to 5 fractions, then it should be reportedas fractionated SRS or SBRT.Average physician payment $ in 2014All of the ancillary codes associated with either or may be reported at the time of setup or subsequent treatment except guidance codes with IGRT.
67This puts it in perspective NIBThis puts it in perspectiveCourtesy of MEVION
68Still River Systems – Compact Proton Therapy NIBSingle Room contains allequipmentCyclotron mounted on gantryClean clinical environmentFDA 510k cleared68
69This is a big machine, But it still fits in one room. NIB
70MEVION is now FDA approved. The first three units are being installed NIBMEVION1) Barnes Jewish hospital inSt. Louis, Mo. Now operational treating patients.2) University of Oklahoma inOkla. City, OK.3) Robert Wood Johnson University, in New JerseyMEVION is now FDA approved. The first three units are being installed250 MeV~20 tons- Very high B field: 9 T
71Double Scattering, Aperture, and compensator NIBDouble Scattering, Aperture, and compensatorTwo ScatterersRotatingRange ModulatorFixedScattererAperture & CompensatorSecondP+Two Patient specific scattering compensators and an aperture and compensator each of which is billed as a 77334
72Intensity 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.
73Depth doses of photons, protons, and carbon ions NIBDepth doses of photons, protons, and carbon ionsCarbon ion beamPristine (Bragg) peak: Bragg peak by a near-monoenergetic carbon ion beam73
82Fixed Beam Treatment Nozzle and Robotic Table 6522ProCure
83PROTON THERAPY REMBURSEMENT 23PROTON THERAPY REMBURSEMENTCMS 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)
84NIB 11 In operation 4 Mevion 9 Under construction/in development MPRI, IN890 patientsHarvard/MGH,MA4270 patientsProCure, WAProCure, MIMayo, MNUC San Francisco, CA(Ocular Tumors)1200 patientsMcLaren, MINIPTRC, ILUPennRWJUH, NJProCure, ILProCure, NJProCure, OK200947 patientsLoma Linda, CA14000 patientsWashU, MOUMaryland, MDHamptonUTenn, TNMayo, AZOUHSC, OKScripps, CAUFPTI, FL1847 patientsBerkeley: John Lawrence was the first to treat cancer with cyclotrons when, in 1954, he began irradiating the pituitaries of patients with metastatic breast cancer.Ernest’s (inventor of the cyclotron) younger brother John Lawrence.UCSD, CAProCure, FLMD Anderson, TX1700 patientsSource: National association for proton therapy84
85WHAT ARE PROTONS? Sub-atomic particle with a positive charge 20Sub-atomic particle with a positive chargeWeigh 2000 times as much as an ElectronBuilding block of all atomsAll 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.