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

2. 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

3. STEREOTACTIC PROCEDURES1
STEREOTACTIC PROCEDURES
Gamma Knife (Radio surgery, SRS)
Cyber Knife (SRS, SBRT)
Conventional XRT (SRS, SBRT )

4. Stereotactic Procedures, SRS1
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.

5. Stereotactic Procedures, SBRT1
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 The remaining fractions are considered bundled into the initial treatment and are not reimbursable.
RULE CHANGE 2014

6. Stereotactic Procedures, SBRT1
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,
If IMRT , is used for planning, treatment delivery should be
Treatment may be delivered using a linear accelerator, Tomotherapy unit, or Cyber Knife unit, but Protons are excluded at this time.

7. MANAGEMENT OF CRANIAL LESIONS BY STEREOTACTIC TREATMENT1
Medicare 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

8. 2
Only 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 SEQUENTIALLY 42

9. Gamma Knife Historical Background2
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.

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

11. 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

12. Removal of the head Frame2
The 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 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 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.

13. GAMMA KNIFE TECHNICIAL TREATMENT DELIVERY CODE2
GAMMA KNIFE TECHNICIAL TREATMENT DELIVERY CODE
The code Gamma Knife one fraction only, complete course of therapy, is used for the technical reimbursement.

14. Gamma knife work page and final narrative of procedure4
Gamma knife work page and final narrative of procedure
ONCOCHART

15. History of Dosimetry Forward Planned IMRT Inverse planned IMRT
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.

16. Hospitals Must use 77371, 77372 for SRS delivery.
APC Rules for Gamma Knife (SRS) Reimbursement 7
Hospitals must bill for Gamma Knife SRS planning using CPT procedure code 77295
Hospital APC ~$1,036.39
Hospitals Must use 77371, for SRS delivery.
THIS IS USUALY A NEGOTIATED RATE Hospital APC ~$ 5,615.41

17. SRS USING A LINEAR ACCELERATOR8
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 may be reported for SRS, fractions 2-5 are now considered bundled.

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

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

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

21. Stereotactic treatment delivery7
G0173--GO340 DELETED
single session, Gamma Knife
sessions, 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

22. NIB 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, MD
Novitas-Solutions

23. This is a change from previous years
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

24. 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.

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

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

27. RULES AND CODES FOR 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 should not be used for the case; rather (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 should not be used for the case. Management will be considered only.

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 $
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

29. Stereotactic Radio Surgery (SRS), 7743210
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)

30. Stereotactic Body Radiation therapy (SBRT) 7743511
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.

31. 12
IGRT
IMAGE
GUIDED
RADIATION THERAPY

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

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

34. 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

35. BILLING FOR IGRT There is no code at this time for IGRT13
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

36. Available Codes for IGRT13
Available Codes for IGRT
Physician treatment management
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

37. 77421 STEREOSCOPIC GUIDANCE13
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

38. 77421 STEREOSCOPIC X-RAY GUIDANCE STEREOSCOPIC GUIDANCE13
77421 STEREOSCOPIC X-RAY GUIDANCE
FIDUCIAL MARKERS FOR
STEREOSCOPIC GUIDANCE

39. FORMAT OF STEREOSCOPIC X-RAY GUIDANCE13
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.

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

41. 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

42. BILLING FOR STEREOSCOPIC GUIDANCE, 7742114
BILLING FOR STEREOSCOPIC GUIDANCE, 77421
The 2014 Medicare value is :
about $ 19.05
77421-TC about $ 51.37
about $70.43
170/216

43. Image Guidance of Radiation Treatment Delivery14
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.

44. 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 The professional component of the CT scan is considered bundled into either the simulation or the treatment delivery procedure.

45. 15
CONE BEAM CT 77014

46. 15 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.

47. RESPIRATORY MOTION MANAGEMENT16
This is 4-D , Vertical , Lateral , Horizontal , Motion is the fourth dimension
Billing code for simulation.
Billing code 0197T for treatment gating.
, (very time intensive)

48. Respiratory motion causes mismatch17
Respiratory motion causes mismatch
Respiratory gating allows treatment only at match time
172/183/216

49. 2014 CPT update 17
NIB
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, or 77301, and reported on the same date of service.

50. T CODE FOR GATING May be discontinued Jan 2015 0197T category III code17
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

51. PARTICLE ACCELERATORS19
PARTICLE ACCELERATORS
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. 21
Tumor

54. Sharp drop off at 45% for hip joints22
Prostate dose 100%
Sharp drop off at 45% for hip joints
Pair of opposed lateral proton ports

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

56. PATIENT SET UP ON TREATMENT TABLE
NIB
PATIENT SET UP ON TREATMENT TABLE

57. Ion Beam Applications (IBA) Isocentric Gantry22
Ion Beam Applications (IBA) Isocentric Gantry

58. Typical IBA 3 room Proton Treatment Installation22
fixed beam
230 MeV Cyclotron
3 gantry rooms

59. 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

60. Single room, single gantry system…..$36,106,125 23
ESTIMATED COSTS OF A PROTON FACILITY EQUIPMENT, FACILITY, AND START UP COST
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

61. Proton Beam Treatment Delivery23
Proton Beam Treatment Delivery
77520 Proton Beam Delivery; Simple
77522 Proton Beam Delivery; Simple, with compensators
77523 Proton Beam Delivery; Intermediate
77525 Proton Beam Delivery; Complex
0664 APC For 77520, 77522,
0419 APC For 77523, 77525,

62. Proton Reimbursement HCPCS APC Descriptor $2014 $2013.00 77520 066424
HCPCS
APC
Descriptor
$2014 $
77520
0664
Simple w/o comp
$872.37 $
77522
Simple with comp
77523
0667
Intermediate $
$682.36
77525
Complex

63. OTHER CHARGES WITH PROTONS25
High Intensity Consultation.
Complex Treatment Planning
Complex Simulation(s) at time of setup.
Simulation as done as pre-plan,
Basic Dosimetry (often multiple done per port)
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)
D planning
Physics Support
Special Physics Report (if documented)
END

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

65. END SECTION 10

66. Fractionated Stereotactic Radiation Therapy Treatment Management51
Medicare 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 reported
as fractionated SRS or SBRT.
Average physician payment $ in 2014
All of the ancillary codes associated with either or may be reported at the time of setup or subsequent treatment except guidance codes with IGRT.

67. This puts it in perspective
NIB
This puts it in perspective
Courtesy of MEVION

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

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

70. MEVION is now FDA approved. The first three units are being installed
NIB
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
250 MeV
~20 tons
- Very high B field: 9 T

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

72. 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.

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

74. Proton Accelerator - CYCLOTRON
NIB
Proton Accelerator - CYCLOTRON

75. Cyclotron opened for maintenance
NIB
Cyclotron opened for maintenance 75

76. Energy Selection System Beam Transport and Switching System
NIB

77. Milled brass compensators21
Proton Beam Shaping
Milled brass compensators

78. Comparison of single photon versus single proton beams21
Photon Beam
Proton Beam
TUMOR
TUMOR

79. Skull base tumor, Single Proton Port21

80. Proton treatment of rib lesion22
Proton treatment of rib lesion

81. Proton Plan for a Lung tumor22

82. Fixed Beam Treatment Nozzle and Robotic Table65 22
ProCure

83. PROTON THERAPY REMBURSEMENT23
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)

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

85. WHAT ARE PROTONS? Sub-atomic particle with a positive charge20
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.

86. Proton machines Fixed beam physics adapted units23
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