2016 Medicare Reimbursement Proposals for the TomoTherapy System
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- Bethany Hawkins
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1 2016 Medicare Reimbursement Proposals for the TomoTherapy System On July 1, 2015, and July 8, 2015, CMS released the 2016 Medicare Proposed Rules for Hospitals, Physicians, and Freestanding Centers. Below we provide an overview of the rules and the impact they may have on your TomoTherapy practice. Executive Summary In 2016, CMS has proposed policies that reflect their growing interest in developing Ambulatory Payment Classifications (APCs) with greater resource and clinical homogeneity. While CMS has made changes to APCs that include radiation therapy services, these changes have resulted in no major shifts in overall payment for TomoTherapy services delivered in the hospital outpatient department over For IMRT, CMS has proposed maintaining simple and complex IMRT treatment in the same APC, with no difference in payment between simple or complex delivery. No significant changes in payment for 2016 over 2015 have been proposed. Similarly for 3D CRT, CMS has maintained the two separate APCs developed in 2015 for simple/intermediate 3D CRT and complex 3D CRT delivery. Total technical and global payments also remain relatively unchanged over 2015 for both IMRT and 3D CRT (ranging from no change to a 6 percent increase). For stereotactic radiosurgery (SRS) performed in the hospital outpatient department, CMS has proposed continuation of its Comprehensive APC policy for single session SRS. No significant changes have been proposed for single session extracranial or multisession stereotactic body radiation therapy (SBRT). When comparing only the delivery code for single session extracranial and multisession SRS/SBRT or the Comprehensive APC proposed for single session SRS to 2015, payment would be reduced in However, when factoring in the ancillary codes CMS proposes to still pay separately, the total technical and global payments would remain relatively stable over 2015 (ranging from a 3 percent increase to a 7 percent decrease). For IMRT and 3D CRT performed in freestanding centers, CMS proposed several changes that have resulted in a more significant impact on payment. CMS has proposed to implement the new simple IMRT delivery code (for prostate and breast cancer treatment) and the complex IMRT delivery code (for all other sites). CMS also proposes to implement three new codes for simple, intermediate and complex 3D CRT delivery (no longer stratified by energy level). In addition, CMS proposes to bundle the technical component of image guidance when billed with IMRT delivery (now billed under CPT code 77387). The professional component remains separately paid. For 3D CRT, CMS proposes to allow payment for image guidance for both the professional and technical components (also billed under 77387). However, CMS is seeking comments on this proposal. For SRS/SBRT treatment delivery billing codes and CMS has proposed an increase in payment over 2015 of 9 percent, primarily due to additional Relative Value Units (RVUs) that have been added for practice and malpractice expenses.
2 Hospital Outpatient Proposals IMRT and 3D Conformal CMS has proposed no CPT coding changes for IMRT and 3D treatment delivery codes. As in 2015, simple IMRT (prostate and breast and physical compensator) and complex IMRT (all others) are assigned to the same APC with the same payment rate. As in 2015, simple and intermediate 3D-CRT codes are assigned to the same APC, while complex (TomoTherapy) remains assigned to a separate APC with a higher payment rate. CMS has renamed APCs to improve clinical and resource homogeneity and renumbered to achieve consecutive numbering within each clinical family. These changes have contributed to changes in payment for some ancillary procedures. However, there is no significant difference in the overall technical payment for IMRT or 3D- CRT. Payment for the delivery codes and total global payments (including professional and technical services) are shown in the tables below: Modality (Delivery) HCPCS/CPT Code Diff ($) Diff (%) IMRT Simple $ $ $ % IMRT Complex $ $ $ % 3DCRTComplex $ $ $4.03 2% Simple & Complex IMRT Tech Prof Global Tech Prof Global Global Diff ($) Global Diff (%) TT - IMRT 10 fx $7,079 $1,877 $8,956 $7,268 $1,828 $9,096 $139 2% TT - IMRT 20 fx $12,381 $2,690 $15,071 $12,676 $2,538 $15,214 $143 1% TT - IMRT 30 fx $17,683 $3,503 $21,186 $18,083 $3,249 $21,332 $146 1% TT - IMRT 40 fx $22,984 $4,316 $27,300 $23,490 $3,959 $27,450 $149 1% TT - IMRT 45 fx $25,635 $4,723 $30,358 $26,194 $4,315 $30,509 $151 0% Complex 3D-CRT Tech Prof Global Tech Prof Global Global Diff ($) Global Diff (%) TT 3D 10 fx $4,593 $1,736 $6,329 $4,868 $1,680 $6,548 $219 3% TT 3D 20 fx $6,751 $2,549 $9,300 $7,060 $2,390 $9,451 $151 2% TT 3D 30 fx $8,909 $3,362 $12,271 $9,252 $3,101 $12,353 $82 1% TT 3D 40 fx $11,067 $4,175 $15,242 $11,444 $3,812 $15,256 $14 0% TT 3D 45 fx $12,145 $4,582 $16,727 $12,540 $4,167 $16,707 -$20 0%
3 Retention of Comprehensive APC for Single Session Cranial Radiosurgery CMS proposes to retain a comprehensive APC (now C-APC 5631) for single session cranial SRS, but identifies and excludes several ancillary codes from the bundled payment. These codes will be separately reimbursed in addition to the comprehensive APC payment and tracked with a modifier. As a result of this proposal, the base payment for the comprehensive APC would be 25 percent lower than in However, separate payment for some ancillary codes improves the overall picture. The specific codes CMS proposes be billed and separately paid are: o CT localization (HCPCS codes and 77014) o MRI imaging (HCPCS codes 70551, 70552, and 70553) o Clinical treatment planning (HCPCS codes 77280, 77285, 77290, and 77295) o Physics consultation (HCPCS code 77336) If your practice bills any of these codes as medically necessary in the course of a TomoTherapy single session cranial treatment, be sure to continue billing these codes in 2016 as they will be used to calculate a revised C-APC in the future. Assuming only the codes specifically identified by CMS above are separately payable (and using only the codes we understand are applicable to TomoTherapy), total technical payment would decrease by 7 percent. Changes to the Physician Fee Schedule have contributed to slight changes in total global payment with the total for technical and professional proposed to also decrease 7 percent over Changes in payment for single session cranial SRS delivery only are outlined as follows: Delivery HCPCS/CPT Code Diff $ Diff % SRS 1 Fx $9, $7, $2, % Changes in total global payment (including technical and professional) for single session cranial SRS are outlined as follows: SRS/SBRT Tech Prof Global Tech Prof Global Global Diff ($) Global Diff (%) 1 Fx $9,765 $1,712 $11,477 $8,868 $1,802 $10,670 -$807-7%
4 Single Session Extracranial and Multisession SRS/SBRT CMS proposes to maintain a separate APC (now APC 5625) for single session extracranial and multisession SRS/SBRT and to continue to pay for all ancillary services separately. While CMS proposes a fairly significant cut to the delivery code (77373) of 11 percent, other changes in payment for technical service billed by hospitals and changes to the Physician Fee Schedule mitigate the cut. o o Changes to APCs for ancillary codes would contribute to slight changes in the overall technical payment for SBRT, resulting in a 3 percent decrease in total technical payment for an average three-fraction case. Changes to the Physician Fee Schedule have contributed to slight changes in total global payment, resulting in a 1 percent decrease for an average three-fraction case over Changes in payment for single session extracranial and multisession SRS/SBRT delivery only are outlined as follows: Delivery HCPCS/CPT Code Diff $ Diff % SRS/SBRT - Mult Fx $1, $1, $ % Changes in total global payment for single session extracranial and multisession SRS/SBRT are outlined as follows: SRS/SBRT Tech Prof Global Tech Prof Global Global ($) Global (%) 1 Fx EC $5,863 $1,925 $7,788 $6,002 $2,027 $8,029 $242 3% 2 Fx $7,765 $1,925 $9,690 $7,701 $2,027 $9,728 $38 0% 3 Fx average $9,668 $1,925 $11,593 $9,399 $2,027 $11,427 -$166-1% 4 Fx $11,570 $1,925 $13,495 $11,098 $2,027 $13,125 -$370-3% 5 Fx $13,473 $2,038 $15,511 $12,907 $2,027 $14,934 -$577-4% We encourage all hospital providers to review their coding and cost reporting systems to ensure these proposals accurately reflect the cost to provide single session cranial, single session extracranial and multisession SRS/SBRT services. Because these data will be used for rate setting in 2016 and in future years, Accuray recommends all TomoTherapy providers review the Proposed Rule and consider submitting comments to CMS if your costs are not accurately reflected. Comments on the Proposed Rule affecting hospital outpatient departments are due to CMS by August 31, The Proposal (CMS-1633-P) and instructions for commenters can be found at:
5 Freestanding Center Proposals The Conversion Factor (multiplier used to calculate all services under Medicare) for 2016 is proposed to increase slightly to $ vs. $ in 2015, which reflects a budget neutrality adjustment of and the 0.5 percent update specified under Medicare Access and CHIP Reauthorization Act (MACRA), aka SGR reform. CMS has proposed multiple changes in its methodology and inputs for calculating payment for radiation therapy, most notably increasing the utilization assumption from 50 percent in 2015 to 60 percent in 2016 and 70 percent in Payment for other ancillary codes have changed as a result of, but not limited to, a comprehensive analysis of all codes stemming from RUC review of potentially misvalued codes, packaging, changes to inputs (e.g. practice expense and malpractice), coding changes, etc. 3D CRT CMS has proposed to implement 3D-CRT coding changes already in place in the hospital setting. However, unlike in the hospital setting, CMS has proposed to allow payment for both the technical and professional component of image guidance when performed with 3D CRT. o Payment for image guidance under the new CPT code has increased significantly, contributing to a higher overall payment for 3D-CRT, however, CMS has noted conflicting recommendations from the CPT panel and RUC on how to use and value this code when billed with 3D-CRT, therefore the increase in global payment may change in the Final Rule. Unless changes are made in the Final Rule dictating the circumstances under which may be billed, the total global payment for a typical 30 fraction 3D-CRT case would increase 19 percent. IMRT CMS has proposed to implement IMRT coding changes already in place in the hospital setting. These code changes and RUC valuations result in changes in payment ranging from a 4 percent decrease to a 31 decrease. CMS also has proposed to implement the CPT changes for image guidance (packaging the technical component) when billed with IMRT delivery. However, as in the hospital outpatient department, the professional component is still separately payable. Single Session Intracranial, Single Session Extracranial and Multisession SRS/ SBRT CMS has proposed changes in practice expense and malpractice RVUs for single session cranial and single session extracranial and multisession SBRT, largely contributing to a 9 percent increase in payment for both services.
6 Payment for 3D CRT, IMRT, and SRS/SBRT are shown in the tables below: Delivery Only 2015 CPT Code 2016 CPT Code Diff ($) Diff (%) IMRT Simple G $410 $280 $121-30% IMRT Complex G $410 $421 $21 5% 3DCRTComplex G $228 $214 $14 6% SRS 1 Fx IC $1,063 $1,158 $95 9% SBRT Multiple Fx $1,350 $1,473 $123 9% IMRT - Complex Tech Prof Global Tech Prof Global Global Diff ($) Global Diff (%) TT - IMRT 10 fx $6,818 $1,877 $8,695 $6,494 $1,828 $8,322 -$373-4% TT - IMRT 20 fx $11,706 $2,690 $14,396 $10,877 $2,538 $13,415 -$980-7% TT - IMRT 30 fx $16,593 $3,503 $20,097 $15,260 $3,249 $18,509 -$1,588-8% TT - IMRT 40 fx $21,481 $4,316 $25,797 $19,643 $3,959 $23,603 -$2,195-9% TT - IMRT 45 fx $23,925 $4,723 $28,648 $21,835 $4,315 $26,149 -$2,498-9% IMRT - Simple Tech Prof Global Tech Prof Global Global Diff ($) Global Diff (%) TT - IMRT 10 fx $6,818 $1,877 $8,695 $5,079 $1,828 $6,906 -$1,789-21% TT - IMRT 20 fx $11,706 $2,690 $14,396 $8,046 $2,538 $10,584 -$3,811-26% TT - IMRT 30 fx $16,593 $3,503 $20,097 $11,014 $3,249 $14,263 -$5,834-29% TT - IMRT 40 fx $21,481 $4,316 $25,797 $13,981 $3,959 $17,941 -$7,857-30% TT - IMRT 45 fx $23,925 $4,723 $28,648 $15,465 $4,315 $19,780 -$8,868-31% Complex 3D-CRT Tech Prof Global Tech Prof Global Global Diff ($) Global Diff (%) TT 3D 10 $4,220 $1,736 $5,956 $5,258 $1,680 $6,938 $982 16% TT 3D 20 $7,384 $2,549 $9,933 $9,366 $2,390 $11,757 $1,824 18% TT 3D 30 $10,548 $3,362 $13,911 $13,475 $3,101 $16,576 $2,665 19% TT 3D 40 $13,713 $4,175 $17,888 $17,584 $3,812 $21,395 $3,507 20% TT 3D 45 $15,295 $4,582 $19,877 $19,638 $4,167 $23,805 $3,928 20% Total Payment Change SRSSBRT Tech Prof Global Tech Prof Global Global Diff ($) Global Diff (%) 1 Fx IC $2,736 $1,712 $4,448 $2,986 $1,802 $4,788 $340 8% 1 Fx EC $3,023 $1,925 $4,947 $3,301 $2,027 $5,328 $381 8% 1 Fx 2 Fx $4,372 $1,925 $6,297 $4,774 $2,027 $6,801 $504 8% 3 Fx average $5,722 $1,925 $7,647 $6,247 $2,027 $8,274 $627 8% 4 Fx $7,072 $1,925 $8,997 $7,720 $2,027 $9,747 $750 8% 5 Fx $8,499 $1,925 $10,42 $9,279 $2,027 $11,306 $883 8% We encourage all TomoTherapy centers to review the CMS proposals that may impact their practices. We also recommend reading the summaries of the other major proposals that may impact the radiation oncology community, found on the website of the American Society for Radiation Oncology (ASTRO) at: For any questions regarding these changes we encourage you to join the upcoming CKC Webex and contact accesssupport@accuray.com.
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