Radiation Therapy Coverage, Coding, and Reimbursement for New Technologies

Transcription

1 Radiation Therapy Coverage, Coding, and Reimbursement for New Technologies Presented by Susan Granucci, Healthcare Reimbursement Specialist Topics 1. Intensity Modulated Radiation Therapy (IMRT) 2. Tomotherapy 3. Image Guided Radiation Therapy (IGRT) 4. Stereotactic Radio Surgery (SRS), Stereotactic Radiation Therapy (SRT) or Stereotactic Body Radiation Therapy (SBRT) 5. Accelerated Partial Breast Irradiation (APBI) Susan Granucci Healthcare Reimbursement Specialist 808 Sagebrush Ct, SE Albuquerque, NM Ph & Fax

2 IMRT Intensity Modulated Radiation Therapy IMRT is a type of external beam radiation therapy that delivers highly conformal, 3-D radiation treatment. It typically includes inverse planning, and features numerous beams of radiation involving multiple targets with different doses, intended to maximize the dose to the tumor and minimize the dose to normal tissue. The difference between 3-D and IMRT is the linear accelerator equipped with multileaf collimation (MLC) or moving aperture which shuts down portions of the beam during each treatment to modulate 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 three directions.) Coverage Medicare Code Bundling Two codes are primarily used for reporting IMRT: for planning, and for treatment delivery. 1. Planning code is intended to include all of the following: All codes for Diagnostic CT All Visits & Psychotherapy & ***except consults may be billed T 0 (sbrt tx mgt) Free-standing and hospital edits are different. Hospital Outpatient edits do not include tx devices. Source : CCI 4/1/05 See current CCI edit tables for additional edits. 0 Coverage not allowed if billed same day (with or without a modifier) 1 Coverage may be allowed if coded with Modifier 59 when billed on same date as the treatment plan, and documentation supports separate service. Certain of the above codes are acceptable on different days, such as treatment planning 77263, devices , physician management 77427, and treatment delivery Note, basic dosimetry has been removed from the planning code edit table, and may be quantity billed as appropriate. 2

3 IMRT Continued IMRT Treatment Delivery includes & Dx ultrasound ***All Visits & Psychotherapy except consults Hospital 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 4/1/05 Note, port films-77417, weekly QA-77336, treatment devices , and physician weekly management have been removed from the above daily treatment edit tables. Commercial Insurance Coverage Limits One insurance company's perspective: Aetna considers intensity modulated radiation therapy (IMRT) medically necessary for the following indications: 1. Treatment of radiosensitive tumors of the brain, head, neck, spine and paraspinal regions; or 2. Treatment of prostate carcinoma in individuals with an intact prostate when ultra high 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 investigational because of a lack of evidence that it provides clinical outcomes equivalent to collimator-based IMRT. For these reasons, prior authorization is always recommended. 3

4 IMRT Coding BAT 76950, Acculoc and Other Image Guidance Ultrasound guidance for field placement, code 76950, is currently the code used most often for verifying precise targeting for daily treatment. Other image guidance may include implanted marker seeds, CT and portal imaging systems, and a variety of codes from CT localization to simple simulation are being reported. New guidance code(s) are in development. Additional discussion to follow. Typical Coding for IMRT Course of Therapy Prof Tech 9924X Initial Consult Yes No Physician Plan Yes No Pretreatment Simulation Yes Yes CT Guidance No 2 Yes IMRT Plan (after CT imaging) Yes Yes Treatment Devices (after planning) Yes Yes Daily Treatment Delivery No Yes Daily Ultrasound Set Up or No 2 Yes Port films as needed if no other guidance No Yes Weekly QA (after planning) No Yes Weekly Physician Management Yes No Special Treatment Procedure Yes Yes Other codes may or may not apply depending on individual case, documentation, and payer guidelines. Use new Category III code for compensator-based IMRT: 0073T. Reimbursement compares to ACR suggests treatment devices be billed once for immobilization, and for each complex IMRT field 1 2 No 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

5 IMRT Revenues For IMRT, 2005 Medicare reimbursement continues to be quite favorable, more-so in the free-standing facility at this time. IMRT Services Hosp APC Prof Free- Standing TC 9924X Initial Consult $ $ $ Physician Plan $0.00 $ $ Pretreatment Simulation $ $81.10 $ CT Guidance $ $44.34 $ IMRT Plan (after CT imaging) $ $ $1, Treatment Devices (after planning) $ $64.43 $ Daily Treatment Delivery $ $0.00 $ Daily Ultrasound Set Up or $ $30.32 $ Port films if no other guidance $ $0.00 $ Weekly QA (after planning) $ $0.00 $ Weekly Physician Management $0.00 $ $ Special Treatment Procedure $ $ $ Medicare fees are unadjusted for local wage or geographic cost indexes are IMRT treatment delivery code at $309 - $687 to standard external beam daily treatment delivery code fee ranges of $124 - $93 for APC or Free Standing Facility. 3 are IMRT planning code at $814 - $1115 to traditional simulation and isodose codes & combined fees of fees $448 - $366. One table of billing statistics for 2003 shows code represents 13% of treatment delivery codes and 52% of treatment delivery revenues. 3 enssator based IMRT treatment delivery code 0073T is allowed at the same rates as by Medicare for

6 TomoTherapy TomoTherapy (brand name for TomoTherapy Hi-Art System ) takes IMRT several steps further. It combines planning, patient positioning and treatment delivery into one system. Radiation is delivered in a unique helical (or spiral) delivery pattern which travels in multiple circles all the way around the gantry ring. The patient's couch also moves, guiding the beam at slightly different planes during treatment. For tumor localization, a special verification CT scan is taken just before each treatment to verify the patient's position and position of the tumor. Treatment delivery is via IMRT, but with a spiral delivery pattern. uter controlled MLC has two sets of interlaced leaves for continuous beam modulation. Coverage, Coding and Revenues Coverage issues are not readily found. There are no TomoTherapy references in CMS'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 daily, in lieu of BAT or port films. Image Guidance Hosp APC Prof Free Standing TC CT Guidance $ $44.34 $ Medicare fees are unadjusted for local wage or geographic cost indexes 6

7 Image Guided Radiation Therapy (IGRT) To deal with tumor changes, patient changes, and variations in the targeted area of interest such as movement caused by breathing, heart, and gastric motility, radiation therapy is embracing image guided radiation therapy (IGRT). IGRT is typically used with daily IMRT treatment delivery, but can also be applied to other 3-D treatments such as stereotactic radiation therapy and accelerated partial breast irradiation. Improved precision with IGRT sometimes results in fewer treatment fractions. Some have labeled IGRT as a new type of radiation therapy. Based on the wide variety of equipment and modalities available, it appears that IGRT should be considered another "tool" to enhance precision in treatment delivery rather than the therapy itself. IGRT may include any of the following Fluoroscopy e.g., On Board Imager, used with CyberKnife; two images beneath and two over the table Electronic portal imaging e.g., Portal Vision, iviewgt- megavoltage x- ray imaging systems used for IMRT portal imaging Ultrasound BAT, SonArray - B-mode ultrasonic imaging system for IMRT image guidance and patient positioning on a daily basis Respiratory gating technology RPM - lightweight reflective marker and camera track motion and breathing pattern; correlates data with treatment plan; beam off / beam on signals more accurate treatment delivery CT scan reconstruction Elekta's Synergy integrated system uses cone beam CT for daily verification; Tomotherapy uses sonograms to compare CT for the current fraction to a reference sonogram for each fraction Partial list of manufacturers Next generation of IGRT: ART - Adaptive Radiation Therapy takes IGRT one step further from shifting the patient's position to actually modifying the daily treatment. PET and MRI have also been mentioned in connection with image guidance, but they are fairly uncommon at this time. 7

8 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 gating are intrafractional) Coverage, Coding and Revenues Technology is still relatively new, and targeted payer coverage guidelines have not yet been established and/or published. Coding and revenues specific to IGRT are based on the following codes, until such time as a more specific code(s) is developed. A new code is expected in Possible IGRT Codes Hosp APC Prof Free Standing Tech CT Guidance $ $44.34 $ Fluoroscopy up to 1 hr $79.09 $8.72 $ Electronic portal imag $43.87 n/a $ Simple simulation (sometimes used for Acculoc) $97.48 $36.38 $ Ultrasnd guidance (BAT) $67.44 $30.32 $52.30 C9722 Stereoscopy kv imaging with infrared tracking $75.00 n/a n/a N/A Respiratory Gating n/a n/a n/a 2005 Medicare fees are unadjusted for local wage or geographic cost indexes 8

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

10 Coding and Reimbursement Medicare has established unique HCPCS "G" codes for hospital outpatient claims. For free-standing facilities, the G codes are not generally accepted. Commercial payers should be contacted for prior authorization and coding preference. SRT CPT Codes if performed & documented Hosp APC Prof Free Standing TC Treatment Planning Code Choices D Plan or $ $ $1, G0242 Cobalt 60 Plan or $1, $0.00 $0.00 G0338 Linac plan $1, $0.00 $0.00 Treatment Delivery Code Choices Treatment Delivery or $ $0.00 $93.23 G0243 Cobalt 60 Delivery 1 session only $5, $0.00 $0.00 G0173 Linac non-robotic 1 session only $5, $0.00 $0.00 G0251 Linac non-robotic, fractionated $1, $0.00 $0.00 G0339 Linac robotic 1 or 1 st session $5, $0.00 $0.00 G0340 Linac robotic 2 nd thru 5 th session $3, $0.00 $0.00 Additional Codes (Caution, see bundling tables below) 9924x Initial Consult $ $ $ Treatment Plan $0.00 $ $ CT Guidance SRS $ $ $ Basic Dosimetry $97.48 $32.21 $ Trt Device(s) $ $64.43 $ Spec Trt Procedure $ $ $ Phys Mgt cerebral 1 session $0.00 $ $ T Phys Mgt body, per day $0.00 $0.00 $ Medicare fees are unadjusted for local wage or geographic cost indexes Bundling (as of 4/1/2005 CCI Edit Tables) Includes: guidance simulation isodose physics QA And a few others is included in IMRT planning Physician bundling includes all E&M and psych as well. G planning codes include all other radiation therapy codes from to 77470, 0083T, and most 61xxx codes. The only exceptions are initial plan 77263, dosimetry with mod 59, port films 77417, and treatment device codes G treatment delivery codes permit most other 77xxx codes with modifier

11 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 segment surrounding the tumor rather than the entire breast. Since the duration of treatment is 4 to 5 days rather than 5 to 6 weeks, radiation is delivered in fewer fractions at larger doses per fraction. APBI features: interstitial brachytherapy (high dose rate) via balloon catheters placed into lumpectomy cavity usually immediately after surgery, but can follow later the MammoSite radiation treatment system 3-D conformal planning two treatments each day for five days (BID treatments require modifier 59) breast conserving therapy Coverage Medical 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 node evaluation. 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 denial is implied, it does not specifically so state. At this time, it would appear most insurers are paying for APBI claims. Based on the available evidence, the Blue Cross and Blue Shield Association Medical Advisory Panel made the following judgments about whether accelerated partial breast irradiation using brachytherapy meets the Technology Evaluation Center criteria to decrease recurrence after breast-conserving surgery for early stage breast cancer. Accelerated partial breast irradiation using brachytherapy as the sole radiation treatment after breast-conserving surgery for early stage breast cancer does not meet the TEC criteria. Nov., 2002 TEC Assessments are scientific opinions, provided solely for informational purposes. TEC Assessments 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; any particular course of treatment, procedure, or service; or the payment or non-payment of the technology or technologies evaluated. 11

12 APBI / MammoSite Coding and Reimbursement Service Hosp APC Prof Tech Surgery varies Lumpectomy or lesion excision Place catheter in breast post op $3, $ na Place catheter post during lumpect $2, $95.88 na Radiation or US guidance for rtx placement or $67.44 $30.32 $ Echo guidance rtx interstitial $67.44 $70.11 $ Phys rad therapy planning $0.00 $ na Simple simulation $97.48 $36.38 $ Planning lex simulation $ $81.10 $ Ct scan for therapy guide $97.70 $44.34 $ Brachy plan, simple $97.48 $48.51 $94.36 or D Treatment plan $ $ $1, Additional Codes Basic Dosimetry $97.48 $32.21 $ Radiation physics QA $97.48 na $ Spec physics consult $97.48 na $ Radiation tx management, x 5 $0.00 $ na Special radiation treatment $ $ $ High intensity brachytherapy or $ $86.03 $ High intensity brachytherapy $ $ $ C1717 Brachy source IR 192* $0.00 na $ Medicare fees are unadjusted for local wage or geographic cost indexes Modifier 59 is essential to bypass the following edits: is bundled into on same day is bundled into on same day When treatments are BID, always use mod 59 on second treatment to avoid duplicate denial * C1717 hospital pass through cost may be allowed by Medicare according to the vendor Bundling: When 3-D treatment plan code is used, it includes other plan codes 77290, 76370, and (as well as codes mentioned previously). 12

13 Quick Facts on Correct Coding Initiative (CCI) Easy to use CD is available from NTIS (have your credit card ready) $299 for National Correct Coding Policy Manual fee includes quarterly updates by CD for one year Or download CCI free, from Free of charge Multiple files to manage, fairly difficult to navigate between files Edits apply to codes on same day Edits are different for hospitals and doctors or freestanding providers Edits are different for mutually exclusive and column 1 & 2 files Need 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 quarterly Each code edit is followed by a suffix: 0 Coverage not allowed if billed same day (with or without a modifier) 1 Coverage may be allowed if coded with Modifier 59 when billed on same date as the treatment plan, and documentation supports separate service. 13