Radiation Oncology, SRS, SBRT, Protons. Advanced Concepts

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

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

4. 1 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.

5. Stereotactic Procedures, SBRT 1 • 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

6. 1 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.

7. MANAGEMENT OF CRANIAL LESIONS BY STEREOTACTIC TREATMENT 1 • 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

8. 2 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 42

9. 2 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. 2 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.

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

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

15. History of Dosimetry 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. APC Rules for Gamma Knife (SRS) Reimbursement 7 Hospitals must bill for Gamma Knife SRS planning using CPT procedure code 77295 Hospital APC ~$1,036.39 Hospitals Must use 77371, 77372 for SRS delivery. THIS IS USUALY A NEGOTIATED RATE Hospital APC 0067 ~$ 5,615.41

17. SRS USING A LINEAR ACCELERATOR 8 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.

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

19. 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. 7 Stereotactic treatment delivery G0173--GO340 DELETED 1-1-14 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

22. NIB . 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

23. RULES AND CODES FOR SRS 8 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, Tomotherapyunit, 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 77373 5th 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

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. 10 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)

30. 11 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.

31. 12 IGRT IMAGE GUIDED RADIATION THERAPY

32. 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 13 • 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. 13 Available Codes for IGRT • 77427 Physician treatment management • 77418 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. 13 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. 13 77421 STEREOSCOPIC X-RAY GUIDANCE FIDUCIAL MARKERS FOR STEREOSCOPIC GUIDANCE

39. FORMAT OF STEREOSCOPIC X-RAY GUIDANCE 13 • 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. 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. 14 BILLING FOR STEREOSCOPIC GUIDANCE, 77421 • The 2014 Medicare value is : • 77421-26 about $ 19.05 • 77421-TC about $ 51.37 • 77421 about $70.43 170/216

43. 14

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 2014. 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

47. 16 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)

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

49. 2014 CPT update 17 NIB • +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.

50. 17 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