IMRT Reimbursement

1. IMRT Reimbursement James M. Hevezi, Ph.D. CTRC, San Antonio Joint Economics Committee, ACR/ASTRO

2. Where have we come from? In 1999, ASTRO took the new procedure of IMRT up for approval of new planning and delivery codes (with help from AAPM, ACMP, and ACR members) We were successful at gaining approval and valuation for an IMRT planning code, CPT 77301 and an IMRT delivery code, CPT 77418

3. Where have we come from? In CPT 2000, descriptors for the new codes were published by the AMA and CMS began covering work in stand-alone centers performing indicated IMRT treatments Hospitals were already covering IMRT treatments under temporary �G� codes, and now would use the new APC/CPT codes to cover this work

4. Where did we come from? In successfully convincing the approval bodies of the complexity in planning and delivering IMRT, CPT 77301 and 77418 are two of our �highest valued� codes in Radiation Oncology Some say that IMRT has been responsible for the growth of new Medical Physics positions in many of our RO programs in the United States

5. Where did we come from? What about private carriers?? Most follow CMS� lead (and level!) of reimbursement - but not necessarily Eg., we�re currently fighting Aetna nationwide in their denial of 77336 payment Rad Onc�s can usually send a letter to carrier to authorize a particular patient for IMRT, if denied coverage (do it before tx!)

6. Where did we come from? Fortunately, there is a body of literature touting the advantage of IMRT � this will likely continue to grow as more use IMRT 2002 ASTRO/ACR Coding Guide describes how to use the IMRT codes in practice ASTRO/AAPM White Paper in Red Journal ACR Guideline written for IMRT

7. Where did we come from? CMS has periodically attempted to �bundle� other 77XXX codes into the IMRT codes, generally through CCI edits There were only a few codes agreed to by ASTRO that form the basis for IMRT (77295, 77331, 76370, etc) CPT 77300 bundling will be discussed

8. Where are we currently? CMS continues to reimburse IMRT at high levels, reflective of the large work effort and complexity of the procedure Both in Hospitals and Stand-Alone Centers Private carriers are still �mixed� in their coverage of the procedure Some still call IMRT �experimental�

9. Where are we currently? Some groups/vendors say they can do IMRT without following descriptor (�field-within-field�, compensator beam modulation, etc) Unfortunately, waters are �muddied� by CMS pronouncements on what qualifies as IMRT Transmittal 32 and 132 from CMS equivocal on coverage issues on IMRT

10. Where do we go from here? Need to be vigilant for �back pedaling� on IMRT coverage by CMS or private groups There has been some diminution in $$�s paid for IMRT since 2000 - but not much! Attempts at �bundling� other codes into the IMRT codes will likely continue Unsure of what will happen when everyone begins doing IMRT

11. Where do we go from here? Image Guided Radiation Therapy is on our radar screen Natural for IMRT precision to include it More work � so need a code (current or new?) Since all reimbursement is �local�, please keep your professional societies informed about abnormalities in your locale And now, I�M Really Tired!