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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. 1.

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slide1

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

slide2

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

stereotactic procedures
STEREOTACTIC PROCEDURES

1

Gamma Knife (Radio surgery, SRS)

Cyber Knife (SRS, SBRT)

Conventional XRT (SRS, SBRT )

stereotactic procedures srs

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.
stereotactic procedures sbrt
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
stereotactic procedures sbrt1

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.
slide7

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
slide8

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

slide9

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.

slide10

NIB

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

slide11

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

removal of the head frame

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.
gamma knife technicial treatment delivery code

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.

slide14

4

Gamma knife work page and final narrative of procedure

ONCOCHART

history of dosimetry
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.

slide16

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

slide17

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.

slide18

4-5

Brain Lab Micro Multileaf collimator

Removable head frame

slide19

5

BRAIN LAB STEREOTACTIC PLANING;

THIS USES

IMRT FORWARD PLANNING ALGORYTHM SOFTWARE, AND SHOULD BE BILLIED AS ADVANCED 3-D

77295

slide20

6

A report is absolutely required for proper documentation of this procedure

136/216

stereotactic treatment delivery

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

slide22

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

slide23

RULES AND CODES FOR SRS

8

This is a change from previous years

slide24

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.
slide25

SBRT, Body Only

77373 1st FX

77373 2nd FX

77373 3rd FX

77373 4th FX

77373 5th FX

slide26

9

Notice the detailed and customized clinical comments as part of the statement of medical necessity

Courtesy ONCOCHART

slide28

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

stereotactic radio surgery srs 77432

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)

stereotactic body radiation therapy sbrt 77435

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.

slide31

12

IGRT

IMAGE

GUIDED

RADIATION THERAPY

slide32

12

COMBINED CT AND LINEAR ACCELERATOR

THE TREATMENT IS IMRT 77418,

THE GUIDANCE IS DAILY CONE BEAM

CT IMAGING BILLED AS 77014, OR;

slide33

12

LINEAR ACCELERATOR IMRT USING KILOVOLTAGE X-RAY IMAGING, ON BOARD IMAGING (OBI)

77421 STEREOSCOPIC

advantage of igrt
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
billing for igrt
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
slide36

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

77421 stereoscopic guidance

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
slide38

13

77421 STEREOSCOPIC X-RAY GUIDANCE

FIDUCIAL MARKERS FOR

STEREOSCOPIC GUIDANCE

format of stereoscopic x ray guidance
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.
slide40

NIB

SIMULATION IMAGES AND ON TREATMENT KV BEAM SET UP IMAGES SUPERIMPOSED

168/183/216

documentation for 77421

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

billing for stereoscopic guidance 77421

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

cone beam ct
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.
slide45

15

CONE BEAM CT 77014

respiratory motion management

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)
slide48

17

Respiratory motion causes mismatch

Respiratory gating allows treatment only at match time

172/183/216

2014 cpt update
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.
t code for gating

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
particle accelerators
PARTICLE ACCELERATORS

19

The concept of a Proton radiation therapy unit was first proposed by physicists in 1946

slide52

20

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.

slide53

21

Tumor

slide54

22

Prostate dose 100%

Sharp drop off at 45% for hip joints

Pair of opposed lateral proton ports

slide56

NIB

PATIENT SET UP ON TREATMENT TABLE

slide57

22

Ion Beam Applications (IBA) Isocentric Gantry

typical iba 3 room proton treatment installation
Typical IBA 3 room Proton Treatment Installation

230 MeV Cyclotron

22

fixed beam

3 gantry rooms

slide59

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

estimated costs of a proton facility equipment facility and start up cost

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
proton beam treatment delivery
Proton Beam Treatment Delivery

23

  • 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,
other charges with protons
OTHER CHARGES WITH PROTONS

25

  • 99205 High Intensity Consultation.
  • 77263-22 Complex Treatment Planning
  • 77290-22 Complex Simulation(s) at time of setup.
  • 77290 Simulation as done as pre-plan,
  • 77300 Basic Dosimetry (often multiple done per port)
  • 77334 Complex Treatment Devices, blocks, compensators, degraders, etc
  • 77321 Special Beam Considerations (Protons)
  • 77470-22 Special Treatment Procedure (Protons)
  • 77431-22 Short Week of Radiation Management (Single Fraction)
  • 77427 standard week(s) of therapy
  • 77315 Complex Isodose Plan(s) (Proton Isodose)
  • 77295 3-D planning
  • 77336 Physics Support
  • 77370 Special Physics Report (if documented)

END

slide66

Fractionated Stereotactic Radiation Therapy Treatment Management

51

Medicare will not allow 77435 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 77435 fractionated SRS or SBRT.

Average physician payment $601.87 in 2014

All of the ancillary codes associated with either 77432 or 77435 may be reported at the time of setup or subsequent treatment except guidance codes with IGRT.

slide67

NIB

This puts it in perspective

Courtesy of MEVION

slide68

Still River Systems – Compact Proton Therapy

NIB

Single Room contains all

equipment

Cyclotron mounted on gantry

Clean clinical environment

FDA 510k cleared

slide70

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

double scattering aperture and compensator
Double Scattering, Aperture, and compensator

Rotating

Range Modulator

Second

Scatterer

Aperture & Compensator

Fixed

Scatterer

P+

NIB

Two Scatterers

Two Patient specific scattering compensators and an aperture and compensator each of which is billed as a 77334

slide72

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.
depth doses of photons protons and carbon ions
Depth doses of photons, protons, and carbon ions

NIB

Carbon ion beam

Pristine (Bragg) peak: Bragg peak by a near-monoenergetic carbon ion beam

slide74

NIB

Proton Accelerator - CYCLOTRON

slide76

Energy Selection System

Beam Transport and Switching System

NIB

proton beam shaping
Proton Beam Shaping

21

Milled brass compensators

slide80

22

Proton treatment of rib lesion

proton therapy rembursement

23

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)
slide84

11 In operation

9 Under construction/in development

4 Mevion

NIB

MPRI, IN

1993-2009

890 patients

Harvard/MGH,MA

2001-2009

4270 patients

ProCure, WA

ProCure, MI

Mayo, MN

UC San Francisco, CA

1994 -2009 (Ocular Tumors)

1200 patients

McLaren, MI

NIPTRC, IL

UPenn

RWJUH, NJ

ProCure, IL

ProCure, NJ

ProCure, OK

2009

47 patients

Loma Linda, CA

1990 - 2009

14000 patients

UMaryland, MD

WashU, MO

Hampton

UTenn, TN

OUHSC, OK

Mayo, AZ

UFPTI, FL

2006-2009

1847 patients

Scripps, CA

UCSD, CA

ProCure, FL

MD Anderson, TX

2006-2009

1700 patients

Source: National association for proton therapy

what are protons
WHAT ARE PROTONS?

20

  • 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.
proton machines
Proton machines

23

  • 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