1. Radiation Therapy Coding Changes
The following analysis has been prepared based on a review of third party coding guidance published by the American Society of Radiation Oncology (“ASTRO”) & Revenue Cycle, Inc., the final Medicare Physician Fee Schedules (“MPFS”), and VMG experience. The commentary presented in the attached slides are meant to be a general guide to historical reimbursement changes for radiation oncology and is not intended to be a comprehensive coding guide. Actual coding practices vary among providers depending on the payor and the location of the radiation therapy center.

2. 2014 MPFS Changes
Effective January 1, 2014 CPT code is no longer separately reported for simulation services. The payment for this code has been bundled into CPT codes 77280, 77285, 77290, or If codes 77280, 77285, 77290, or are not reported (which would be rare in a typical course of therapy) then can be billed for the initial simulation will still be used report IGRT guidance using a CT.
Effective January 1, 2014 if IMRT is the chose course of treatment then a simulation code (CPT codes 77280, 77285, 77290, 77014) cannot be reported prior to the completion of the IMRT treatment plan even if the services are performed on different days. Following the completion of the CPT code plan, CPT code may be reported separately for the work performing a verification simulation of the treatment field after the planning process is complete. ASTRO notes that historically there has been conflicting guidance regarding CPT As a result several providers have continued to report the simulation codes in addition to The CPT bundling was reiterated in the 2016.
Source: ASTRO Coding Guidance for CPT code and overview for treatment preparation

3. 2015 MPFS Changes
In the FY 2015 MPFS final ruling, CMS decided to delay the implementation of the radiation therapy coding changes released by the American Medical Association The delay would allow CMS to seek feedback from stakeholders in order to properly assign RVU values to the new CPT codes.
In the interim CMS established temporary G-codes to replace CPT codes that had been deleted in the 2015 fees schedule so that providers could continue report services in a similar manner as compared to Presented in the table on the following page is a summary of the new G-codes and the 2014 CPT codes they replaced. It should be noted that the permant CPT coding changes published by the American Medical Association were subsequently delayed until 2019 by the Patient Access and Medicare Protection Act (“PAMPA”) passed in December Therefore, the temporary G-codes are still utilized by a majority of providers to report radiation therapy services. It should be noted that certain commercial payors and Medicare carriers have transitioned to the new coding changes proposed by the AMA which are summarized in the following pages.
CPT codes (isodose plan simple), (isodose plan intermediate), (isodose plan complex) were replaced by (isodose plan simple) and (isodose plan complex). The new CPT codes bundle the work for CPT Code In addition, the brachytherapy isodose planning codes (77326, 77327, and 77328) were replaced with three new isodose planning codes 77316, 77317, and which also bundle the work for CPT code Therefore, CPT code cannot be billed with 77306, 77307, 77316, 77317, and However, CPT code can be separately reported if these codes are not billed in the course of treatment.
Other changes included in the 2015 MPFS final ruling:
Reimbursement for CPT code was cut due to an RVU adjustment. This code is still utilized to report IGRT using a CT.
Reimbursement for SBRT treatment deliver (CPT code 77373) increased approximately 8.4% due to a decision to increase the assumed treatment delivery time back to 104 minutes (previously 86 minutes).
Source: ASTRO 2015 Final Rule Summary and ASTRO coding guidance on CPT codes and 77300

4. 2015 MPFS Changes (Continued)
The National Institutes of Health (NIH) estimates that the overall costs of cancer in 2007 were $226.8 billion: $103.8 billion for direct medical costs (total of all health expenditures) and $123.0 billion for indirect mortality costs (cost of lost productivity due to premature death).

5. 2016 MPFS Changes
The FY 2016 MPFS final ruling further delayed the implementation of the AMA coding changes.
In the FY 2016 final rule CMS increased the assumed equipment utilization rate for the treatment codes from 50% to 60% in FY The increased utilization rate resulted in a decrease in total reimbursement for all treatment delivery codes. The equipment utilization rate was scheduled to increase further to 70% in FY 2017, however this was prevented by the Patient Access and Medicare Protection Act (“PAMPA”) which was passed in December 2016.
In addition, CMS finalized its proposal to utilize the same linear accelerator capital equipment cost assumption in the determination of IMRT and EBRT reimbursement. IMRT treatment delivery services require a linear accelerator with on board imaging (“OBI”) which were historically more expensive than traditional linear accelerators. As a result, the capital equipment cost assumption utilized to determine IMRT reimbursement was higher historically compared to EBRT. However, over time CMS has determined that the majority of radiation therapy centers have transitioned to newer linear accelerators with OBI capabilities which are able to provide both IMRT and EBRT services. The older linear accelerators which only provide EBRT services are no longer manufactured, therefore the capital equipment cost assumption should be the same for EBRT and IMRT. The revised equipment cost assumption, also scheduled to be implemented over a two year time period, resulted in increased reimbursement for EBRT treatment delivery codes. Please see the following page for a summary of the impact of the coding changes on the treatment delivery codes
In the 2016 final ruling, CMS implemented new brachytherapy skin codes and In addition, brachytherapy codes 77770, 77771, and replaced CPT codes 77785, 77786, and
Effective January 1, 2016, CMS added isosdose planning and special physics & dosimetry consultation services into the bundle for CPT code Therefore, CPT codes 77014, 77280, 77285, 77290, 77295, 77306, 77307, 77321, 77331, and cannot be reported for services provided prior to the completion of the IMRT treatment plan. Following the completion of the IMRT planning, the provider may bill for certain isodose, physics, or dosimetry consultation services if it is documented that the patient requires additional services during the course of treatment. (Source: ASTRO Coding Updates).
Source: ASTRO 2016 Final Rule Summary and ASTRO coding update

6. 2016 MPFS Changes (Continued)

7. Regulatory Update
In December of 2015 President Obama signed the Patient Access and Medicare Protection Act (“PAMPA”) which effectively blocked further reimbursement cuts for radiation therapy treatment delivery codes until According to PAMPA the 2017 & 2018 code definitions, wRVUS, and direct inputs for the practice expense RVUs used for CPT codes G6001 through G6015 shall be the same definitions, units, and inputs utilized in the 2016 final MPFS ruling.
Furthermore, radiation treatment delivery and related imaging services shall not be considered potentially misvalued codes under CMS screening process.
Finally, PAMPA stated that no later than 18 months after the date of the enactment of the law that the Secretary of Health and Human Services shall submit to Congress a report on the development of an episodic payment model for radiation therapy services furnished in a non-facility setting.

8. 2017 MPFS Changes
The FY 2017 MPFS final rule was the first following the passage of the PAMPA, therefore the were minimal reimbursement changes. Specific codes impacted by the FY 2017 ruling are summarized below:
Reimbursement for CPT code G6011 was cut in 2017 due to a decrease in indirect PE RVUs assigned to the code. The change was a result of an analysis of claims data which showed a shift in claims from dermatology to radiation oncology which has a lower indirect PE RVU assigned to it.
Radiation therapy treatment devices (77332, 77333, 77334) received a significant payment adjustment in FY 2017 due to a change in the assumed time to provide the services. Reimbursement for CPT codes and was cut while reimbursement for increased significantly. It should be noted that these codes were identified through the high expenditure specialty screening tool.
Reimbursement for the special treatment devices CPT code was also cut in 2017 due to a decrease in assumed wRVUs. CPT code was also identified through the high expenditure screening tool.
Source: Revenue Cycle Inc. analysis of FY 2017 coding changes.

9. Comments AMA Coding Changes:
Analysis of AMA Coding Changes
Presented in the chart below is a summary of the radiation therapy coding changes proposed by the American Medical Association in August of As mentioned previously, these coding changes have been delayed by until 2019 as a result of PAMA. However, certain commercial payors and Medicare carriers have already switched to the new coding methodology.
77402 – EBRT TX Delivery
77403 – EBRT TX Delivery
77404 – EBRT TX Delivery
77406 – EBRT TX Delivery
77407 – EBRT TX Delivery
77409 – EBRT TX Delivery
77411 – EBRT TX Delivery
77412 – EBRT TX Delivery
77413 – EBRT TX Delivery
77414 – EBRT TX Delivery
77416 – EBRT TX Delivery
77418 – IMRT TX Delivery
77421 – X-Ray Guidance
76950 – Echo Guidance
77014 – CT Guidance
0179T – Track Motion
2014 CPT Codes:
AMA CPT Codes:
77402 – EBRT TX Delivery - Simple
77407 – EBRT TX Delivery – Intermed.
77416 – EBRT TX Delivery - Complex
77385 – IMRT TX Delivery - Simple
77386 – IMRT TX Delivery - Complex
77387 – IGRT Guidance For TX Delivery
Comments AMA Coding Changes:
The energy level of the megavoltage beam no longer defines the complexity level of the EBRT delivery codes. Complexity levels for the new EBRT Codes are defined below:
Simple: All of the following are met – single treatment area, 1-2 ports, <2 simple blocks
Intermediate: Any of the following are met - two treatment areas, 3+ ports, 3+ simple blocks
Complex: Any of the following are met - 3+ treatment areas, custom block, tangential port, wedges, rotational beam or electronic beam
All IGRT services reported with 77387
TC component of is bundled with IMRT delivery codes & 77386) and therefore not billed separately
77387 billed globally with EBRT treatment codes
Simple: Prostate, breast, all compensator based IMRT
Complex: All other sites not using compensator based IMRT
Note: Chart above excludes brachytherapy isodose changes. Source: ASTRO coding guidance.

10. Overall Impact – IMRT With CT
Disclaimer: Net revenue per treatment presented above is based on the Medicare Physician Fee Schedule for the respective year assuming an example course of treatment. Actual coding patterns, and subsequent reimbursement, will vary from provider to provider based on actual services provided due to medical necessity.

11. Overall Impact – IMRT With X-Ray
Disclaimer: Net revenue per treatment presented above is based on the Medicare Physician Fee Schedule for the respective year assuming an example course of treatment. Actual coding patterns, and subsequent reimbursement, will vary from provider to provider based on actual services provided due to medical necessity.

12. Overall Impact – EBRT
Disclaimer: Net revenue per treatment presented above is based on the Medicare Physician Fee Schedule for the respective year assuming an example course of treatment. Actual coding patterns, and subsequent reimbursement, will vary from provider to provider based on actual services provided due to medical necessity.