1 / 83

Radiation Oncology, SRS, SBRT, Protons. Advanced Concepts

Section 10 Pages 1-45. Radiation Oncology, SRS, SBRT, Protons. Advanced Concepts. 9:00-10:00. 010814. 82. Revised for 2/21/2014. 46.

zasha
Download Presentation

Radiation Oncology, SRS, SBRT, Protons. Advanced Concepts

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Section 10 Pages 1-45 Radiation Oncology, SRS, SBRT, Protons. Advanced Concepts 9:00-10:00 010814 82 Revised for 2/21/2014 Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

  2. 46 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 Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

  3. Gamma Knife (Radio surgery, SRS) Cyber Knife (SRS, SBRT) Conventional XRT (SRS, SBRT ) STEREOTACTIC PROCEDURES NIB Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

  4. SRS, Stereotactic Radio Surgery was the original definition of this code. SRS is now limited to the cranial vault, and is limited to only 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. 47 Stereotactic Procedures, SRS Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

  5. SBRT, Stereotactic Body Treatment may be delivered to the cranial vault or any where in the body, but is restricted to 2-5 fractions to the cranial vault, and 1-5 fractions to the body. 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. 47 Stereotactic Procedures, SBRT Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

  6. MANAGEMENT OF CRANIAL LESIONS BY STEREOTACTIC TREATMENT 46 • Medicare would expect to see 77432 reported one time for 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 77435, Treatment Management upto 5 fractions must be used. • If the treatment extends beyond 5 fractions,77427 must be used to report the entire course of treatment. Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

  7. 46 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 EXCLUSIVECANNOT BE USED SEQUENTIALLY 42 Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

  8. 46 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. Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

  9. NIB The patient is fixed into a head frame for total accuracy of localization of the lesion Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

  10. 47 The head frame locks in to the Gamma Knife unit for absolute accuracy of set up and treatment. Bill each helmet as a 77334 Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

  11. 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. 47 Removal of the head Frame Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

  12. The code 77371 Gamma Knife one fraction only, complete course of therapy, is used for the technical reimbursement. GAMMA KNIFE TECHNICIAL TREATMENT DELIVERY CODE 47 Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

  13. 48 Gamma knife work page and final narrative of procedure ONCOCHART Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

  14. Conventional Dosimetry. Basic 3-D planning Forward Planned IMRT Advanced 3-D planning Inverse planned IMRT The use of forward planned IMRT planning algorithms is the basis of all Advanced 3-D Dosimetry for SRS and SBRT. History of Dosimetry Section 7 Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

  15. APC Rules for Gamma Knife (SRS) Reimbursement 51 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 Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

  16. SRS USING A LINEAR ACCELERATOR 48 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.CPT Technical delivery Code 77372- single FX, or 77373 - 2 to 5 FX, (FSC). (2007, ASTRO, CMS Hospital 2014), The patient support platform (the treatment couch) may have the capability of moving in various (x, y and z) directions. (Robotic couch) Each of the megavoltage treatment portals is directed to the area of interest within the brain. Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

  17. 48 Brain Lab Micro Multileaf collimator Removable head frame Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

  18. 49 BRAIN LAB STEREOTACTIC PLANING; THIS USES IMRT FORWARD PLANNING ALGORYTHM SOFTWARE, AND SHOULD BE BILLIED AS ADVANCED 3-D 77295 Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

  19. 50 A report is absolutely required for proper documentation of this procedure Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege 136/216

  20. 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. Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

  21. 51 Stereotactic treatment delivery G0173--GO340 DELETED 1-1-14 77371 single session,Gamma Knife 77372 single session, Linac, free standing center, or hospital. 77373 2-5 sessions, Linac, free standing center, or hospital, bill for each session as done If the planning is done using IMRT planning 77301, then treatment should be IMRT 77418 IF YOU TREAT OVER 5 SESSIONS Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

  22. RULES AND CODES FOR SRS 52 Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

  23. 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. • If treatment is being delivered to the cranial vault by means of a linear accelerator, exceeding one fraction, it must be considered SBRT. • SBRT treatment may be delivered utilizing a linear accelerator, Tomo therapy unit, or Cyberknife. • Check your LCD for specific rules related to payment for SBRT based on ICD 9. Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

  24. Notice the detailed and customized clinical comments as part of the statement of medical necessity Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege Courtesy ONCOCHART

  25. RULES AND CODES FOR SBRT 53 Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

  26. 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. Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

  27. 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) 54 Stereotactic Radio Surgery (SRS), 77432 Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

  28. 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. 55 Stereotactic Body Radiation therapy (SBRT) 77435 Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

  29. IMAGE GUIDED RADIATION THERAPY 56 IGRT Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

  30. 56 COMBINED CT AND LINEAR ACCELERATOR THE TREATMENT IS IMRT 77418, THE GUIDANCE IS DAILY CONE BEAM CT IMAGING BILLED AS 77014, OR; Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

  31. 56 LINEAR ACCELERATOR IMRT USING KILOVOLTAGE X-RAY IMAGING, ON BOARD IMAGING (OBI) 77421 STEREOSCOPIC Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

  32. 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 ADVANTAGE OF IGRT 57 Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

  33. 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 BILLING FOR IGRT 57 Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

  34. 77427 Physician treatment management 77418 IMRT treatment delivery 77421 Fiducial treatment guidance, or 77014 CT treatment guidance (2014??) 57 Available Codes for IGRT Treatment with SRS or SBRT may still be considered IGRT, but the guidance codes are bundled, and the treatment cannot be IMRT, 77418 Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

  35. 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 57 77421 STEREOSCOPIC GUIDANCE Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

  36. 57 77421 STEREOSCOPIC X-RAY GUIDANCE FIDUCIAL MARKERS FOR STEREOSCOPIC GUIDANCE Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

  37. 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. FORMAT OF STEREOSCOPIC X-RAY GUIDANCE 57 Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

  38. NIB SIMULATION IMAGES AND ON TREATMENT KV BEAM SET UP IMAGES SUPERIMPOSED 168/183/216 Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

  39. 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 58 DOCUMENTATION for 77421 Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

  40. The 2014 Medicare value is : 77421-26 about $ 19.05 77421-TC about $ 51.37 77421 about $70.43 58 BILLING FOR STEREOSCOPIC GUIDANCE, 77421 170/216 Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

  41. 58 Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

  42. 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. CONE BEAM CT 59 Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

  43. 59 CONE BEAM CT 77014 Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

  44. 59 Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

  45. 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) 60 RESPIRATORY GATING Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

  46. 60 Respiratory motion causes mismatch Respiratory gating allows treatment only at match time 172/183/216 Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

  47. +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. 2014 CPT update NIB Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

  48. 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 60 T CODE FOR GATING Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

  49. PARTICLE ACCELERATORS 63 The concept of a Proton radiation therapy unit was first proposed by physicists in 1946 Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

  50. 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. WHAT ARE PROTONS? 63 Privileged and Confidential Work Product – Subject to the Attorney – Client Privilege

More Related