Multiple site SBRT charges

[Soapcat]

Dear colleagues,

Recently saw an elderly patient with severe COPD, with bilateral lung lesions, most consistent with 2 site early stage NSCLC. Both lesions were very close to the chest wall, and I recommended 2 site SBRTs, each site getting 5 fractions QOD. I did 2 iso plans to achieve the best conformality, improve cardiac sparing and limit low dose bath to the lungs between the lesions. To account for the limitation of our machine time and patient's comfort per tx session, I decided to treat her on alternating days, so that she is done in 2 wks total.

Evicore denied 2 site SBRT - because it is more than 5 fractions, they approved for 10 fraction IMRT plans.
I had a peer to peer with an agent, asked what's the rationale to call 2 site SBRT plans to a non-SBRT IMRT plan. The agent said it is purely based on the fact that it is more than 5 fractions - this is not based on per treatment target, but per 'episode'; apparently, even if I decided to treat her second target after completing the first target, they weren't going to approve 2 site SBRTs because it is under the same 'episode' and would have approved for 10 fraction IMRT. An example the agent provided for them to approve another SBRT is if the patient came a year after for the treatment.

I asked how does this logically, and technically makes sense, and he quote our very ASTRO SBRT reimbursement guideline - that anything beyond 5 fraction is not SBRT and will not reimburse as such. Many of you will agree with me that this is simply not true. Also, if they are insisting about the 5 fraction aspect of the treatment, this should be per treatment target, not per 'episode' or whatever they call it. Unfortunately, I did not have this ASTRO reimbursement guideline when I was talking to the agent (I quickly searched for the guideline while chatting with him, and found out it wasn't free...more like a $1000...and could not load it up). Regardless, they werent going to approve 2 site SBRTs no matter what. I found out later that my partner had the same issue before.

I am furious about how evicore and potentially other insurance companies are twisting the words and meaning of SBRT to undermine our (not just myself, but my dosimetrists, physicists, therapists) time and resource we put into creating high quality plans for our patients. The '10 fraction IMRT' that evicore insisted will not be acceptable for my patient, and I am delivering the 2 SBRT plans regardless (and still charging the 10 fraction IMRT). However, it is absolutely wrong for evicore to take advantage of us this way (or alternatively, give suboptimal care with non-SBRTs). I am also concerned about the future implication of the 5 fraction definition for the SBRT per the ASTRO guideline - how can we appropriately charge multiple site SBRTs in the era of oligometastatic treatment paradigm? Let's say we are treating a spine and a liver lesion for >5 treatments (2-5 fraction for spine, 3-5 fractions for liver; examples for more challenging SBRTs) under the same 'episode' -should we be charged for non SBRT IMRT for this?

What are your thoughts on this matter? Anyone in ASTRO have looked into this?

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[thecarbonionangle]

I have had the same issue and basically what i was told is you have to do it at the same time or they will not pay for both.

what some do is do a consult of the first lesion. Treat the patient in 1-2 weeks daily or every other day and then bring patient back for a reconsult later to address the second one. Im not sure how this pans out in different markets but i have heard some do this.

in my case, i dont worry about billing so i treat multiple at a time, but i have heard we may not get paid for all.

in any system someone has to be the gatekeeper to save money and unfutunately what they do is find ways not to pay. There are certain insurances we do not even sim unless we have approval. Otherwise once you get going it is denied and they will not pay since you started an “unauthorized” treatment.

man i hate P2P just like all you guys. Lately i have had some very odd ones like i was pretty sure the person in other side was not even in oncology.

 

[Mandelin Rain]

Very common issue. Have to treat at same time or bill IMRT.

 

[FrostyHammer]

I hate it too but it's not that big of a deal to just treat on the same days.

 

[Gfunk6]

Interestingly, this issue was brought up in the RO APM. Not only do you get paid for a single treatment course despite treating multiple sites, but they also implemented a "cooldown" period of 30-60 days to ensure that people are not "gaming" the system but scheduling multiple treatment courses in succession.

 

[OTN]

I have a hard time blaming Evicore for this- ASTRO is the entity who defined SBRT as less than or equal to 5 fx. Happens to me all the time.

The "cool-down" part of the RO-APM was what demonstrated to me that ASTRO had zero power/weight to change a single thing in the APM. We've all had metastatic patients who present with worsening pain within 3 months of their prior treatment. Now we're supposed to treat that for free? Absolutely shameful.

 

[BobbyHeenan]

I have a hard time blaming Evicore for this- ASTRO is the entity who defined SBRT as less than or equal to 5 fx. Happens to me all the time.

The "cool-down" part of the RO-APM was what demonstrated to me that ASTRO had zero power/weight to change a single thing in the APM. We've all had metastatic patients who present with worsening pain within 3 months of their prior treatment. Now we're supposed to treat that for free? Absolutely shameful.

Exactly.

Or they progress somewhere new (but still a bone med ICD10) ....what then? code as something different?

 

[TheWallnerus]

Dear colleagues,

Recently saw an elderly patient with severe COPD, with bilateral lung lesions, most consistent with 2 site early stage NSCLC. Both lesions were very close to the chest wall, and I recommended 2 site SBRTs, each site getting 5 fractions QOD. I did 2 iso plans to achieve the best conformality, improve cardiac sparing and limit low dose bath to the lungs between the lesions. To account for the limitation of our machine time and patient's comfort per tx session, I decided to treat her on alternating days, so that she is done in 2 wks total.

Evicore denied 2 site SBRT - because it is more than 5 fractions, they approved for 10 fraction IMRT plans.
I had a peer to peer with an agent, asked what's the rationale to call 2 site SBRT plans to a non-SBRT IMRT plan. The agent said it is purely based on the fact that it is more than 5 fractions - this is not based on per treatment target, but per 'episode'; apparently, even if I decided to treat her second target after completing the first target, they weren't going to approve 2 site SBRTs because it is under the same 'episode' and would have approved for 10 fraction IMRT. An example the agent provided for them to approve another SBRT is if the patient came a year after for the treatment.

I asked how does this logically, and technically makes sense, and he quote our very ASTRO SBRT reimbursement guideline - that anything beyond 5 fraction is not SBRT and will not reimburse as such. Many of you will agree with me that this is simply not true. Also, if they are insisting about the 5 fraction aspect of the treatment, this should be per treatment target, not per 'episode' or whatever they call it. Unfortunately, I did not have this ASTRO reimbursement guideline when I was talking to the agent (I quickly searched for the guideline while chatting with him, and found out it wasn't free...more like a $1000...and could not load it up). Regardless, they werent going to approve 2 site SBRTs no matter what. I found out later that my partner had the same issue before.

I am furious about how evicore and potentially other insurance companies are twisting the words and meaning of SBRT to undermine our (not just myself, but my dosimetrists, physicists, therapists) time and resource we put into creating high quality plans for our patients. The '10 fraction IMRT' that evicore insisted will not be acceptable for my patient, and I am delivering the 2 SBRT plans regardless (and still charging the 10 fraction IMRT). However, it is absolutely wrong for evicore to take advantage of us this way (or alternatively, give suboptimal care with non-SBRTs). I am also concerned about the future implication of the 5 fraction definition for the SBRT per the ASTRO guideline - how can we appropriately charge multiple site SBRTs in the era of oligometastatic treatment paradigm? Let's say we are treating a spine and a liver lesion for >5 treatments (2-5 fraction for spine, 3-5 fractions for liver; examples for more challenging SBRTs) under the same 'episode' -should we be charged for non SBRT IMRT for this?

What are your thoughts on this matter? Anyone in ASTRO have looked into this?

Welcome to modern rad onc is all I can say. As an aside in the setting of a Medicare patient where you can “do what you want” (no prior auth or peer review), I think the very rigid view Evicore is espousing should also (unfortunately) be adopted. All CMS guidance limits SBRT to five fractions. Trying to bill more than five with no change in diagnosis codes would potentially look fishy and might even cause a denial of everything or clawback later.

 

[evilbooyaa]

EviCore is evil on a loto fthings, but on this they are literally just listening to ASTRO which has said any SBRT that is 6 fractiokns or above is automatically billed as IMRT.

I generally do multi site on the same day and at least get paid for one SBRT charge in these multi iso situations.

 

[medgator]

EviCore is evil on a loto fthings, but on this they are literally just listening to ASTRO which has said any SBRT that is 6 fractiokns or above is automatically billed as IMRT.

I generally do multi site on the same day and at least get paid for one SBRT charge in these multi iso situations.

My understanding is that you can only bill one treatment charge per day... so if you do an SBRT and an IMRT fx on the same pt on the same day, you're only getting paid for the SBRT charge, or when you treat 3D and IMRT on a pt the same day, only getting paid for the IMRT charge etc

 

[drewdog1973]

It’s the equivalent of a surgeon doing 2 procedures on the same day to make things convenient for a patient and only getting paid for one. We should be rewarded to treat multiple sites, but instead get penalized.

 

[evilbooyaa]

My understanding is that you can only bill one treatment charge per day... so if you do an SBRT and an IMRT fx on the same pt on the same day, you're only getting paid for the SBRT charge, or when you treat 3D and IMRT on a pt the same day, only getting paid for the IMRT charge etc

Correct, this is same if it is 2 SBRT charges, which is what I would normally do, for sake of patient convenience.

 

[Ray D. Ayshun]

So it's okay to concurrently do 5 fx sbrt and 10-15+ fx IMRT concurrently and charge SBRT for the first 5? My understanding is that an SBRT COURSE has to be 5 or less, and though that particular body site would be getting SBRT'd, the course length is dictated by the IMRT plan.

 

[Mandelin Rain]

So it's okay to concurrently do 5 fx sbrt and 10-15+ fx IMRT concurrently and charge SBRT for the first 5? My understanding is that an SBRT COURSE has to be 5 or less, and though that particular body site would be getting SBRT'd, the course length is dictated by the IMRT plan.

I believe this is correct

 

[Ray D. Ayshun]

I believe this is correct

In turn, this means we can't bill for sbrt concurrent with imrt right?

 

[drewdog1973]

I thought once the course hits >5, it’s all IMRT.

Example - 3 fx sbrt to right lung, 3 fx sbrt to left lung.

If done sequentially, then 6 fx so whole treatment is IMRT. No?

 

[Ray D. Ayshun]

In turn, this means we can't bill for sbrt concurrent with imrt right?

I'm not liking that I got two likes, but wondering if people give it a shot anyway. Would be hard to feel asking to get paid for what you do would be construed as fraud if found on audit.

 

[Ray D. Ayshun]

I thought once the course hits >5, it’s all IMRT.

Example - 3 fx sbrt to right lung, 3 fx sbrt to left lung.

If done sequentially, then 6 fx so whole treatment is IMRT. No?

That I don't even want to think about. I bill for SBRT as long as I'm SBRTing everything, which is never more than two sites. I'm not aware of any probs yet.

Edit: didn't read sequentially

 

[TheWallnerus]

So it's okay to concurrently do 5 fx sbrt and 10-15+ fx IMRT concurrently and charge SBRT for the first 5? My understanding is that an SBRT COURSE has to be 5 or less, and though that particular body site would be getting SBRT'd, the course length is dictated by the IMRT plan.

Trying to put an SBRT charge, and then an IMRT charge, together, that close in time, is very problematic. And good luck getting Evicore to go for that.

In turn, this means we can't bill for sbrt concurrent with imrt right?

No (right).

I thought once the course hits >5, it’s all IMRT.

Example - 3 fx sbrt to right lung, 3 fx sbrt to left lung.

If done sequentially, then 6 fx so whole treatment is IMRT. No?

Yes (right).


None of us are smart enough to outwit this problem.

EDIT: btw this a problem unique to the US where all payors (CMS included) define(d) SBRT as 5 fractions or less (initially at 5 Gy or more per fraction though this is variously dropped payor to payor). The 5 fx limit was done completely arbitrarily and in opposition to the global RO medical literature.

 

[TheWallnerus]

"The new radiotherapy treatment, called Stereotactic Ablative Radiotherapy, uses between three to eight high dose radiotherapy sessions to treat early stage, medically inoperable lung cancer."

 

[Palex80]

It is going to be really interesting if at some point data emerged showing that a specific number of sessions of radiotherapy with a specific timing in between produced the highest possible immunogenic effect and triggered abscopal effects in various cancers. Let's say it's 10 x 5 Gy for instance. We would then be asked to irradiate all kinds of tumors (NSCLC, pulmonary, hepatic, bone mets) and you guys would have to see how to bill for that.
The whole flaw in the system is linking SBRT to an amount of sessions of radiotherapy. This should not be the case. Stereotactic treatment should only be linked to the specific treatment technique (precise immobilization, motion management, steep dose gradient, multi beam arrangement).

 

[FrostyHammer]

Stereotactic treatment should only be linked to the specific treatment technique (precise immobilization, motion management, steep dose gradient, multi beam arrangement).

That's too complicated for billing people and insurance companies to understand. They are more of the 0 & 1 binary code type of robots.