ROCR Town Hall/Webinar Discussion

[RadOncDoc21]

Medicine is a dirty business.

Business is dirty!

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[NotMattSpraker]

Business is dirty!

All true, and others in other fields of medicine are not always saints.

I do think Rad Onc is uniquely dirty though with uniquely bad leadership.

 

[medgator]

All true, and others in other fields of medicine are not always saints.

I do think Rad Onc is uniquely dirty though with uniquely bad leadership.

💯💯💯

 

[evilbooyaa]

All true, and others in other fields of medicine are not always saints.

I do think Rad Onc is uniquely dirty though with uniquely bad leadership.

It's only bad leadership if you think about those not in leadership. Those in leadership with their protons, PPS-exempt status, etc. are going to do just fine!

Some PPs will like it because it will fix the site neutrality issue that is putting them at a competitive disadvantage compared to HOPPS locations. And, they can go to hypofrac without droping their revenues. Thus, if they can see more patients and treat more patients, they'll make more. I'm sure some PPs are bursting at the seams with their 44fx prostates/33fx breast patients (which they won't change b/c of FFS), even if most ar enot.

 

[thecarbonionangle]

All true, and others in other fields of medicine are not always saints.

I do think Rad Onc is uniquely dirty though with uniquely bad leadership.

I agree there seems to be a pretty deep and pervasive level of corruption in our field. I think the small size lends itself to the same people having power and nothing ever changes. The “leadership” is generally absolutely awful, elitist and arrogant

 

[Radadabbadoo]

It's only bad leadership if you think about those not in leadership. Those in leadership with their protons, PPS-exempt status, etc. are going to do just fine!

Some PPs will like it because it will fix the site neutrality issue that is putting them at a competitive disadvantage compared to HOPPS locations. And, they can go to hypofrac without droping their revenues. Thus, if they can see more patients and treat more patients, they'll make more. I'm sure some PPs are bursting at the seams with their 44fx prostates/33fx breast patients (which they won't change b/c of FFS), even if most ar enot.

45 - 48 fractions for prostate! Don't short change yourself with just 44!

 

[medgator]

It's only bad leadership if you think about those not in leadership. Those in leadership with their protons, PPS-exempt status, etc. are going to do just fine!

I've never seen competitive specialities do this to their own but it makes sense when you consider rad onc was only truly competitive in the US post-IMRT and now it's just going back competitively where it always has been, in the gutter with Neuro, fp, peds etc (all of which actually have more of a need, societally).

Never belonged with plastics, derm, urology, or Ortho

 

[fiji128]

Only Astro could try and pull something like this. A whole new stand alone bill requiring passage through congress and a signature of the president that fundamentally changes much about the specialty and affecting everyone that practices. A bill who's full text/details was never even released to its membership before hand. Just an outline with a 1 hour town hall for comment. Such a rotten org to its core. At least, just based on probabilities alone, the chances of this getting through has to be fairly close to zero.

 

[Fpg1245]

All true, and others in other fields of medicine are not always saints.

I do think Rad Onc is uniquely dirty though with uniquely bad leadership.

I mean I can’t imagine a PP spine group making a junior attending write a ten page essay about why they should be made partner.

 

[elementaryschooleconomics]

Only Astro could try and pull something like this. A whole new stand alone bill requiring passage through congress and a signature of the president that fundamentally changes much about the specialty and affecting everyone that practices. A bill who's full text/details was never even released to its membership before hand. Just an outline with a 1 hour town hall for comment. Such a rotten org to its core. At least, just based on probabilities alone, the chances of this getting through has to be fairly close to zero.

This is what cracks me up the most.

The hubris of the Boomer-dominated ASTRO "leadership" is off the charts with this one.

ASTRO couldn't steward the specialty through the "good" times, what in the world makes them think they can do it in the "bad" times with a plan that requires A NEW LAW TO BE CREATED THAT WOULD PULL THE ENTIRE SPECIALTY OUT OF MEDICARE?

Big brain time!

 

[RadOncDoc21]

This is what cracks me up the most.

The hubris of the Boomer-dominated ASTRO "leadership" is off the charts with this one.

ASTRO couldn't steward the specialty through the "good" times, what in the world makes them think they can do it in the "bad" times with a plan that requires A NEW LAW TO BE CREATED THAT WOULD PULL THE ENTIRE SPECIALTY OUT OF MEDICARE?

Big brain time!

Classic double down hard mentality.

 

[WanderingRad3]

You cannot be serious. A single skin CA exclusion is not worth this entire dumpster-fire of a bill meant to drive more cases to the higher cost centers and destroy private practices in the process.

This is just step 1. You will take a huge cut upfront and then cuts will continue from there as they always have. Rates won't go up. They never have and they never will. Including increases in this bill is just fantasy-land.

All technological advancements in this field will stop immediately. There will be no market for ANY new technology if you aren't paid more to implement them. It's just more cost that you will be eating. The demand for older sh** machines will increase so you can't even get those for cheap.

The excluded "academic" centers will continue to buy the newest machines since they can actually be paid more for their use and they will advertise to your patients about how much better their technology is than yours - and for once they will actually be right.

RTT and radonc job markets will be decimated. You don't need 2 radoncs for 10 on beam. You will still have to be there all day.

Protons exclusion is just dirty. They are a huge driver of cost with no proven benefit. If it won't pass without protons included, it shouldn't pass.

I don’t care about the skin stuff really. Just was arguing the counter point for why I think excluding SRT is good. I also hate skincure.

I ran the numbers for our practice and we make more $. Plus inflationary updates is nice.

Re new tech, you can introduce new CPT codes paid FFS outside of the model. That was both in the ASTRO proposal and the bill.

Reasonable to disagree and think it would be bad for the field, but I personally think it will be good for me as a PP doc (and for the field). Sounds like from the signatory list a lot of the bigger PP groups think the same.

 

[TheWallnerus]

I mean I can’t imagine a PP spine group making a junior attending write a ten page essay about why they should be made partner.

I would have an extremely hard time (pun intended) if asked to do this not titling said essay as “Have You Seen the Size of My Testicles?”

 

[thecarbonionangle]

I mean I can’t imagine a PP spine group making a junior attending write a ten page essay about why they should be made partner.

“Please tell us in a single spaced, 11 roman font, small header and footer why we should even consider making you a partner”

Oh yeah sorry we read your essay and it was decided you will remain employed. Enjoy that free ASTRO membership through our very generous CME!

 

[GapCalc]

I'm no legal eagle, but after briefly reviewing the text of the bill, it's not all bad. In fact, this may be better for community rad onc than the status quo, primarily for payment stabilization. For context, Medicare cuts to RO have been >20% over the last decade.

- payment rates maintained prior to date of effective regulation (no big cut prior to implementation)
- half of the episode based pain med within 30 days of 1st treatment (reliable payments are important for smaller practices)
- inflation adjusted changes in reimbursement (not a cut)
- annual updates to payment rates (not a cut)
- payment floor will be the prior year payment rate (not a cut)
- payment floor should not be reduced by more than 1% every 5 years (huge if true)

Basically, the worst part of Medicare for most ROs doing bread-and-butter stuff is the decrease in reimbursement over the last 10-15 years, and the yearly fight against it hasn't succeded. Clearly, our leadership did not do a good job of avoiding cuts, but we're also an easy target because we are (a) small and (b) expensive. Now I'd argue we are very 'high value' but that's not what the bean counters see.

This bill has lots of problems, but stabilizing payments and potentially increasing reimbursement will likely have a favorable impact on most community practices.

The other stuff like exempting PPS and protons sucks, but that probably isn't changing your day-to-day life. Stabilizing payments is good, or at least better than the current long-term trend of cuts occurring year after year.

Now that being said, the way this whole thing was carried out is B.S. and even if there is a good financial outcome, that doesn't excuse ASTRO from criticism for just how poorly they approached this legislation.

 

[communitydoc13]

In fact, this may be better for community rad onc than the status quo, primarily for payment stabilization. For context, Medicare cuts to RO have been >20% over the last decade.

Agree.

The carve outs mean different things to different people. For many docs, there is no large PPS exempt or proton (anticipating more academic investment going forward) center in their region for the carveouts to matter much. For others. proton investment and direct to patient marketing are already a threat and impact volume to some degree.

For me, the exemptions do not help the field make the right decisions (principled opposition) and will perpetuate a growing regional threat (practical opposition).

I would support the bill without the carve outs. Of course, the rollout has been abysmal.

 

[elementaryschooleconomics]

I'm no legal eagle, but after briefly reviewing the text of the bill, it's not all bad. In fact, this may be better for community rad onc than the status quo, primarily for payment stabilization. For context, Medicare cuts to RO have been >20% over the last decade.

I completely agree, it's definitely not the worst version they could have produced. They even tweaked some things compared to the original announcement!

However, at the end of the day - even if the bill flat out said something like "immediately increase all RadOnc reimbursements by 50%" - I still can't support this.

Why?

Because it removes RadOnc (sans carve-outs) from the Medicare system.

It legally distinguishes reimbursements for one of the smallest specialties in medicine. Sure, it would be great to escape from the budget neutrality issue, where increasing our reimbursement means decreasing someone else's.

However...we have close to zero political presence in DC. ASTRO has a single day for advocacy. The PAC budget is like, 10% of a single Chair's salary.

If (when?) the government decides to focus on RadOnc again, like what happened in 2012 - how is that going to go for us? This is literally legislating us to be "fish in a barrel".

And what is CMS going to do? They still need to administer our reimbursement. So either several CMS employees need to shoulder increased workloads AFTER standing up an unprecedented, unique payment system, or there needs to be a budget to create a new division and/or hire new CMS employees etc.

The nail that sticks out gets hammered down. As it is written, ROCR would leave protons and DermRads to drain reimbursement from "regular" Medicare, while simultaneously creating this unique little standout that will require, at minimum, a new division (or at least division of labor) at CMS in order to, you know, design the administration of this thing from scratch.

Oh.

I almost forgot.

What will Americans and their representatives think when other specialties figure out the loophole to escaping budget neutrality is just...leaving Medicare...like RadOnc did, setting the precedent?

ASTRO has never been able to see the forest for the trees, so at least they're remaining consistent with this, too.

 

[metallica81788]

Now that being said, the way this whole thing was carried out is B.S. and even if there is a good financial outcome, that doesn't excuse ASTRO from criticism for just how poorly they approached this legislation.

💯

 

[NotMattSpraker]

And what is CMS going to do? They still need to administer our reimbursement. So either several CMS employees need to shoulder increased workloads AFTER standing up an unprecedented, unique payment system, or there needs to be a budget to create a new division and/or hire new CMS employees etc.

Ok so, I've heard literally nothing about this since last summer's fake town hall.

Is there anything in there about coding? Is it still expected that there will now need to be two separate sets of codes per patient?

Also, does anyone know anything more about this rumor that some of the authors have a patent on coding software?

This all came up and seemed like kind of a big COI and a huge administrative mess, and no one has really said anything since.

Accreditation + extra coding... just what I thought my department needed, more non-clinical administrators.

 

[thecarbonionangle]

Ok so, I've heard literally nothing about this since last summer's fake town hall.

Is there anything in there about coding? Is it still expected that there will now need to be two separate sets of codes per patient?

Also, does anyone know anything more about this rumor that some of the authors have a patent on coding software?

This all came up and seemed like kind of a big COI and a huge administrative mess, and no one has really said anything since.

Accreditation + extra coding... just what I thought my department needed, more non-clinical administrators.

Implementing an Electronic Data Capture System to Improve Clinical Workflow in a Large Academic Radiation Oncology Practice

To describe the feasibility and benefits of implementing a custom radiation oncology electronic data capture (EDC) system in a large academic radiation oncology practice.A Web-based point-and-click EDC known as Brocade was internally developed and implemented ...

www.ncbi.nlm.nih.gov

 

[WanderingRad3]

Ok so, I've heard literally nothing about this since last summer's fake town hall.

Is there anything in there about coding? Is it still expected that there will now need to be two separate sets of codes per patient?

Also, does anyone know anything more about this rumor that some of the authors have a patent on coding software?

This all came up and seemed like kind of a big COI and a huge administrative mess, and no one has really said anything since.

Accreditation + extra coding... just what I thought my department needed, more non-clinical administrators.

77261/77262/77263 would trigger payment, you would submit CPT codes like you usually do (77301, 77427, etc) but payment would not be based on those CPT codes. It would be based on the M code (prostate cancer would have an M code, lung cancer would have an M code). My understanding, from the way the bill is written, the 77261/77262/77263 and M code combo would trigger payment (50% upfront and 50% at the end) and disallow the other standard CPT codes we usually submit. So less nit picking at the end of treatment frankly on did we code the entire course correctly (because it won't matter for payment...)

Personally, I review each course of treatment at end of treatment to ensure we put all the right codes (takes 2 min/patient and I catch something missing about 20% of the time, like a missed 77427 code or something even though we did the work). So....I would not do that anymore.

 

[elementaryschooleconomics]

77261/77262/77263 would trigger payment, you would submit CPT codes like you usually do (77301, 77427, etc) but payment would not be based on those CPT codes. It would be based on the M code (prostate cancer would have an M code, lung cancer would have an M code). My understanding, from the way the bill is written, the 77261/77262/77263 and M code combo would trigger payment (50% upfront and 50% at the end) and disallow the other standard CPT codes we usually submit. So less nit picking at the end of treatment frankly on did we code the entire course correctly (because it won't matter for payment...)

Personally, I review each course of treatment at end of treatment to ensure we put all the right codes (takes 2 min/patient and I catch something missing about 20% of the time, like a missed 77427 code or something even though we did the work). So....I would not do that anymore.

In one of Mantz's presentations - I think the fake Town Hall - he (or Adler, who knows) said you're still going to need to code ROCR cases like normal, with the justification being something about future adjustments to the case rates.

Or something like that. I mean if you mean you won't be double-checking codes because it won't matter, I get it, but the M-codes will be in addition to regular codes.

 

[Ray D. Ayshun]

In one of Mantz's presentations - I think the fake Town Hall - he (or Adler, who knows) said you're still going to need to code ROCR cases like normal, with the justification being something about future adjustments to the case rates.

Or something like that. I mean if you mean you won't be double-checking codes because it won't matter, I get it, but the M-codes will be in addition to regular codes.

I guess you can better quantity savings with that dataset. Could be the makings of a radonc centric nejm article. It's been a minute.

 

[MidwestRadOnc]

So the RVU rates for each code stay the same?

 

[elementaryschooleconomics]

So the RVU rates for each code stay the same?

lol

if anyone at big brain ASTRO has considered that question

they have shared the answer with no one

 

[MidwestRadOnc]

Most rad oncs are employed and paid per RVU. The case rate collections don’t matter to them/us. If the payments per case go up or down, it doesn’t change my income unless

1. The code multipliers are affected.
2. The hospital does not renew my contract at the same RVU rate.

If I treat a 45 fraction prostate, do I still get 3.37 RVU x 9 77427 even though this hospital is collecting less than it did before?

 

[elementaryschooleconomics]

Most rad oncs are employed and paid per RVU. The case rate collections don’t matter to them/us. If the payments per case go up or down, it doesn’t change my income unless

1. The code multipliers are affected.
2. The hospital does not renew my contract at the same RVU rate.

If I treat a 45 fraction prostate, do I still get 3.37 RVU x 9 77427 even though this hospital is collecting less than it did before?

Yeah, too bad we didn't get to have any actual discussion about this proposal, because this is an important point/thought experiment.

In a world where ROCR passes, we're looking at making "the system" even more complicated, with different rates and coding/billing mechanisms for:

1) Private payors
2) Medicare Advantage
3) ROCR case rates
4) VA/Tricare
5) Medicaid
6) Cash pay
7) Uninsured/other

At the moment, wRVUs are disconnected from actual charges/reimbursements, at least as far as I've heard. If anyone out there has an employed gig where your wRVUs change based on reimbursement, please post about it (I'm sure this will happen somewhere, sometime).

As it stands, there are already significantly misaligned incentives with the "normal" arrangement, with the most glaring example being IMRT bundling.

For those that don't know: while yes, in terms of monetary reimbursement, 60Gy in 30 fractions nets the HOSPITAL more money if delivered via IMRT, but the exact same treatment delivered via a 4-field 3D plan actually generates significantly more wRVUs for the PHYSICIAN.

ROCR would create, at best, another misalignment (if the coding is still done the same way as FFS, and wRVUs are unaffected by reimbursement).

At worst, it could be the start of the avalanche that triggers hospital reimbursement being tied to W2 employed doctor wRVU totals, and therefore, salary.

I mean the justification from an MBA-wielding admin writes itself:

"Sorry, Dr Smith, but obviously your salary has to come from somewhere, right? wRVUs are just a surrogate for revenue. You can't really expect the hospital to pay you AS IF the revenue matched the wRVUs, because they don't. If we get paid, you get paid, yeah?"

This dystopian future can be seen coming to a hospital near you!

 

[RickyScott]

Yeah, too bad we didn't get to have any actual discussion about this proposal, because this is an important point/thought experiment.

In a world where ROCR passes, we're looking at making "the system" even more complicated, with different rates and coding/billing mechanisms for:

1) Private payors
2) Medicare Advantage
3) ROCR case rates
4) VA/Tricare
5) Medicaid
6) Cash pay
7) Uninsured/other

At the moment, wRVUs are disconnected from actual charges/reimbursements, at least as far as I've heard. If anyone out there has an employed gig where your wRVUs change based on reimbursement, please post about it (I'm sure this will happen somewhere, sometime).

As it stands, there are already significantly misaligned incentives with the "normal" arrangement, with the most glaring example being IMRT bundling.

For those that don't know: while yes, in terms of monetary reimbursement, 60Gy in 30 fractions nets the HOSPITAL more money if delivered via IMRT, but the exact same treatment delivered via a 4-field 3D plan actually generates significantly more wRVUs for the PHYSICIAN.

ROCR would create, at best, another misalignment (if the coding is still done the same way as FFS, and wRVUs are unaffected by reimbursement).

At worst, it could be the start of the avalanche that triggers hospital reimbursement being tied to W2 employed doctor wRVU totals, and therefore, salary.

I mean the justification from an MBA-wielding admin writes itself:

"Sorry, Dr Smith, but obviously your salary has to come from somewhere, right? wRVUs are just a surrogate for revenue. You can't really expect the hospital to pay you AS IF the revenue matched the wRVUs, because they don't. If we get paid, you get paid, yeah?"

This dystopian future can be seen coming to a hospital near you!

If our department truly went all out hypofract, number on beam would be cut by more than half, and we would be done by lunch. Can’t see the hospital paying for a full time doc.

 

[StealthTech]

Yeah, too bad we didn't get to have any actual discussion about this proposal, because this is an important point/thought experiment.

In a world where ROCR passes, we're looking at making "the system" even more complicated, with different rates and coding/billing mechanisms for:

1) Private payors
2) Medicare Advantage
3) ROCR case rates
4) VA/Tricare
5) Medicaid
6) Cash pay
7) Uninsured/other

At the moment, wRVUs are disconnected from actual charges/reimbursements, at least as far as I've heard. If anyone out there has an employed gig where your wRVUs change based on reimbursement, please post about it (I'm sure this will happen somewhere, sometime).

As it stands, there are already significantly misaligned incentives with the "normal" arrangement, with the most glaring example being IMRT bundling.

For those that don't know: while yes, in terms of monetary reimbursement, 60Gy in 30 fractions nets the HOSPITAL more money if delivered via IMRT, but the exact same treatment delivered via a 4-field 3D plan actually generates significantly more wRVUs for the PHYSICIAN.

ROCR would create, at best, another misalignment (if the coding is still done the same way as FFS, and wRVUs are unaffected by reimbursement).

At worst, it could be the start of the avalanche that triggers hospital reimbursement being tied to W2 employed doctor wRVU totals, and therefore, salary.

I mean the justification from an MBA-wielding admin writes itself:

"Sorry, Dr Smith, but obviously your salary has to come from somewhere, right? wRVUs are just a surrogate for revenue. You can't really expect the hospital to pay you AS IF the revenue matched the wRVUs, because they don't. If we get paid, you get paid, yeah?"

This dystopian future can be seen coming to a hospital near you!

Can you explain the 3D vs IMRT thing?

 

[TheWallnerus]

Can you explain the 3D vs IMRT thing?

You get sim charges (start and boosts), complex devices per beam; this adds up for complex definitive treatments to (sometimes) be more wRVUs.

 

[medgator]

You get sim charges (start and boosts), complex devices per beam; this adds up for complex definitive treatments to (sometimes) be more wRVUs.

Is igrt bundled with 3D in the hospital as well? Don't think it is... That's a biggie right there also

 

[MidwestRadOnc]

You get sim charges (start and boosts), complex devices per beam; this adds up for complex definitive treatments to (sometimes) be more wRVUs.

Significantly more wRVUs….

Can we clarify the difference for a 33 fraction IMRT plan with an SIB vs. a 33 fraction 3DCRT plan with a sequential boost and daily CBCTs? Anyone actually added up all the codes and wRVU totals in each scenario?

 

[MidwestRadOnc]

Is igrt bundled with 3D in the hospital as well? Don't think it is... That's a biggie right there also

You get 0.85 wRVU per cbct review on an IMRT plan as the physician.

 

[temujim]

Yeah, too bad we didn't get to have any actual discussion about this proposal, because this is an important point/thought experiment.

In a world where ROCR passes, we're looking at making "the system" even more complicated, with different rates and coding/billing mechanisms for:

1) Private payors
2) Medicare Advantage
3) ROCR case rates
4) VA/Tricare
5) Medicaid
6) Cash pay
7) Uninsured/other

At the moment, wRVUs are disconnected from actual charges/reimbursements, at least as far as I've heard. If anyone out there has an employed gig where your wRVUs change based on reimbursement, please post about it (I'm sure this will happen somewhere, sometime).

Aware of some practices where no reimbursement = no wRVU.

 

[elementaryschooleconomics]

Aware of some practices where no reimbursement = no wRVU.

Well shoot.

I was hoping it would take at least 24 hours before someone said the arrangement already existed, haha.

We're talking employed docs right?

(because, of course, private practice means reimbursement = income)

 

[elementaryschooleconomics]

Significantly more wRVUs….

Can we clarify the difference for a 33 fraction IMRT plan with an SIB vs. a 33 fraction 3DCRT plan with a sequential boost and daily CBCTs? Anyone actually added up all the codes and wRVU totals in each scenario?

I haven't done the math in awhile, but just to sketch it out:

Assume 60Gy, 30 fractions. 1-arc VMAT plan vs 4-field box 3D plan (using MLC-modified beams for each field). For the sake of argument we can pretend this is a Stage III NSCLC case.

E&M is the same.

CTSIM - bundled with IMRT, not bundled for 3D.
Assume 77290 at CTSIM, and 77280 at VSIM = 1.56 + 0.7 = +2.26 for 3D

Any sort of immobilization devices are the same, so is 4D scan and special treatment procedure (chemo), and 77263 (clinical treatment planning).

3D Plan = 77295 = 4.29
IMRT Plan = 77301 = 7.99

So the IMRT plan is worth +3.7 wRVU over 3D.

(right now, IMRT is winning at +1.44).

This is where there's A TON of variation based on number of arcs vs fields.

For IMRT, you drop 77338 x1 no matter how many arcs (4.29)
For 3D, you drop 77334 x[fields], so in this example x4 (4.6)
(IMRT now winning at +1.13)

Then we get to 77300, which is used the same way MLB players use rituals when stepping up to the plate. While one guy will slap his left glove with his right hand three times in a counter-clockwise motion, the next batter thinks he's nuts - before proceeding to stomp his right foot twice while kissing his cross necklace he received as a gift in 1st grade and pointing at the sky.

In general, you can drop 77300 x[arcs] for IMRT and 77300 x[fields] for 3D. However, then we get into the whole FiF thing, and also the MUE of 10. For the purposes of this illustration, since it's a theoretical definitive lung, I'm going to say I aggressively FiF'ed to spare OARs.

For IMRT, you'd drop 77300 x1 = 0.62
For 3D, you'd drop 77300 x10 = 6.2
(3D now winning at 5.07)

Once you hit on beam, that's where it separates out. OTVs are the same.

IGRT is...annoying.

@MidwestRadOnc is correct, I think, if you use 77387 with a 26 modifier for daily CBCT for IMRT (someone check me on that, please). This might depend on geography/MAC/commercial payor. You could also use G6002 (which is 0.59).

For the sake of argument, I'll go with 0.85 x30 = 25.5

For daily CBCT with 3D, you should be able to use 77014 which is 1.3.

So 1.3 x30 = 39

So daily CBCT has 3D winning at +13.5

Putting it together, for this artificial example of 60Gy in 30 fractions, a 4-field 3D plan beats a 1-arc VMAT plan by 18.57 wRVU.

But the technical revenue is still greater for the IMRT.

(as a disclaimer, this is back-of-the-envelope using wRVU values I have in notes from a year or two ago, and I didn't go out of my way to double check all this, and there's a lot of variation, and...well anyway, it illustrates the point hahaha)

 

[TheWallnerus]

Is igrt bundled with 3D in the hospital as well? Don't think it is... That's a biggie right there also

Can still do the professional and get the wRVUs. Only the IGRT technical is bundled (and only with IMRT).

 

[temujim]

Well shoot.

I was hoping it would take at least 24 hours before someone said the arrangement already existed, haha.

We're talking employed docs right?

(because, of course, private practice means reimbursement = income)

Yeah, and one is even an "academic" institution.

 

[MidwestRadOnc]

Aware of some practices where no reimbursement = no wRVU.

This is literally the entire point on the RVU employed model. You still get paid the exact same no matter what/if the hospital collects. Otherwise you are on a collections based model with all of the downside and none of the upside.

 

[MidwestRadOnc]

I haven't done the math in awhile, but just to sketch it out:

Assume 60Gy, 30 fractions. 1-arc VMAT plan vs 4-field box 3D plan (using MLC-modified beams for each field). For the sake of argument we can pretend this is a Stage III NSCLC case.

E&M is the same.

CTSIM - bundled with IMRT, not bundled for 3D.
Assume 77290 at CTSIM, and 77280 at VSIM = 1.56 + 0.7 = +2.26 for 3D

Any sort of immobilization devices are the same, so is 4D scan and special treatment procedure (chemo), and 77263 (clinical treatment planning).

3D Plan = 77295 = 4.29
IMRT Plan = 77301 = 7.99

So the IMRT plan is worth +3.7 wRVU over 3D.

(right now, IMRT is winning at +1.44).

This is where there's A TON of variation based on number of arcs vs fields.

For IMRT, you drop 77338 x1 no matter how many arcs (4.29)
For 3D, you drop 77334 x[fields], so in this example x4 (4.6)
(IMRT now winning at +1.13)

Then we get to 77300, which is used the same way MLB players use rituals when stepping up to the plate. While one guy will slap his left glove with his right hand three times in a counter-clockwise motion, the next batter thinks he's nuts - before proceeding to stomp his right foot twice while kissing his cross necklace he received as a gift in 1st grade and pointing at the sky.

In general, you can drop 77300 x[arcs] for IMRT and 77300 x[fields] for 3D. However, then we get into the whole FiF thing, and also the MUE of 10. For the purposes of this illustration, since it's a theoretical definitive lung, I'm going to say I aggressively FiF'ed to spare OARs.

For IMRT, you'd drop 77300 x1 = 0.62
For 3D, you'd drop 77300 x10 = 6.2
(3D now winning at 5.07)

Once you hit on beam, that's where it separates out. OTVs are the same.

IGRT is...annoying.

@MidwestRadOnc is correct, I think, if you use 77387 with a 26 modifier for daily CBCT for IMRT (someone check me on that, please). This might depend on geography/MAC/commercial payor. You could also use G6002 (which is 0.59).

For the sake of argument, I'll go with 0.85 x30 = 25.5

For daily CBCT with 3D, you should be able to use 77014 which is 1.3.

So 1.3 x30 = 39

So daily CBCT has 3D winning at +13.5

Putting it together, for this artificial example of 60Gy in 30 fractions, a 4-field 3D plan beats a 1-arc VMAT plan by 18.57 wRVU.

But the technical revenue is still greater for the IMRT.

(as a disclaimer, this is back-of-the-envelope using wRVU values I have in notes from a year or two ago, and I didn't go out of my way to double check all this, and there's a lot of variation, and...well anyway, it illustrates the point hahaha)

77387 doesn’t have any wRVU attached to it, and 77014 is 0.85. We use 77014 for all daily cone beam whatever the plan. Where are you getting 1.3 wRVU for daily cone beam for 3D?

Also, I didn’t think you could report 77300 with 3D plans (77295)

 

[elementaryschooleconomics]

77387 doesn’t have any wRVU attached to it, and 77014 is 0.85. We use 77014 for all daily cone beam whatever the plan. Where are you getting 1.3 wRVU for daily cone beam for 3D?

77014-26

https://www.acr.org/-/media/ACR/NOINDEX/Advocacy/Advocacy-News/2022-MPFS/Impact-Table-70000-Series.pdf

This is what I meant from my disclaimer about years haha, maybe it's down to 0.85 in 2024 but I didn't have an easy file with the latest codes.

I'll have to go dig my personal production reports out of the system because I'm 99% sure you're right, I just can't remember what code they're using.

My uncertainty stems from the fact that, over the last 5-8 years, there's been a lot of flip flopping from CMS and private payors over IGRT reimbursement and at this moment in 2024, I'm pretty sure there are two codes you can use.

An additional disclaimer is that this is all hospital outpatient stuff, I don't talk about freestanding because I don't work for GenesisCare.

 

[elementaryschooleconomics]

Also, I didn’t think you could report 77300 with 3D plans (77295)

Oh you definitely can.

Unless it recently changed, you can also do it per arc for VMAT (disclaimer being I haven't looked at that in a year or two).

You can't for superficial/orthovoltage, though.

 

[MidwestRadOnc]

If you’re

Oh you definitely can.

Unless it recently changed, you can also do it per arc for VMAT (disclaimer being I haven't looked at that in a year or two).

You can't for superficial/orthovoltage,

“
Do not report dosimentry calculations (77300) with 3D plans (77295) These are considered integral to the planning process and should not be reported separately
“

https://www.aapm.org/pubs/enews/documents/NewCodeEdit.pdf

This is why I’m confused.

 

[TheWallnerus]

If you’re

“
Do not report dosimentry calculations (77300) with 3D plans (77295) These are considered integral to the planning process and should not be reported separately
“

https://www.aapm.org/pubs/enews/documents/NewCodeEdit.pdf

This is why I’m confused.

Never seen this guidance before. And I have never followed it, or been counseled on this. And I have worked with some persnickety billers.

 

[elementaryschooleconomics]

Never seen this guidance before. And I have never followed it, or been counseled on this. And I have worked with some persnickety billers.

Uh...agreed.

I drop 77300 all the time for 3D plans and have for years without issue.

I have two theories, seeing your link:

1) It's a PDF on the AAPM website. Frequently, DumbDumb Ron and RCCS Staff are the authors of coding PDFs which appear on AAPM and AAMD resources. They are often wildly incorrect, but at this point are a borderline monopoly in an era where massive employment has atrophied physician knowledge and skill in billing.

2) It's talking about a 2016 change. It's possible that was definitely true, but sometime in the last few years it became OK again. I know I was having a lot of issues around certain things in 2018/2019 which are long gone now.

Does anyone remember "you can't bill VMAT for lung because that was an unplanned secondary analysis in RTOG 0617"??

I remember. I have ulcer scars which remember.

 

[medgator]

Does anyone remember "you can't bill VMAT for lung because that was an unplanned secondary analysis in RTOG 0617"??

Evilcore routinely required a 3D vs IMRT plan comparison on every stage III lung pt until sometime in 2020 using that exact same logic when you would do a P2P with the doc

 

[TheWallnerus]

Evilcore routinely required a 3D vs IMRT plan comparison on every stage III lung pt until sometime in 2020 using that exact same logic when you would do a P2P with the doc

IMRT for lung was controversial universally in 2000-05, its infancy. By the time prior auth came on the scene around 2010-13, it was getting a lot less controversial to rad oncs but was still very controversial to insurance companies. RTOG 0617 is, evidence-wise, data of weak strength to prove IMRT is superior to 3D for every case. But, it was something to hang a hat on in arguments to insurance companies… plus it comes with that solid “RTOG name drop.” After insurance companies added stage III lung cancer to the list of IMRT medical necessity indications (which did occur en masse around 2020, yeah) I think it weirdly bolstered IMRT’s street cred in lung. And I say that to say shame on rad onc a bit, and f**k you insurance companies. You still have to come hat in hand to do IMRT for stage one or two lung, any stage small cell, or oligoprogressive or oligometastatic lung. Regarding the former, the insurance companies are happy to argue against a cheaper 15 fraction IMRT course versus the more expensive 35 fraction 3D course. Again… f**k you insurance companies (and the rad oncs who went to work there over the past 15 years and helped set policy).

Now can we talk about breast IMRT…

 

[HolySmokes]

If you’re

“
Do not report dosimentry calculations (77300) with 3D plans (77295) These are considered integral to the planning process and should not be reported separately
“

https://www.aapm.org/pubs/enews/documents/NewCodeEdit.pdf

This is why I’m confused.

Agree with Wallnerus, I have never seen nor followed this particular advice. It does say it's not reportable on the same day as 77295, and we always bill the 77295 on the day the Rx was signed and 77300 on the day the MU Check was signed so maybe that's still kosher?

That said re: ese's example above there has been guidance from Evicore and others that only allowed distinct 77300 charges for field-in-field on breast plans but no others. You could only charge 77300 per beam (and even that you are technically only supposed to change if the apertures of the beam are different) if it were a lung, palliative, etc.

 

[NotMattSpraker]

Has anyone heard what happened to on table adaptive or has this been discussed at all? Im sorry if I missed it, there is a general lack of organized discussion on this bill. Not surprised, but still frustrating.

Reflexion just got a new CPT code, will that be excluded or is it now bundled?

If now bundled in, that seems like a very big development and a threat to the on-table adaptive space?

 

[RickyScott]

Has anyone heard what happened to on table adaptive or has this been discussed at all? Im sorry if I missed it, there is a general lack of organized discussion on this bill. Not surprised, but still frustrating.

Reflexion just got a new CPT code, will that be excluded or is it now bundled?

If now bundled in, that seems like a very big development and a threat to the on-table adaptive space?

Since rocr is so great, proponents of adaptive and reflexion are pushing to bundle them.