Summary of Final Medicare Hospital Outpatient and ... · Summary of Final Medicare Hospital...

Summary of Final Medicare Hospital Outpatient and Physician Fee Schedule (Physicians and Freestanding Centers) CY 2014 Rules

12/13 PRC-626

On November 27, 2013, the Centers for Medicare and Medicaid Services (CMS) issued the CY 2014 final payment rules for the Hospital Outpatient Prospective Payment System (HOPPS) and the Medicare Physician Fee Schedule (MPFS). Below is a summary of the key provisions of the rule and attached is the Revenue Cycle Inc. preliminary analysis which details the estimated payment changes for specific radiation therapy codes and typical courses of treatments.

2014 Hospital Outpatient Department (HOPPS) Final Rule

Preliminary analysis shows an overall 1.8% increase to the majority of the codes billed for radiation therapy services as well as a similar increase for the complete course of treatments.

Packaging Proposal

CMS did not finalize its proposal to package additional radiation oncology codes that CMS considered ancillary services. Packaged ancillary services would have included planning, simulation, medical physics consultation and treatment device codes within radiation oncology. Packaged codes mean that they are those services that are provided with another “significant” service on the same day – meaning that there would be no separate payment for these services. As a result, some of the individual treatment delivery codes, such as IMRT, SRS and SBRT which had received a significant increase in payment in the proposed rule due to the packaging of additional codes with the treatment delivery code, decreased in the Final Rule, yet the overall reimbursement for a course of treatment increases from CY2013.

Stereotactic Radiosurgery (SRS)/Stereotactic Body Radiation Therapy (SBRT)

CMS finalized its proposal to overhaul the stereotactic radiosurgery treatment delivery codes. CMS eliminated the robotic and Linac based treatment delivery codes and put both single fraction cranial delivery codes (77371 and 77372) in the same Ambulatory Payment Classification (APC) in order to ensure equal payment. Beginning in January of 2014, stereotactic procedures will be reported using only one of three treatment delivery codes:

77371- Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multisource Cobalt 60 based

77372- Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; linear accelerator based

77373- Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions

CMS clearly stated that 77371 and 77372 are to be used only for single faction cranial cases and that 77373 is the only code to be used for fractionated cases regardless of disease site.

The final rule maintains equal payment regardless of the device.


12/13 PRC-626

Stereotactic Treatment Delivery

2013 CPT® Code

2013 Payment

Rate

2014 CPT® Code

2014 APC

2014 Proposed

Rate

2014 Final Payment

Rate

SRS multisource (Gamma Knife)

77371 $3,300 77371 0067 $5,615 $3,591.65*

SRS single fraction (Linac) Robotic

G0339 $3,300 77372 0067 $5,615 $3,591.65*

SRS single fraction (Linac) Non-Robotic

G0173 $3,300 77372 0067 $5,615 $3,591.65*

SBRT, multi-fraction, (Linac) Robotic

G0340 $2,355 77373 0066 $2,300 $1,921.30*

SBRT, multi-fraction, (Linac) Non-Robotic

G0251 $978 77373 0066 $2,300 $1,921.30*

Use of the robotic and non-robotic G-codes are for the purpose of comparing CY 2013 reimbursement as those codes no longer exist in HOPPS.

*This rate is lower than the proposed rule because CMS eliminated the packaging proposal as discussed above.

Proton Therapy

CMS did not finalize its proposal to reassign the simple proton treatment delivery codes (77520 – simple w/o compensators and 77522 – simple w/ compensators) from APC 0664 to APC 0667, in which CMS proposed to place all four proton codes in a single APC with a proposed payment rate of $988. Using additional claims data, CMS determined that a two times rule violation within APC 0664 did not exist for CY 2014. The current configuration of both APC 0664 and 0667 will remain in place for CY 2014. Finalized payment rates are APC 0664 (77520 – simple w/o compensators and 77522 – simple w/ compensators) = $872.37 and APC 0667 (77523 – intermediate and 77525 – complex) = $1,205.27.

Proton Treatment Delivery CPT® Code

2014 APC

2013 Rate

2014 Rate

Proton treatment simple without compensators

77520

0664

$1,136.61

$872.37

Proton treatment simple with compensators

77522

0664

$1,136.61

$872.37

Proton treatment intermediate 77523 0667 $682.36 $1,205.27

Proton treatment complex 77525 0667 $682.36 $1,205.27


12/13 PRC-626

2014 Medicare Physician Fee Schedule (Physicians and Freestanding Facilities) Final Rule

Preliminary analysis shows that finalized CMS policies would increase payments overall to radiation oncologists by 1% and a total reduction to radiation therapy centers by 1%. Under current law, physicians and non-physician practitioners will face steep across-the-board reductions in payment rates, based on the Sustainable Growth Rate (SGR) methodology adopted in the Balanced Budget Act of 1997. Without a change in the law, the conversion factor will be reduced by 20.1 percent for services in 2014. It is expected that Congress will again act as they have in the past to stave off this payment reduction.

OPPS/ASC Cap Proposal

CMS did not finalize its proposal to adjust payment rates for more than 200 codes where Medicare pays more for services furnished in an office or freestanding setting than in an outpatient hospital department or an ambulatory surgery center (ASC). If CMS had finalized this proposal it would have resulted in significant reductions for several radiation oncology codes.

Stereotactic Radiosurgery (SRS)/Stereotactic Body Radiation Therapy (SBRT)

CMS accepted comments on but did not finalize a change to the existing stereotactic radiosurgery treatment delivery codes under MPFS as they did in the OPPS. CMS will continue to maintain the contractor-priced robotic (G0339 and G0340) Linac based radiosurgery codes in MPFS for CY 2014.

2014 CPT Update for Radiation Oncology

On August 29, 2013, the American Medical Association (AMA) released the 2014 CPT Update which included an update to the radiation oncology simulation code family and created a new code to describe respiratory motion management at simulation. The descriptors for 77280, 77285, and 77290 were revised so that the level of complexity is defined by the number of “treatment area,” rather than the number of ports, volumes and blocks. Additional coding guidance from ASTRO and RCI will be forthcoming on these new codes.

Clinical Treatment Planning (External and Internal Sources)

77280 Therapeutic radiology simulation-aided filed setting; simple 77285 Therapeutic radiology simulation-aided field setting; intermediate 77290 Therapeutic radiology simulation-aided field setting; complex +77293 Respiratory motion management simulation (List separately in addition to code

for primary procedure) 77295 Three-dimensional radiotherapy plan, including dose-volume histograms


12/13 PRC-626

The information contained in the attached analyses is based solely on and limited to RCI’s understanding

and interpretation of the current rules and regulations published by CMS. While we believe the

information in this analysis is reliable, we have not independently verified the information contained in the

analysis, and we do not make any representation as to the accuracy of the information. RCI’s analysis and

this summary are provided for your information only and may contain various forward-looking statements

and include assumptions concerning reimbursement rates. These statements and assumptions are based

on current expectations, are subject to change and represent no statement, promise or guarantee by

Varian Medical Systems, Inc. or RCI concerning reimbursement, coverage, levels of payment, margins or

revenue. The statements are subject to risk and uncertainties, which are difficult to predict and beyond our

control. Any such statements speak only as of the date made and we caution you not to place undue

reliance on them. We undertake no obligation to update any information contained in RCI’s analysis or this

summary based upon new information, future events or otherwise.

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CY2014 Final Rule Summary

Treatment Course Impact Tables

Medicare Physician Fee Schedule (MPFS)

&

Hospital Outpatient Prospective Payment System (HOPPS)

Prepared For:

Varian Medical Systems

Prepared On:

December 3, 2013

http://www.revenuecycleinc.com/

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Page 2 of 4

Introductory Summary As requested by the Client, the following information is provided to illustrate the impact of the CY2014 Final

Rule for both MPFS and HOPPS. The estimated reimbursement amounts included have made

assumptions based on example courses of radiotherapy utilizing different treatment modalities and

fractionation schemes. The associated coding detail for the assumptions is provided in a separate

document detailing the full summation of the CY2014 Final Rule.

2013-2014 Medicare Physician Fee Schedule Course Example Impacts

Using the information regarding finalized payment for MPFS in CY2014, the following examples are

provided. The payment amounts are based upon the published Medicare allowable for the CPT® codes

utilized for the examples. The actual conversion factor contained within the information is $35.6446

representative of the CY2013 CF adjusted by the budget neutrality factor. This methodology is utilized

under the assumption legislative action will prevent the finalized CF of $27.2006 from taking effect. When

considering the procedure codes, which comprise the courses of therapies, simulation, dosimetry, imaging,

treatment delivery and physics codes were included. The variance and the percentage of change shown in

the final two columns illustrate the change in estimated reimbursement as compared to CY2013.

MPFS Global Non-Facility Course Compare

Type

2013 Course Collections - Global

CF = $34.0230


CF = $35.6446

2014-2013 Variance without the CF

Decrease -Global GLOBAL %

Change

2D $ 4,532.20 $ 4,591.74 $ 59.53 1%

3D – W/out Respiratory Management $ 9,384.90 $ 9,577.35 $ 192.44 2%

3D – With Respiratory Management $ 9,327.75 $ 9,951.97 $ 624.23 7%

IMRT – W/out Respiratory Management $ 20,051.11 $ 19,821.61 $ (229.51) -1%

IMRT – With Respiratory Management $ 16,740.00 $ 16,972.53 $ 232.54 1%

SRS $ 3,665.98 $ 3,982.57 $ 316.59 9%

SBRT 5 Fractions $ 9,229.08 $ 9,611.92 $ 382.84 4%

APBI MultiCath $ 10,349.80 $ 10,455.27 $ 105.48 1%

Prostate HDR $ 6,006.08 $ 5,660.01 $ (346.07) -6%

GYN T&O $ 5,251.11 $ 5,024.11 $ (227.00) -4%

Note: Actual practice patterns may vary for different providers resulting in differences in estimated

reimbursement.





Page 3 of 4

2013-2014 Hospital Outpatient Prospective Payment System Course Example Impacts

Using the information regarding finalized payment for HOPPS in CY2014, the following examples are


utilized for the examples. When considering the procedure codes, which comprise the courses of

therapies, simulation, dosimetry, imaging, treatment delivery and physics codes were included. The

variance and the percentage of change shown in the final two columns illustrate the change in estimated

reimbursement as compared to CY2013.

2013-2014 HOPPS Course Compare

Type HOPPS 2013 Course Medicare Allowable

HOPPS 2014 Course Medicare

Allowable

2013 - 2014 Final Rule Variance

2013- 2014 Final Rule %

Change

2D $ 3,531.11 $ 3,851.79 $ 320.68 9.08%

3D – W/Out Respiratory Mgmt $ 7,911.26 $ 8,502.70 $ 591.44 7.48%

3D – With Respiratory Mgmt $ 7,911.26 $ 8,502.70 $ 591.44 7.48%

IMRT –W/Out Respiratory Mgmt $ 16,563.64 $ 17,571.04 $ 1,007.40 6.08%

IMRT – With Respiratory Mgmt $ 16,563.64 $ 17,571.04 $ 1,007.40 6.08%

SRS- Cobalt $ 5,591.51 $ 6,101.44 $ 509.93 9.12%

SRS- Linac $ 6,341.92 $ 6,888.18 $ 546.26 8.61%

SRS - Robotic $ 6,341.92 $ 6,888.18 $ 546.26 8.61%

SBRT 5 Fractions - Linac $ 7,932.53 $ 12,903.03 $ 4,970.50 62.66%

SBRT 5 Fractions - Robotic $ 15,761.08 $ 12,903.03 $ (2,858.05) -18.13%

SBRT – With Respiratory Mgmt $ 7,932.53 $ 12,903.03 $ 4,970.50 62.66%

Proton - 44 Fractions $ 32,999.10 $ 56,258.18 $ 23,259.08 70.48%

Prostate - HDR $ 8,547.62 $ 9,204.15 $ 656.53 7.68%

GYN - T&O $ 7,595.85 $ 10,736.11 $ 3,140.26 41.34%

Note: Actual practice patterns may vary for different providers resulting in differences in estimated

reimbursement.





Page 4 of 4

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Hospital Outpatient Prospective Payment System

(HOPPS)

Prepared For:


Prepared On:

December 3, 2013





Page 2 of 24

Introductory Summary

On November 27, 2013, the Centers for Medicare and Medicaid Services (CMS) issued the final rule for the

Hospital Outpatient Prospective Payment System (HOPPS) for CY2014. The delay in this release was a

direct result of the government shutdown occurring earlier in the year and the public was notified on

October 23, 2013 of the delay. The notice published by CMS read:

“Although we are still assessing the impact of the partial government shutdown on completion of the

calendar year 2014 Medicare fee for service payment regulations, we intend to issue the final rules on or

before November 27, 2013, generally to be effective on January 1, 2014. The impacted regulations

include:

Medicare Program; End-Stage Renal Disease Prospective Payment System, Quality Incentive Program,

and Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (CMS-1526-F)

CY 2014 Changes to the Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center

Payment System (CMS-1601-FC)

CY 2014 Home Health Prospective Payment System Final Rule (CMS-1450-F)

Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY

2014 Final Rule with Comment Period (CMS-1600-FC)”

Source: http://cms.gov/Center/Provider-Type/Hospital-Center.html

Within the following pages, the Final Rule will be summarized. In addition, a recap of items presented in

the Proposed Rule will be summarized as well as changes made to current CPT® codes specific to

oncology.

Re-cap of Proposed Rules

In the Proposed Rule released earlier this year for comment, the following items were identified as

proposed areas felt to have a major impact on oncology for CY2014:

Proposed increase to payment rates under OPPS by a factor of 1.8%

Proposed packaging of services whereby procedures occurring on a single date would be

packaged into a single payment under a single pseudo claim

Proposed removal of specific 77-codes from the Bypass List due to packaging

Proposed payment for LDR brachytherapy composite APC 8001 set at $4,340

Proposal of significant changes in stereotactic coding instruction and available codes

Proposed reassignment of proton beam radiation therapy services




http://cms.gov/Center/Provider-Type/Hospital-Center.html




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Proposed deletion of HCPCS code C9726 resulting in the placement and removal of the applicator

into the breast being reimbursed within CPT® codes 77424 and 77425

Proposed cessation of the non-enforcement of supervision guidelines for CAHs and small rural

hospitals

Proposed creation of a specific G-code to report clinic visits

Correction Notice

Following the release of the proposed rules, CMS issued a correction notice on August 26, 2013. The

update contained adjustments to proposed payment rates. This correction notice and files can be viewed

at the following link:

http://cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/index.html

CPT® Code Changes

In addition to the payment information released within the Final Rule, there were additional CPT® code

changes finalized which will be included in payment information and necessary process changes for

CY2014. A brief summary of these items is provided below:

Changes in definitions of current simulation codes 77280, 77285 & 77290

Changes in definition and category for code 77295

Addition of an add-on code CPT® 77293

While the finalized changes will be present in the 2014 CPT® Manual, the American Medical Association

(AMA) publicized the changes in the November 2013 CPT® Assistant on page 11. Within this document,

the history of simulation codes was discussed and focus on the changes from fluoroscopy based to CT

based simulation was detailed. The article stresses the evolution of the simulation process has created a

discrepancy with the work performed and description of the services, therefore, this subsection within the

CPT® manual will be revised. The article goes on to discuss the new guidelines added to define the

simulation process, the difference in simple, intermediate and complex and finally provides the definition

and descriptors each.

The above-mentioned article includes the following sentence: “Simulation is the process of defining

relevant normal and abnormal target anatomy and acquiring the images and data necessary to develop an

optimal radiation treatment process for the patient.” Along with additional explanation provided by the

American Society of Therapeutic Radiation Oncology (ASTRO), it is assumed the imaging performed

during the simulation is included in the procedure and not separately billable. The result is the omission of

the utilization of CPT® 77014 to account for the images acquired which are subsequently transferred to the

treatment planning system for the next phase in preparing for treatments. When the 1st Quarter NCCI edits

are released, an edit for the 77014 and the simulation codes may clarify this interpretation.




http://cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/index.html




Page 4 of 24

Regarding the new guidelines and how they define the three simulation levels, the AMA provided the

following information: “For CPT 2014, a simulation is characterized as complex if any of the following

criteria are met: particle beam, rotation or arc therapy, complex or custom blocking, brachytherapy

simulation, hyperthermia probe verification, or any use of contrast material. If these criteria are not met,

then the complexity is determined by the number of treatment areas: one treatment area is considered

simple, two treatment areas are considered intermediate, and three or more treatment areas are

considered complex.” Lastly, the guidelines clarify the terminology i.e. treatment area as “a contiguous

anatomic location that will be treated with radiation therapy.” This additional clarification directs providers

to consider, for example, a breast and supraclavicular area to be considered a single area of treatment.

A new CPT® code was also added to account for the increasing utilization of respiratory motion

management for patients with a disease in a location where respiration can affect the target volume

location. By performing motion management procedures, the tumor can be delineated and the documented

motion can be accounted for as well. The new CPT® code is 77293 and is defined by the AMA as

“Respiratory motion management simulation (List separately in addition to the code for primary procedure).”

The codes indicated as the primary procedure in which this service will apply are 77295, 3D planning and

77301, IMRT planning. In reviewing the clinical examples detailed by the AMA, the work involved with this

code includes acquiring multiple imaging sets, fusion of imaging sets, and finally, extensive work by the

Radiation Oncologist in determining total volume to be treated. After this is completed, the treatment

planning process can begin.

An additional change was made to CPT® 77295 historically described as 3D Simulation. In order to better

describe the actual work performed; this code has been moved to the Medical Radiation Physics,

Dosimetry, Treatment Devices, and Special Services section of the CPT® manual. The code has also

been redefined as “3-dimensional radiotherapy plan, including dose-volume histograms.” This move is

acknowledged by the AMA as appropriate since this procedure code represents the work involved in

creating necessary calculations and isodose plans and generally does not require the presence of the

patient. Due to these factors, the description was changed and the code was moved into a more accurate

section.

To fully appreciate of the detail provided by the AMA within the CPT® Assistant regarding the changes

provided above, the November 2013 issue is recommended reading. This can be obtained at

https://commerce.ama-assn.org/store/.

HOPPS Final Rule Summary

The CY2014 may be located in its entirety by following the link below:

http://www.ofr.gov/(S(lumktjktrcn1foicwdb5hp0h))/OFRUpload/OFRData/2013-28737_PI.pdf

This document in PDF form is 1281 pages in length. The volume of information directly related to Oncology

is significant as compared with previous years. The information contains historic reference items, proposed




https://commerce.ama-assn.org/store/





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information, comments received regarding proposed changes and finally, the final ruling as determined by

CMS. The finalized changes are intended to be effective January 1, 2014. The format of the information

on the following pages is intended to serve as highlights, and readers are encouraged to view the

document in its entirety for further details. Within the summation, which follows, Revenue Cycle Inc. has

provided examples of potential reimbursement based on the interpretation of the published ruling. It is

important to note, coding information is provided as an example and actual practice patterns may differ

from facility to facility and provider to provider. It is imperative for actual coding to coincide with

documentation within the medical record, medical necessity information provided by the physician(s) and

actual services provided on behalf of the patient.

CY2014 HOPPS Final Rule Highlights

The highlights of the Final Rule are provided below in a succinct manner. Where appropriate, more detail

is provided following the listed items.

Payment rates under OPPS were finalized to increase by a factor of 1.8%

Packaging of ancillary services resulting in payment for a single procedure was not finalized

The final payment LDR brachytherapy composite APC 8001 is set at $ 3,844.64 this is a decrease

from the $4,340 which was proposed

Significant changes in stereotactic coding instruction and available codes were finalized. This

resulted in the deletion of the specific G-codes and instruction for treatments to be captured as

77371, 77372 or 77373

Proton beam radiation therapy services did not violate the 2 times rule and remained in 2 separate

APC groups

HCPCS code C9726 was not deleted but now considered an add-on code to either CPT® code

77424 or 77425

CMS did finalize the instruction to no longer “not enforce” supervision guidelines for CAHs and

small rural hospitals. This results in the necessity for all CAH and/or small rural hospitals to ensure

appropriate supervision guidelines are followed

The creation of a specific G-code to report clinic visits was finalized. The new code is G0463

To expand on the highlighted list of items above, a more in depth summary of these areas is provided on

the subsequent pages.

Payment Rate Changes

For HOPPS, the total estimated impact of the CY2014 changes for the HOPPS for all Facilities is 1.8% as

noted on the tables located on pages 1213-1216. The payment rates under the ASC payment system was

increased by 1.2% as noted on the Executive Summary information located on page 45.







Page 6 of 24

Packaging of Services (page 104-105)

The packaging of services whereby procedures occurring on a single date would be packaged into a single

payment under a single pseudo claim was not finalized as proposed. The status indicator (SI) “X” will not

be deleted, therefore codes having a status indicator of “X” w ill be defined as major procedures and

continue to be paid separately. CMS did state, however, this policy would be reexamined in the future.

Composite APC for LDR Brachytherapy (page 271 – 274)

The composite APC 8001 will continue to be paid for LDR prostate brachytherapy for CY2014.

Stereotactic Radiosurgery Services (pages 517 – 534)

CMS did finalize the proposal to delete the G-codes, which differentiated robotic and non-robotic treatment

delivery. The available codes for SRS and SBRT will be 77371, 77372 or 77373 under HOPPS. It was

also indicated that in the event the G-codes existed on the MPFS, they would continue to be paid for

CY2014. It is important to note the presence of the G-codes should be confirmed on your specific payors

fee schedule prior to assuming utilization is applicable to a particular location.

There was extensive inclusion of comments related to this treatment modality both for and against the

proposed changes. The results of the comments, the claims data utilized to set the rates, etc. ended with

the final decision as:

CPT® 77371, SRS utilizing a Cobalt-60 based system and CPT® 77372, SRS using a Linac Based system

would both be contained in APC 0067 with a final payment rate of $3591.65. For fractionated stereotactic

delivery SBRT, the appropriate CPT® is 77373 with a finalized payment rate of $1921.30.

Within the Final Rule document, beginning on page 531, CMS provides extensive instruction on the correct

coding of the single fraction or the multi-fraction stereotactic procedure. They further indicate the addition

of edits to assist in correct coding. This is made clear in their statement on page 532 “Although we believe

that this coding guidance is clear to ensure reporting compliance, we will activate coding edits to prevent

the use of more than one type of SRS treatment delivery CPT code per diagnosis per patient along with no

more than five fractions for CPT code 77373.”

Proton Beam Radiation Therapy (pages 515-517)

Using additional claims data, it was determined that a 2 times rule violation within APC 0664 does not exist

for CY2014. Since there is no 2 times rule violation CMS is not finalizing the proposal to delete APC 0664

and reassign codes 77520 and 77522 to APC 0667. The current presence of both APC 0664 and 0667 will

remain in place for CY2014. Finalized payment rates are APC 0664 = $872.37 and APC 0667 = $1,205.27.

IORT (pages 511-515)

HCPCS code C9726 was not deleted as proposed. This code has been designated as an add-on code and

payment will be packaged into the payment for CPT® codes 77424 and 77425, the primary procedures







Page 7 of 24

which involve the placement of the applicator into the breast. The code descriptor for C9726 has been

revised to read “Placement and removal (if performed) of applicator into breast for intraoperative radiation

therapy, add-on to primary breast procedure”. The CPT® codes 77424 and 77425 will continue to be in

APC 0065 for CY2014 with a final payment of $1,248.28.

Creation of G-Code for Clinic Visits (pages 665 - 687)

CMS, after consideration of public comments finalized the creation of HCPCS code G0463 (Hospital

outpatient clinic visit for assessment and management of a patient), for hospital use only representing any

clinic visit under the OPPS. This new code is assigned to APC 0463 with a payment rate of $92.53.

Supervision (pages 737 – 742)

Although commenters urged CMS to extend the supervision instruction due to small rural hospitals and CAHs having insufficient staff to furnish direct supervision, CMS finalized the proposed decision to not extend the enforcement instruction another year for CAH. The comments received included mention of radiation oncology services and chemotherapy. MedPac was also cited indicating a request to CMS to

continue to work with the Panel to define services appropriate for general supervision. After consideration of the comments, CMS stated “we are not extending the enforcement instruction another year for CY 2014. The enforcement instruction will expire December 31, 2013.”







Page 8 of 24

Example Reimbursement By Treatment Modality

Using the information regarding finalized payment for HOPPS in CY2014, the following examples are


utilized for the examples. When considering the procedure codes, which comprise the courses of

therapies, simulation, dosimetry, imaging, treatment delivery and physics codes were included. The

variance and the percentage of change shown in the final two columns illustrate the change in estimated

reimbursement as compared to CY2013.

2013-2014 Hospital Outpatient Prospective Payment System Course Example Impacts

Type HOPPS 2013 Course Medicare Allowable

HOPPS 2014 Course Medicare

Allowable

2013 - 2014 Final Rule Variance

2013- 2014 Final Rule %

Change

2D $ 3,531.11 $ 3,851.79 $ 320.68 9.08%

3D – W/Out Respiratory Mgmt $ 7,911.26 $ 8,502.70 $ 591.44 7.48%

3D – With Respiratory Mgmt $ 7,911.26 $ 8,502.70 $ 591.44 7.48%

IMRT –W/Out Respiratory Mgmt $ 16,563.64 $ 17,571.04 $ 1,007.40 6.08%

IMRT – With Respiratory Mgmt $ 16,563.64 $ 17,571.04 $ 1,007.40 6.08%

SRS- Cobalt $ 5,591.51 $ 6,101.44 $ 509.93 9.12%

SRS- Linac $ 6,341.92 $ 6,888.18 $ 546.26 8.61%

SRS - Robotic $ 6,341.92 $ 6,888.18 $ 546.26 8.61%

SBRT 5 Fractions - Linac $ 7,932.53 $ 12,903.03 $ 4,970.50 62.66%

SBRT 5 Fractions - Robotic $ 15,761.08 $ 12,903.03 $ (2,858.05) -18.13%

SBRT – With Respiratory Mgmt $ 7,932.53 $ 12,903.03 $ 4,970.50 62.66%

Proton - 44 Fractions $ 32,999.10 $ 56,258.18 $ 23,259.08 70.48%

Prostate - HDR $ 8,547.62 $ 9,204.15 $ 656.53 7.68%

GYN - T&O $ 7,595.85 $ 10,736.11 $ 3,140.26 41.34%

Within the subsequent pages, details of procedure codes utilized to determine the estimated

reimbursement values included in the table above are provided. The amounts are based upon the example coding patterns requested by the Client for each applicable course. Actual practice patterns may vary for different providers resulting in differences in estimated reimbursement.







Page 9 of 24

Disclaimer

The information and guidance provided by Revenue Cycle Inc. on the preceding pages and the following

course comparison data materials is subject to the following terms and limitations and by using this

information or guidance, you agree to such terms and limitations. Terms and limitations may be viewed in

their entirety by visiting http://www.revenuecycleinc.com/disclaimer .





























Page 10 of 24



CY2014 Final Rule

Treatment Course Details Hospital Outpatient Prospective Payment System (HOPPS)

The information on the following pages includes example-coding scenarios to depict the potential reimbursement for a variety of courses

including 2D, 3D CRT, IMRT, SRS, SBRT, Protons and Brachytherapy. The tables contain codes that may be utilized, however, exact coding

should be based on actual services provided and documented within the medical record. The information is not intended to serve as a coding

guide. It is noted, for 3D, IMRT and SBRT, there are examples, which include the new respiratory motion management simulation code CPT®

77293. This code is not applicable to areas in which respiratory motion is not a factor.



Page 11 of 24



2D Typical Course - National Average

Category CPT® 2014 APC

2014 SI

CPT® Description 2013 APC

Rate 2014 APC

Rate Qty

Billed 2013 Total APC Pmt

2014 Total APC Pmt

Pre-Sim G0463 0634 Q3 Hospital outpt clinic visit $ - $ 92.53 1 $ - $ 92.53

Simulation

77014 N Ct scan for therapy guide $ - $ - 1 $ - $ -

77290 0305 X Set radiation therapy field $ 290.99 $ 311.37 1 $ 290.99 $ 311.37

77334 0303 X Radiation treatment aid(s) $ 201.76 $ 213.49 1 $ 201.76 $ 213.49

Planning

77315 0305 X Teletx isodose plan complex $ 290.99 $ 311.37 1 $ 290.99 $ 311.37

77300 0304 X Radiation therapy dose plan $ 109.73 $ 114.65 2 $ 219.46 $ 229.30


Treatment


77413 0301 S Radiation treatment delivery $ 179.52 $ 192.28 10 $ 1,795.20 $ 1,922.80

77417 N Radiology port film(s) $ - $ - 2 $ - $ -

77336 0304 X Radiation physics consult $ 109.73 $ 114.65 2 $ 219.46 $ 229.30

Total for Medicare Only $ 3,531.11 $ 3,851.79

Course of Therapy Variance $ 320.68

% of Change 9.08%

The example course illustrated could potentially represent a whole brain or bone metastasis. It assumes a complex initial simulation to one area with custom blocking for parallel-opposed portals. The fractionation utilized is 10. Note: This is for example purposes only. Actual coding should be based upon actual services provided and documented within the treatment record. Quantities will vary based on the practice patterns of providers.



Page 12 of 24



3D – Without Respiratory Mgmt - National Average


2014 SI

CPT® Description 2013 APC Rate 2014 APC Rate Qty

Billed 2013 Total APC

Pmt 2014 Total APC

Pmt


Simulation




Planning

77295 0310 X 3-d radiotherapy plan $ 984.49 $ 1,036.39 1 $ 984.49 $ 1,036.39




Treatment







% Change 7.48%

The example course has been requested to illustrate a 3D conformal plan which does not necessitate respiratory managment. It assumes a complex initial simulation to one area with custom blocking for a 2-field arrangement. This example also assumes a 2-field arrangement for a boost. The total number of fractions in this example is 23. Note: This is for example purposes only. Actual coding should be based upon actual services provided and documented within the treatment record. Quantities will vary based on the practice patterns of providers.



Page 13 of 24



3D –With Respiratory Mgmt - National Average


2014 SI



2014 Total APC Pmt


Simulation




Planning

77293 N Resp motion mgmt simul $ - $ - 1 $ - $ -





Treatment




0197T N Intrafraction track motion $ - $ - 23 $ - $ -




% Change 7.48%

The example course has been requested to illustrate a 3D conformal plan for an area requiring respiratory motion management. It assumes a complex

initial simulation to one area with custom blocking for a 2-field arrangement. This example also assumes a 2-field arrangement for a boost. A respiratory

motion management simulation is included; however, no reimbursement is included based on HOPPS CY2014 final rule. The total number of fractions in

this example is 23. This example also includes the daily motion tracking (commonly referred to as gating), which also does not have an established

reimbursement under HOPPS.

Note: This is for example purposes only. Actual coding should be based upon actual services provided and documented within the treatment record.

Quantities will vary based on the practice patterns of providers.



Page 14 of 24



IMRT – Without Respiratory Management - National Average


2014 SI

CPT® Description 2013 APC Rate 2014 APC

Rate Qty Billed

2013 Total APC Pmt

2014 Total APC Pmt


Simulation




Planning

77301 0310 X Radiotherapy dose plan imrt $ 984.49 $ 1,036.39 1 $ 984.49 $ 1,036.39


77338 0305 X Design mlc device for imrt $ 290.99 $ 311.37 1 $ 290.99 $ 311.37

Treatment

77418 0412 S Radiation tx delivery imrt $ 483.70 $ 510.46 29 $ 14,027.30 $ 14,803.34


77421 N Stereoscopic x-ray guidance $ - $ - 6 $ - $ -



Course of Therapy Variance $ 1,007.40

% Change 6.08%

The example course has been requested to illustrate an IMRT plan for an area not requiring respiratory motion management. It assumes a complex initial simulation to one area with custom blocking for intensity-modulated portals. This example assumes 2 forms of IGRT is utilized, one for 23 fractions and a different method for 6 fractions. The total number of fractions in this example is 29. Note: This is for example purposes only. Actual coding should be based upon actual services provided and documented within the treatment record. Quantities will vary based on the practice patterns of providers.



Page 15 of 24



IMRT – With Respiratory Management - National Average


2014 SI CPT® Description 2013 APC Rate 2014 APC Rate Qty


Pmt 2014 Total APC

Pmt


Simulation




Planning

77293 N Respirator motion mgmt simul $ - $ - 1 $ - $ -

77301 0310 X Radiotherapy dose plan imrt $ 984.49 $ 1,036.39 1 $ 984.49 $ 1,036.39


77338 0305 X Design mlc device for imrt $ 290.99 $ 311.37 1 $ 290.99 $ 311.37

Treatment

77418 0412 S Radiation tx delivery imrt $ 483.70 $ 510.46 29 $ 14,027.30 $ 14,803.34


77421 N Stereoscopic x-ray guidance $ - $ - 0 $ - $ -

0197T N Intrafraction track motion $ - $ - 29 $ - $ -




% Change 6.08%

The example course has been requested to illustrate an IMRT plan requiring respiratory management. It assumes a complex initial simulation to one area with custom blocking for intensity-modulated portals. The total number of fractions in this example is 29. It is noted, since it is necessary to monitor respiratory motion for the patient, code 0197T is the appropriate code utilized versus other forms of IGRT. Note: This is for example purposes only. Actual coding should be based upon actual services provided and documented within the treatment record. Quantities will vary based on the practice patterns of providers.



Page 16 of 24



Linac SRS - National Average

Category CPT® 2014 APC 2014

SI CPT® Description 2013 APC Rate 2014 APC Rate

Qty Billed

2013 Total APC Pmt

2014 Total APC Pmt


77470 0299 S Special radiation treatment $ 392.41 $ 413.22 1 $ 392.41 $ 413.22

Simulation




Planning





Treatment

G0173 B Linear acc stereo radsur com $ 3,300.64 $ - 1 $ 3,300.64 $ -

77372 0067 S Srs linear based $ - $ 3,591.65 1 - $ 3,591.65




% Change 8.61%

The example course has been requested to illustrate an SRS course of therapy. It assumes a complex initial simulation to one area with custom blocking for SRS portals. This example assumes 5 portals using 2 blocking patterns/arcs. The total number of fractions in this example is 1. It is further noted, due to CY2014 updates and for the purpose of comparing CY2013 reimbursement, both the G-code and the 77372 are included. Associated reimbursement only appears in the CY in which it applies. Note: This is for example purposes only. Actual coding should be based upon actual services provided and documented within the treatment record. Quantities will vary based on the practice patterns of providers.



Page 17 of 24



Robotic SRS - National Average


2014 SI CPT® Description 2013 APC Rate 2014 APC Rate Qty


Pmt 2014 Total APC Pmt



Simulation




Planning





Treatment

G0339 B Robot lin-radsurg com, first $ 3,300.64 $ - 1 $ 3,300.64 $ -

77372 0066 S Srs linear based $ - $ 3,591.65 1 - $ 3,591.65




% Change 8.61%

The example course has been requested to illustrate an SRS “Robotic” course of therapy. It assumes a complex initial simulation to one area with custom blocking for SRS portals. This example assumes 5 portals using 2 blocking patterns/arcs. The total number of fractions in this example is 1. It is further noted, due to CY2014 updates and for the purpose of comparing CY2013 reimbursement, both the G-code and the 77372 are included. Associated reimbursement only appears in the CY in which it applies. It is further noted, for CY2014, there will no longer be a differentiation between “Robotic” and “non-Robotic” in regards to coding for the treatment delivery. Note: This is for example purposes only. Actual coding should be based upon actual services provided and documented within the treatment record. Quantities will vary based on the practice patterns of providers.



Page 18 of 24



CO-60 SRS - National Average


2014 SI


Rate Qty


2014 Total APC Pmt



Simulation




Planning

77370 0304 X Radiation physics consult $ 109.73 $ 114.65 0 $ - $ -




Treatment 77371 0067 S Srs multisource $ 3,300.64 $ 3,591.65 1 $ 3,300.64 $ 3,591.65

77336 0304 X Radiation physics consult $ 109.73 $ 114.65 1 $109.73 $114.65

Total for Medicare Only $ 5,591.51 $6,101.44

Course of Therapy Variance $509.93

% Change 9.12%

The example course has been requested to illustrate an SRS course of therapy utilizing Cobalt-60. It assumes a complex initial simulation to one area with custom blocking for SRS. This example assumes one unique blocking pattern. The total number of fractions in this example is 1. Note: This is for example purposes only. Actual coding should be based upon actual services provided and documented within the treatment record. Quantities will vary based on the practice patterns of providers.



Page 19 of 24



Linac SBRT - National Average; 5 Fractions

Category CPT® 2014 APC 2014 SI CPT® Description 2013 APC

Rate 2014 APC Rate

Qty Billed

2013 Total APC Pmt

2014 Total APC Pmt



Simulation




Planning





Treatment

G0251 B Linear acc based stero radio $ 978.25 $ - 5 $ 4,891.25 $ -

77373 0066 S Sbrt delivery $ - $ 1,921.30 5 - $ 9,606.50




% Change 62.66%

The example course has been requested to illustrate an SBRT course of therapy. It assumes a complex initial simulation to one area with custom blocking for SBRT portals. This example assumes 5 portals using 2 blocking patterns/arcs. The total number of fractions in this example is 5. It is also noted, due to CY2014 updates and for the purpose of comparing CY2013 reimbursement, both the G-code and the 77373 are included. Associated reimbursement only appears in the CY in which it applies. Note: This is for example purposes only. Actual coding should be based upon actual services provided and documented within the treatment record. Quantities will vary based on the practice patterns of providers.



Page 20 of 24



Robotic SBRT - National Average


2014 SI CPT® Description 2013 APC Rate 2014 APC Rate Qty Billed 2013 Total APC Pmt

2014 Total APC Pmt


77470 0299 B Special radiation treatment $ 392.41 $ 413.22 1 $ 392.41 $ 413.22

Simulation

77014 B Ct scan for therapy guide $ - $ - 1 $ - $ -

77290 0305 B Set radiation therapy field $ 290.99 $ 311.37 1 $ 290.99 $ 311.37

77334 0303 B Radiation treatment aid(s) $ 201.76 $ 213.49 1 $ 201.76 $ 213.49

Planning

77370 0304 B Radiation physics consult $ 109.73 $ 114.65 1 $ 109.73 $ 114.65

77295 0310 B 3-d radiotherapy plan $ 984.49 $ 1,036.39 1 $ 984.49 $ 1,036.39

77300 0304 B Radiation therapy dose plan $ 109.73 $ 114.65 5 $ 548.65 $ 573.25

77334 0303 B Radiation treatment aid(s) $ 201.76 $ 213.49 2 $ 403.52 $ 426.98

Treatment

G0339 B Robot lin-radsurg com, first $ 3,300.64 $ - 1 $ 3,300.64 $ -

G0340 B Robt lin-radsurg fractx 2-5 $ 2,354.79 $ - 4 $ 9,419.16 $ -

77373 0066 S Sbrt delivery $ - $ 1,921.30 5 - $ 9,606.50

77336 0304 B Radiation physics consult $ 109.73 $ 114.65 1 $ 109.73 $ 114.65


Course of Therapy Variance $ (2,858.05)

% Change -18.13%

The example course has been requested to illustrate an SBRT “Robotic” course of therapy. It assumes a complex initial simulation to one area with custom blocking for SBRT portals. This example assumes 5 portals using 2 blocking patterns/arcs. The total number of fractions in this example is 5. It is also noted, due to CY2014 updates and for the purpose of comparing CY2013 reimbursement, both the G-code and the 77373 are included. Associated reimbursement only appears in the CY in which it applies. It is further noted, there will no longer be a differentiation between “Robotic” and “non-Robotic” in regards to coding for treatment delivery. Note: This is for example purposes only. Actual coding should be based upon actual services provided and documented within the treatment record. Quan tities will vary based on the practice patterns of providers.



Page 21 of 24



Linac SBRT – With Respiratory Management - National Average; 5 Fractions


2014 SI



2014 Total APC Pmt

Pre-Sim G0463 0634 Q3 Hospital outpt clinic visit 0 $ 92.53 1 $ - $ 92.53


Simulation




Planning


77293 N Respirator motion mgmt simul $ - $ - 1 $ -




Treatment

G0251 B Linear acc based stero radio $ 978.25 $ - 5 $ 4,891.25 $ -

77373 0066 S Sbrt delivery $ - $ 1,921.30 5 - $ 9,606.50




% Change 62.66%

The example course has been requested to illustrate an SBRT course of therapy. It assumes a complex initial simulation to one area with custom blocking for SBRT portals. This example assumes 5 portals using 2 blocking patterns/arcs. The total number of fractions in this example is 5. This course is designated as area requiring motion management due to normal respirations; therefore, a Respiratory Motion Management simulation procedure is included. It is also noted, due to CY2014 updates and for the purpose of comparing CY2013 reimbursement, both the G-code and the 77373 are included. Associated reimbursement only appears in the CY in which it applies. Note: This is for example purposes only. Actual coding should be based upon actual services provided and documented within the treatment record. Quantities will vary based on the practice patterns of providers.



Page 22 of 24



Proton - National Average


2014 SI


Rate Qty


Pmt 2014 Total APC Pmt


Simulation




Planning



77321 0305 X Special teletx port plan $ 290.99 $ 311.37 1 $ 290.99 $ 311.37


Treatment

77523 0667 S Proton trmt intermediate $ 682.36 $ 1,205.27 44 $ 30,023.84 $ 53,031.88


77336 0304 X Radiation physics consult $ 109.73 $ 114.65 9 $ 987.57 $ 1,031.85



% Change 70.48%

The example course has been requested to illustrate a Proton Therapy course of therapy. It assumes a complex initial simulation to one area with custom blocking for Proton Therapy portals. This example assumes 1 portal. The total number of fractions in this example is 44. Note: This is for example purposes only. Actual coding should be based upon actual services provided and documented within the treatment record. Quantities will vary based on the practice patterns of providers.



Page 23 of 24



Prostate HDR - National Average


2014 SI

CPT® Description 2013 APC

Rate 2014 APC

Rate Qty


2014 Total APC Pmt

Pre-Sim

G0463 0634 Q3 Hospital outpt clinic visit $ - $ 92.53 1 $ - $ 92.53


55875 0163 Q3 Transperi needle place pros $ 2,737.09 $ 2,905.01 1 $ 2,737.09 $ 2,905.01

76965 N Echo guidance radiotherapy $ - $ - 1 $ - $ -

Simulation 77014 N Ct scan for therapy guide $ - $ - 1 $ - $ -


Planning



77328 0305 X Brachytx isodose plan compl $ 290.99 $ 311.37 2 $ 581.98 $ 622.74



C1717 1717 U Brachytx, non-str,hdr ir-192 $ 249.07 $ 278.25 3 $ 747.21 $ 834.75

C1715 N Brachytherapy needle $ - $ - 1 $ - $ -

Treatment 77787 0313 S Hdr brachytx over 12 chan $ 687.68 $ 733.80 3 $ 2,063.04 $ 2,201.40




% Change 7.68%

The example course has been requested to illustrate an HDR course of therapy for prostate. It assumes 3 fractions of HDR utilizing over 12 channels. Prior to each fraction, the activity of the HDR source was calculated to ensure appropriate treatment times. Note: This is for example purposes only. Actual coding should be based upon actual services provided and documented within the treatment record. Quantities will vary based on the practice patterns of providers.



Page 24 of 24



GYN T&O HDR - National Average


2014 SI


Rate Qty


2014 Total APC Pmt

Pre-Sim

G0463 0634 Q3 Hospital outpt clinic visit $ - $ 92.53 1 $ - $ 92.53


57155 0193 T Insert uteri tandem/ovoids $ 498.11 $ 1,375.20 3 $ 1,494.33 $ 4,125.60

Simulation 77014 N Ct scan for therapy guide $ - $ - 3 $ - $ -


Planning



77328 0305 X Brachytx isodose plan compl $ 290.99 $ 311.37 2 $ 581.98 $ 622.74



C1717 1717 U Brachytx, non-str,hdr ir-192 $ 249.07 $ 278.25 3 $ 747.21 $ 834.75

C1715 N Brachytherapy needle $ - $ - 1 $ - $ -

Treatment 77787 0313 S Hdr brachytx over 12 chan $ 687.68 $ 733.80 3 $ 2,063.04 $ 2,201.40




% Change 41.34%

The example course has been requested to illustrate an HDR course of therapy for a gynecological case. It assumes 3 fractions of HDR utilizing over 12 channels and 3 separate insertions of the tandem and ovoid apparatus. Prior to each fraction, the activity of the HDR source was calculated to ensure appropriate treatment times. Note: This is for example purposes only. Actual coding should be based upon actual services provided and documented within the treatment record. Quantities will vary based on the practice patterns of providers.






Prepared For:


Prepared On:

December 3, 2013





Page 2 of 23

Introductory Summary

On November 27, 2013, the Centers for Medicare and Medicaid Services (CMS) issued the final rule for the

Medicare Physician Fee Schedule (MPFS) for CY2014. The delay in this release was a direct result of the

government shutdown occurring earlier in the year and the public was notified on October 23, 2013 of the

delay. The notice published by CMS read:

“Although we are still assessing the impact of the partial government shutdown on completion of the

calendar year 2014 Medicare fee for service payment regulations, we intend to issue the final rules on or

before November 27, 2013, generally to be effective on January 1, 2014. The impacted regulations

include:

Medicare Program; End-Stage Renal Disease Prospective Payment System, Quality Incentive Program,

and Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (CMS-1526-F)

CY 2014 Changes to the Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center

Payment System (CMS-1601-FC)

CY 2014 Home Health Prospective Payment System Final Rule (CMS-1450-F)

Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY

2014 Final Rule with Comment Period (CMS-1600-FC)”

Source: http://cms.gov/Center/Provider-Type/Hospital-Center.html

Within the following pages, the Final Rule will be summarized. In addition, a recap of items presented in

the Proposed Rule will be summarized as well as changes made to current CPT® codes specific to

oncology.

Re-cap of Proposed Rules

In the Proposed Rule released earlier this year for comment, the following items were identified as

proposed areas felt to have a major impact on oncology for CY2014:

The Conversion Factor (CF) was proposed as $26.8199, which would be a 24.4% reduction. The

proposed rule further indicated that in the event legislation intervened, the CF could be set at

$35.6653.

A change in the Practice Expense (PE) Methodology was proposed for CY2014 and subsequent

years. The proposed rule stated the current PE was inaccurate and should be more aligned with

OPPS data.

Geographic Practice Cost Indices (GPCIs) were included in the proposed rule as the work GPCI

floor of 1.0 is scheduled to expire on December 31, 2013.




http://cms.gov/Center/Provider-Type/Hospital-Center.html




Page 3 of 23

For stereotactic codes G0339 and G0340, which currently appear on MPFS were not proposed to

be replaced for PFS payment. CMS was seeking comment on the direct PE inputs for 77372 and

77373 to accurately estimate the resources.

CMS proposed creating an input based on the AMA RUC recommendation of a new direct PE

input, "ultrasound unit, portable, breast procedures," for breast procedures performed in a

surgeon's office and where ultrasound imaging is included in the code descriptor. This would

include CPT® codes 19296 and 19298.

It was proposed to reconsider the procedure time assumption currently used to establish direct PE

inputs from 45 minutes to 10 minutes. CMS noted this would reduce the clinical labor and

equipment minutes associated with the code from 58 to 23 minutes.

It was proposed that CMS would consider collecting information to analyze the frequency, type and

payment for services furnished in off-campus provider-based hospital departments. Amongst

considerations was the development of a new POS code or new HCPCS modifier.

CPT® Code Changes

In addition to the payment information released within the Final Rule, there were additional CPT® code

changes finalized which will be included in payment information and necessary process changes for

CY2014. A brief summary of these items is provided below:

Changes in definitions of current simulation codes 77280, 77285 & 77290

Changes in definition and category for code 77295

Addition of an add-on code CPT® 77293

While the finalized changes will be present in the 2014 CPT® Manual, the American Medical Association

(AMA) publicized the changes in the November 2013 CPT® Assistant on page 11. Within this document,

the history of simulation codes was discussed and focus on the changes from fluoroscopy based to CT

based simulation was detailed. The article stresses the evolution of the simulation process has created a

discrepancy with the work performed and description of the services, therefore, this subsection within the

CPT® manual will be revised. The article goes on to discuss the new guidelines added to define the

simulation process, the difference in simple, intermediate and complex and finally provides the definition

and descriptors each.

The above-mentioned article includes the following sentence: “Simulation is the process of defining

relevant normal and abnormal target anatomy and acquiring the images and data necessary to develop an

optimal radiation treatment process for the patient.” Along with additional explanation provided by the

American Society of Therapeutic Radiation Oncology (ASTRO), it is assumed the imaging performed

during the simulation is included in the procedure and not separately billable. The result is the omission of

the utilization of CPT® 77014 to account for the images acquired which are subsequently transferred to the

treatment planning system for the next phase in preparing for treatments. When the 1st Quarter NCCI edits

are released, an edit for the 77014 and the simulation codes may clarify this interpretation.







Page 4 of 23

Regarding the new guidelines and how they define the three simulation levels, the AMA provided the

following information: “For CPT 2014, a simulation is characterized as complex if any of the following

criteria are met: particle beam, rotation or arc therapy, complex or custom blocking, brachytherapy

simulation, hyperthermia probe verification, or any use of contrast material. If these criteria are not met,

then the complexity is determined by the number of treatment areas: one treatment area is considered

simple, two treatment areas are considered intermediate, and three or more treatment areas are

considered complex.” Lastly, the guidelines clarify the terminology i.e. treatment area as “a contiguous

anatomic location that will be treated with radiation therapy.” This additional clarification directs providers

to consider, for example, a breast and supraclavicular area to be considered a single area of treatment.

A new CPT® code was also added to account for the increasing utilization of respiratory motion

management for patients with a disease in a location where respiration can affect the target volume

location. By performing motion management procedures, the tumor can be delineated and the documented

motion can be accounted for as well. The new CPT® code is 77293 and is defined by the AMA as

“Respiratory motion management simulation (List separately in addition to the code for primary procedure).”

The codes indicated as the primary procedure in which this service will apply are 77295, 3D planning and

77301, IMRT planning. In reviewing the clinical examples detailed by the AMA, the work involved with this

code includes acquiring multiple imaging sets, fusion of imaging sets, and finally, extensive work by the

Radiation Oncologist in determining total volume to be treated. After this is completed, the treatment

planning process can begin.

An additional change was made to CPT® 77295 historically described as 3D Simulation. In order to better

describe the actual work performed; this code has been moved to the Medical Radiation Physics,

Dosimetry, Treatment Devices, and Special Services section of the CPT® manual. The code has also

been redefined as “3-dimensional radiotherapy plan, including dose-volume histograms.” This move is

acknowledged by the AMA as appropriate since this procedure code represents the work involved in

creating necessary calculations and isodose plans and generally does not require the presence of the

patient. Due to these factors, the description was changed and the code was moved into a more accurate

section.

To fully appreciate the detail provided by the AMA within the CPT® Assistant regarding the changes

provided above, the November 2013 issue is recommended reading. This can be obtained at

https://commerce.ama-assn.org/store/.

MPFS Final Rule Summary

The CY2014 may be located in its entirety by following the link below:


This document in PDF form is 1369 pages in length. The volume of information directly related to Oncology

is significant as compared with previous years. The information contains historic reference items, proposed




https://commerce.ama-assn.org/store/





Page 5 of 23

information, comments received regarding proposed changes and finally, the final ruling as determined by

CMS. The finalized changes are intended to be effective January 1, 2014. The format of the information

on the following pages is intended to serve as highlights, and readers are encouraged to view the

document in its entirety for further details. Within the summation, which follows, Revenue Cycle Inc. has

provided examples of potential reimbursement based on the interpretation of the published ruling. It is

important to note, coding information is provided as an example and actual practice patterns may differ

from facility to facility and provider to provider. It is imperative for actual coding to coincide with

documentation within the medical record, medical necessity information provided by the physician(s) and

actual services provided on behalf of the patient.

CY2014 MPFS Final Rule Highlights

The highlights of the Final Rule are provided below in a succinct manner. Where appropriate, more detail

is provided following the listed items.

Conversion factor finalized as $27.2006, however, data tables contained on page 1289-1290

include payments using the following methodologies:

1. Payments based on the 2013 conversion factor of 34.0230

2. Payments based on the 2013 conversion factor of 34.0230, adjusted to 35.6446 to include the budget neutrality adjustment

3. Payments based on the estimated 2014 conversion factor of 27.2006

Conversion factor increased by 0.046 percent in relation to the proposed figure due to an offset of

RVUs finalized for CY2014

Finalized the CY2013 interim final direct PE inputs for 77301, IMRT planning

PE inputs for 77293, respiratory motion management simulation will use existing “radiation virtual

simulation system”

Equipment item “radiation treatment vault” will continue to be used as a direct PE input for 77373,

stereotactic treatment delivery

Ultrasound unit, portable, finalized as direct PE input for breast procedures performed in a

surgeon’s office and where ultrasound imaging is included in the code

Procedure time assumptions were finalized to establish direct PE inputs from 45 minutes to 10

minutes. CMS noted this would reduce the clinical labor and equipment minutes associated with

the code from 58 to 23 minutes.

G codes utilized for stereotactic treatment delivery maintained to allow for evaluation of direct PE

inputs

Eight PQRS measures included within the Oncology Measures Group

Payment for services provided incident to require providers to comply with state laws

Eight new codes developed to describe placement of breast localization devices







Page 6 of 23

To expand on the highlighted list of items above, a more in depth summary of these areas is provided on

the subsequent pages.

Conversion Factor & SGR

The CY2014 Conversion Factor (CF) was calculated to be $27.2006. This would result in a reduction to

payment rates for physicians’ services in CY2014 under the SGR formula (shown in table below). The total

reduction from CY2013 and CY2014 will be 20.1 percent (page 534). The Final Rule acknowledged the

fact Congress has provided temporary relief from the reductions since 2003 and that a long-term solution is

critical. The published CF increased by 0.046 in relation to the proposed figures within earlier rulemaking,

which corresponds with an estimated decrease in Medicare physician expenditures due to RVU changes.

The payment for services under PFS is calculated with the following formula:

Payment = [(Work RVU x Work GPCI) + (PE RVU x PE GPCI) + (Malpractice RVU x Malpractice GPCI)] x

CF

Table 93 on pages 1285-1286 illustrate the impact to the various medical specialties based on the finalized

changes to these RVUs. Radiation Oncology is listed with a combined impact of +1%, while Radiation

Therapy Centers are listed with a combined impact of -1%. It is noted this impacts use a constant

conversion factor and do not include the finalized conversion factor of $27.2006.

PE for IMRT Planning

The CY2013 interim final direct PE inputs for the IMRT planning code, 77301 were finalized as previous

established. These inputs took into account recommendations made by the AMA RUC’s committee

recommendations to remove the “computer system, record and verify” and adjusting the equipment time to

reflect the “treatment planning system, IMRT (Corvus w-Peregrine 3D Monte Carlo)”.







Page 7 of 23

PE for 77293, Respiratory Motion Management Simulation

At the time of the submission of the direct PE inputs for the 77293 code, recommendations were made to

create a new equipment item called a “virtual simulation package”. The information accompanying this

recommendation reflected a price quote for new equipment; however, CMS determined the current

“radiation virtual simulation system” would be appropriate in calculation of the direct PE input for this code.

PE for Stereotactic Delivery

Direct PE inputs for code 77373, stereotactic body radiation therapy, treatment delivery, per fraction to 1 or

more lesions, including image guidance, entire course not to exceed 5 fractions, were updated to include

the “radiation treatment vault” based on public comment. Previous AMA RUC recommendations did not

include this item; however, CMS finalized the inclusion of the vault within the direct PE inputs for CY2014.

PE for Ultrasound Units Used for Breast Procedures

Proposed rulemaking was finalized to account for a new direct PE input of “ultrasound unit, portable, breast

procedures” was created for breast procedures which are performed in a surgeon’s office and include

ultrasound imaging in the code descriptor. These codes include:

19105 (Ablation, cryosurgical, of fibroadenoma, including ultrasound guidance, each fibroadenoma),

19296 (Placement of radiotherapy afterloading expandable catheter (single or multichannel) into the

breast for interstitial radioelement application following partial mastectomy, includes imaging guidance;

on date separate from partial mastectomy), and

19298 (Placement of radiotherapy afterloading brachytherapy catheters (multiple tube and button type)

into the breast for interstitial radioelement application following (at the time of or subsequent to) partial

mastectomy, includesimaging guidance)

CMS received quotes regarding the proposed price of the portable unit; however, these figures were not

utilized as it was felt these were not reliable and did not reflect the prices paid for this equipment.

Procedure Time for Ultrasound Units Used for Needle Placement

CMS finalized procedure time assumptions utilized in the direct PE inputs for code 74942, ultrasonic

guidance for needle placement (for example, biopsy, aspiration, injection, localization device), imaging

supervision and interpretation. Based on the fact this service is typically reported with other services, the

equipment was changed from a room to a portable unit. With this change, CMS proposed procedure time







Page 8 of 23

assumptions, which were previously set at 45 minutes. CMS determined the procedure time ranged from 5

to 20 minutes; therefore, the proposed changes were finalized to reflect a procedure time of 10 minutes. In

turn, this reduced the clinical labor and equipment minutes from 58 to 23 minutes.

Stereotactic G Codes

Based on the proposed changes for the stereotactic G codes outlined within the Hospital Outpatient

Prospective Payment System (HOPPS), similar changes were referenced and proposed within the MPFS

Proposed Rule for CY2014. Per CMS, the G codes differentiating between robotic and non-robotic

techniques are no longer necessary as if it felt all stereotactic techniques encompass some form of robotic

technique. As a result, the G codes were proposed to be deleted, as the current 77372 and 77373 codes

accurately reflect the services being performed. These changes were finalized within the HOPPS Final

Rule; however, CMS will continue to maintain the contractor-priced G0339 and G0340 codes currently

listed on MPFS. Comments regarding the direct PE inputs for the G codes in relation to the existing

stereotactic delivery codes were requested in order to accurately estimate the resources used in furnishing

these types of treatment delivery.

Incident To

CMS proposed to adjust verbiage and regulations related to services provided “incident to” services as a

result of situations in which these services were provided by auxiliary personnel who did not meet the state

standards for those services in the state in which the services were provided. Extensive detail is outlined

within the Final Rule, including the decision to require compliance with applicable State Laws. A statement

by CMS on Page 582 provides guidance on the rationale for the finalization of these guidelines. “We believe

this requirement will protect the health and safety of Medicare beneficiaries and enhance our ability to recover federal

dollars when care is not delivered in accordance with state laws.”







Page 9 of 23

PQRS Measures

A total of eight (8) oncology related Physician Quality Reporting System (PQRS) measures will be available

for reporting in CY2014. Table 76 on pages 1104-1105 provide the tile and description of these measures.







Page 10 of 23

Placement of Breast Localization Devices

Based on AMA RUC review of potentially misvalued codes for breast intervention codes, it was determined

75 percent or more of the codes were potentially misvalued. As a result, the CPT Editorial Panel created

fourteen (14) new codes to include eight (8) codes specific to the placement of breast localization devices.

Table 27 on pages 312-335 includes the following codes and descriptors.

HCPCS Code

Long Descriptor CY2013

Work RVU

AMA RUC/HCPAC

Recommended Work RVU

CY2014 Work RVU

CMS Time Refinement

19281 Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including mammographic guidance

New 2.00 2.00 No

19282

Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; each additional lesion, including mammographic guidance (list separately in addition to code for primary procedure)

New 1.00 1.00 No

19283 Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including stereotactic guidance

New 2.00 2.00 No

19284

Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; each additional lesion, including stereotactic guidance (list separately in addition to code for primary procedure)

New 1.00 1.00 No

19285 Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including ultrasound guidance

New 1.70 1.70 No

19286

Placement of breast localization device(s) (eg, clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; each additional lesion, including ultrasound guidance (list separately in addition to code for primary procedure)

New 0.85 0.85 No

19287 Placement of breast localization device(s) (eg clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; first lesion, including magnetic resonance guidance

New 3.02 2.55 No

19288

Placement of breast localization device(s) (eg clip, metallic pellet, wire/needle, radioactive seeds), percutaneous; each additional lesion, including magnetic resonance guidance (list separately in addition to code for primary procedure)

New 1.51 1.28 No







Page 11 of 23

Example Reimbursement by Treatment Modality

Using the information regarding finalized payment for MPFS in CY2014, the following examples are


utilized for the examples. The actual conversion factor contained within the information is $35.6446

representative of the 2013 CF adjusted by the budget neutrality factor. This methodology is utilized under

the assumption legislative action will prevent the finalized CF of $27.2006 from taking effect. When

considering the procedure codes, which comprise the courses of therapies, simulation, dosimetry, imaging,

treatment delivery and physics codes were included. The variance and the percentage of change shown in

the final two columns illustrate the change in estimated reimbursement as compared to CY2013.

2013-2014 Medicare Physician Fee Schedule Course Example Impacts

MPFS Global Non-Facility Course Compare

Type


CF = $34.0230


CF = $35.6446

2014-2013 Variance without the CF

Decrease -Global GLOBAL %

Change

2D $ 4,532.20 $ 4,591.74 $ 59.53 1%

3D – W/out Respiratory Management $ 9,384.90 $ 9,577.35 $ 192.44 2%

3D – With Respiratory Management $ 9,327.75 $ 9,951.97 $ 624.23 7%

IMRT – W/out Respiratory Management $ 20,051.11 $ 19,821.61 $ (229.51) -1%

IMRT – With Respiratory Management $ 16,740.00 $ 16,972.53 $ 232.54 1%

SRS $ 3,665.98 $ 3,982.57 $ 316.59 9%

SBRT 5 Fractions $ 9,229.08 $ 9,611.92 $ 382.84 4%

APBI MultiCath $ 10,349.80 $ 10,455.27 $ 105.48 1%

Prostate HDR $ 6,006.08 $ 5,660.01 $ (346.07) -6%

GYN T&O $ 5,251.11 $ 5,024.11 $ (227.00) -4%

Within the subsequent pages, details of procedure codes utilized to determine the estimated

reimbursement values included in the table above are provided. The amounts are based upon the example

coding patterns requested by the Client for each applicable course. Actual practice patterns may vary for

different providers resulting in differences in estimated reimbursement.







Page 12 of 23

Disclaimer

The information and guidance provided by Revenue Cycle Inc. on the preceding pages and the following

course comparison data materials is subject to the following terms and limitations and by using this

information or guidance, you agree to such terms and limitations. Terms and limitations may be viewed in

their entirety by visiting http://www.revenuecycleinc.com/disclaimer .





























Page 13 of 23



CY2014 Final Rule

Treatment Course Details


The information on the following pages includes example-coding scenarios to depict the potential reimbursement for a variety of courses

including 2D, 3D CRT, IMRT, SRS, SBRT, Protons and Brachytherapy. The tables contain codes that may be utilized, however, exact coding

should be based on actual services provided and documented within the medical record. The information is not intended to serve as a coding

guide. It is noted, for 3D, IMRT and SBRT, there are examples, which include the new respiratory motion management simulation code CPT®

77293. This code is not applicable to areas in which respiratory motion is not a factor.



Page 14 of 23



MPFS - Example 2D Course of Care - Freestanding Non Facility - National Average

Category CPT® CPT® Description 2013 Global Rate 2014 Global Rate Quantity

Billed 2013 Global Total 2014 Global Total

Pre-Sim 99202 Office/outpatient visit new $ 74.51 $ 74.14 1 $ 74.51 $ 74.14

77263 Radiation therapy planning $ 158.89 $ 165.75 1 $ 158.89 $ 165.75

Simulation

77014 Ct scan for therapy guide $ 82.68 $ 79.49 1 $ 82.68 $ 79.49

77290 Set radiation therapy field $ 531.44 $ 504.73 1 $ 531.44 $ 504.73

77334 Radiation treatment aid(s) $ 150.04 $ 149.71 1 $ 150.04 $ 149.71

Planning

77315 Teletx isodose plan complex $ 133.71 $ 135.45 1 $ 133.71 $ 135.45

77300 Radiation therapy dose plan $ 66.69 $ 67.01 2 $ 133.37 $ 134.02


Treatment


77413 Radiation treatment delivery $ 231.36 $ 223.14 10 $ 2,313.56 $ 2,231.35

77417 Radiology port film(s) $ 14.29 $ 13.90 2 $ 28.58 $ 27.80

77427 Radiation tx management x5 $ 178.28 $ 185.35 2 $ 356.56 $ 370.70

77336 Radiation physics consult $ 43.89 $ 74.50 2 $ 87.78 $ 148.99



% Change 1%

The course illustrated above assumes a 10-fraction course of therapy with custom blocking for opposed portals. Note: This is for example purposes only. Actual coding should be based upon actual services provided and documented within the medical record. Actual coding and quantities will vary based upon practice patterns of providers.



Page 15 of 23



MPFS - Example 3D Course of Care – Without Respiratory Management Freestanding - Non-facility - National Average

Category CPT® CPT® Description 2013 Global

Rate 2014 Global Rate

Quantity Billed

2013 Global Total 2014 Global Total



Simulation




Planning

77295 3-d radiotherapy plan $ 445.36 $ 482.63 1 $ 445.36 $ 482.63




Treatment



77417 Radiology port film(s) $ 14.29 $ 13.90 4 $ 57.16 $ 55.61





% Change 2%

The course illustrated above assumes a 23-fraction course of 3D Conformal therapy for an area not requiring respiratory motion management. The field arrangement for the example includes 2 portals for initial fields and 2 portals for the boost fields. Each has custom blocking. Note: This is for example purposes only. Actual coding should be based upon actual services provided and documented within the medical record. Actual coding and quantities will vary based upon practice patterns of providers.



Page 16 of 23



MPFS - Example 3D Course of Care With Respiratory Motion Management - Freestanding - Non-facility - National Average



Quantity Billed

2013 Global Total

2014 Global Total



Simulation




Planning

77293 Respiratory motion mgmt simul $ - $ 430.23 1 $ - $ 430.23





Treatment



0197T Intrafraction track motion $ - $ - 23 $ - $ -





% Change 7%

The course illustrated above assumes a 23-fraction course of therapy for an area requiring respiratory motion management. This example assumes a Respiratory Motion Management Simulation was performed as well as daily motion tracking. The field arrangement for the example includes 2 portals for initial fields and 2 portals for the boost fields. Each has custom blocking. It is important to note code 0197T may appear on some payors fee schedules, therefore, confirmation of payment rates for each provider is recommended to ensure appropriate payment for services. Note: This is for example purposes only. Actual coding should be based upon actual services provided and documented within the medical record. Actual coding and quantities will vary based upon practice patterns of providers.



Page 17 of 23



MPFS - Example IMRT Course Without Respiratory Motion Management - Freestanding - Non-facility - National Average



Quantity Billed

2013 Global Total

2014 Global Total



Simulation




Planning

77301 Radiotherapy dose plan imrt $ 1,990.35 $ 1,950.12 1 $ 1,990.35 $ 1,950.12


77338 Design mlc device for imrt $ 501.16 $ 499.38 1 $ 501.16 $ 499.38

Treatment

77418 Radiation tx delivery imrt $ 405.55 $ 393.16 29 $ 11,761.07 $ 11,401.64

77421 Stereoscopic x-ray guidance $ 74.51 $ 73.78 6 $ 447.06 $ 442.71

77014 Ct scan for therapy guide $ 124.52 $ 123.33 23 $ 2,864.06 $ 2,836.60

77427 Radiation tx management x5 $ 178.28 $ 185.35 6 $ 1,069.68 $ 1,112.11


Total for Medicare

Only $ 20,051.11 $ 19,821.61

Course of Therapy Variance $ (229.51)

% Change -1%

The course requested by the Client and illustrated above assumes a 29-fraction course of 3D Conformal therapy for an area not requiring respiratory motion management. The field arrangement for the example includes a single arc. The IGRT included for this example is a combination of Stereoscopic Guidance for target localization and CT Guidance for placement of XRT based on the Client's request. Note: This is for example purposes only. Actual coding should be based upon actual services provided and documented within the medical record. Actual coding and quantities will vary based upon practice patterns of providers.



Page 18 of 23



MPFS - Example IMRT Course With Respiratory Motion Management - Freestanding - Non-facility - National Average



Quantity Billed

2013 Global Total 2014 Global Total



Simulation




Planning

77293 Respirator motion mgmt simul $ - $ 430.23 1 $ - $ 430.23

77301 Radiotherapy dose plan imrt $ 1,990.35 $ 1,950.12 1 $ 1,990.35 $ 1,950.12


77338 Design mlc device for imrt $ 501.16 $ 499.38 1 $ 501.16 $ 499.38

Treatment

77418 Radiation tx delivery imrt $ 405.55 $ 393.16 29 $ 11,761.07 $ 11,401.64

0197T Intrafraction track motion $ - $ - 29 $ - $ -

77427 Radiation tx management x5 $ 178.28 $ 185.35 6 $ 1,069.68 $ 1,112.11




% Change 1%

The course requested by the Client and illustrated above assumes a 29-fraction course of 3D Conformal therapy for an area requiring respiratory motion managment. The field arrangement for the example includes a single arc. The assumption also includes a Respiratory Motion Management Simulation and daily motion tracking. Reimbursement is available for 0197T depending on payor. Specific payor published fee schedules shou ld be referenced to determine potential payment for 0197T reported for daily motion tracking. Note: This is for example purposes only. Actual coding should be based upon actual services provided and documented within the medical record. Actual coding and quantities will vary based upon practice patterns of providers.



Page 19 of 23



MPFS - Example SRS Course of Care Freestanding - Non-facility - National Average



Quantity Billed

2013 Global Total

2014 Global Total

Pre-Sim

99204 Office/outpatient visit new $ 164.67 $ 165.39 1 $ 164.67 $ 165.39


77470 Special radiation treatment $ 151.40 $ 154.34 1 $ 151.40 $ 154.34

Simulation




Planning





Treatment

77372 Srs linear based $ 784.91 $ 1,040.11 1 $ 784.91 $ 1,040.11


77432 Stereotactic radiation trmt $ 401.13 $ 417.40 1 $ 401.13 $ 417.40

Total for Medicare

Only $ 3,665.98 $ 3,982.57


% Change 9%

The course requested by the Client and illustrated above assumes a single fraction course of SRS. The field arrangement for the example assumes 5 portals or angles utilizing 2 unique blocking patterns or cones. Note: Where they currently exist, it may be possible to continue capturing G-codes for SRS/SBRT treatments. Within the CY2014, it was stated, “CMS will continue to maintain the contractor-priced G0339 and G0340 codes currently listed on MPFS.” This will not apply to all providers and presence of the G-codes on applicable fee schedules should be verified. Note: This is for example purposes only. Actual coding should be based upon actual services provided and documented within the medical record. Actual coding and quantities will vary based upon practice patterns of providers.



Page 20 of 23



MPFS - Example SBRT (5 Fraction) Course of Care Freestanding - Non-facility - National Average


Rate 2014 Global

Rate Quantity Billed 2013 Global Total 2014 Global Total

Pre-Sim




Simulation




Planning


77293 Respirator motion mgmt simul $ - $ 430.23 1 $ - $ 430.23




Treatment

77373 Sbrt delivery $ 1,268.72 $ 1,245.42 5 $ 6,343.59 $ 6,227.11


77435 Sbrt management $ 605.61 $ 630.55 1 $ 605.61 $ 630.55

Total for Medicare Only

$ 9,229.08 $ 9,611.92

Course of Therapy Variance

$ 382.84

% Change 4%

The course requested by the Client and illustrated above assumes a 5-fraction course of SBRT in an area where respiratory motion is present. For this example, a Respiratory Motion Management Simulation is included. The field arrangement for the example assumes 2 portals or angles util izing 2 unique blocking patterns or cones. Note: Where they currently exist, it may be possible to continue capturing G-codes for SRS/SBRT treatments. Within the CY2014, it was stated, “CMS will continue to maintain the contractor-priced G0339 and G0340 codes currently listed on MPFS.” This will not apply to all providers and presence of the G-codes on applicable fee schedules should be verified. Note: This is for example purposes only. Actual coding should be based upon actual services provided and documented within the medical record. Actual coding and quantities will vary based upon practice patterns of providers.



Page 21 of 23



MPFS - Example APBI Course of Care Freestanding - Non-facility - National Average


Rate 2014 Global

Rate Quantity

Billed 2013 Global

Total 2014 Global Total

Pre-Sim




Simulation 77014 Ct scan for therapy guide $ 82.68 $ 79.49 1 $ 82.68 $ 79.49


Planning 77370 Radiation physics consult $ 118.06 $ 114.06 1 $ 118.06 $ 114.06


Treatment

77280 Set radiation therapy field $ 181.00 $ 270.19 9 $ 1,629.02 $ 2,431.67



77786 Hdr brachytx 2-12 channel $ 556.96 $ 482.27 10 $ 5,569.57 $ 4,822.71


Total for Medicare

Only $ 10,349.80 $ 10,455.27


% Change 1%

The course requested by the Client and illustrated above assumes a 10-fraction course of APBI. For this example, it is assumed imaging and a verification simulation is supported by medical necessity and documented within the medical record. It is also assumed a calculation is performed prior to each fraction to calculate the activity of the brachytherapy source to ensure appropriate treatment delivery time. Note: This is for example purposes only. Actual coding should be based upon actual services provided and documented within the medical record. Actual coding and quantities will vary based upon practice patterns of providers.



Page 22 of 23



MPFS - Example Prostate HDR Course of Care Freestanding - Non-facility - National Average


Rate 2014 Global

Rate Quantity Billed 2013 Global Total 2014 Global Total

Pre-Sim




76965 Echo guidance radiotherapy $ 89.82 $ 91.61 1 $ 89.82 $ 91.61

Simulation




Planning



77328 Brachytx isodose plan compl $ 272.52 $ 271.26 2 $ 545.05 $ 542.51

Treatment



77787 Hdr brachytx over 12 chan $ 955.71 $ 768.14 3 $ 2,867.12 $ 2,304.42


Total for Medicare Only

$ 6,006.08 $ 5,660.01

Course of Therapy Variance

$ (346.07)

% Change

-6%

The course requested by the Client and illustrated above assumes a 3-fraction course of HDR for a prostate case. For this example, it is assumed imaging and a verification simulation is supported by medical necessity and documented within the medical record. It is also assumed a calculation is performed prior to each fraction to calculate the activity of the brachytherapy source to ensure appropriate treatment delivery time. For this example, subsequent brachytherapy isodose plans were performed based on medical necessity. Note: This is for example purposes only. Actual coding should be based upon actual services provided and documented within the medical record. Actual coding and quantities will vary based upon practice patterns of providers.


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