IMRT: Progress in Technology and Reimbursement

Transcription

1 Article reprinted from Radiology Management November/December IMRT: Progress in Technology and Reimbursement by Ralph Young, M.S.; Bette Snyder, M.B.A. Images provided by Varian Medical Systems Copyright 2001 Five field IMRT beam arrangement for treating prostate viewed in three dimension. F or a new treatment technology to become widely accepted in today s healthcare environment where cost-benefit and containment concerns are powerful mandates, the technology must not only be effective but also financially viable. Intensity modulated radiation therapy (IMRT), a technology that enables radiation oncologists to precisely target and attack cancerous tumors with higher doses of radiation using strategically positioned beams while minimizing collateral damage to healthy cells, now meets both criteria. This is due, in part, to the adoption this year of two new reimbursement codes by the Centers for Medicare and Medicaid Services (CMS), formerly the Health Care Finance Administration (HCFA). These two codes, GO174, which pertains to daily treatment delivery, and GO178, which pertains to treatment planning (no future increase), are reimbursable by Medicare for the IMRT. We can expect to see a nationwide trend of oncology departments migrating towards this significant technological breakthrough in radiotherapy. Radiotherapy The use of radiation to treat cancer dates back more than 100 years. The first cancer patient was treated in Chicago in January 1896, less than one month after x-rays were discovered by German physicist Wilhelm Conrad Roentgen. It has long been known that sufficient exposure to high-energy x-rays (4-20 million electron volts or MeV) effectively kills tumors. Photons at these energies interact with the molecules in human tissue (mostly with water) to create highly energized ions (charged atoms).

2 IMRT: Progress in Technology and Reimbursement E X E C U T I V E S U M M A R Y For a new treatment technology to become widely accepted in today s healthcare environment, the technology must not only be effective but also financially viable. Intensity modulated radiation therapy (IMRT), a technology that enables radiation oncologists to precisely target and attack cancerous tumors with higher doses of radiation using strategically positioned beams while minimizing collateral damage to healthy cells, now meets both criteria. With IMRT, radiation oncologists for the first time have obtained the ability to divide the treatment field covered by each beam angle into hundreds of segments as small as 2.5 mm by 5 mm. Using the adjustable leaves of an MLC to shape the beam and by controlling exposure times, physicians can deliver a different dose to each segment and therefore modulate dose intensity across the entire treatment field. Development of optimal IMRT plans using conventional manual treatment planning methods would take days. To be clinically practical, IMRT required the development of inverse treatment planning software. With this software, a radiation oncologist can prescribe the ideal radiation dose for a specific tumor as well as maximum dose limits for surrounding healthy tissue. These numbers are entered into the treatment planning program which then calculates the optimal delivery approach that will best fit the oncologist s requirements. The radiation oncologist then reviews and approves the proposed treatment plan before it is initiated. The most recent advance in IMRT technology offers a dynamic mode or sliding window technique. In this more rapid delivery method, the beam remains on while the leaves of the collimator continually re-shape and move the beam aperture over the planned treatment area. This creates a moving beam that saturates the tumor volume with the desired radiation dose while leaving the surrounding healthy tissue in a protective shadow created by the leaves of the collimator. In the dynamic mode, an IMRT treatment session generally can be initiated and completed within the traditional 15-minute appointment window for radiation oncology clinics. In addition to being comforting for the patient, this rapid treatment delivery mode satisfies a key financial issue for hospitals and clinics by giving them the ability to handle high patient loads and achieve a more rapid return on their investment in an IMRT system. New IMRT reimbursement codes have been issued under the pass-through provisions of Medicare s Outpatient Prospective Payment System (OPPS), which authorize special or increased reimbursement levels for promising new developments in healthcare technology that previous reimbursement procedures did not address. These pass-through payments are generally applicable for defined periods during a promising new technology s early stage of adoption. In the case of codes G0174 and G0178, the effective period has been left open-ended. While the CMS adoption of these new IMRT reimbursement codes certainly paves the economic road for the diffusion of this technology by flattening out some of the economic obstacles, there are still bumps to overcome. The most obvious one is the investment in hardware and software that may be required. However, the added demands on staff and the cost of training cannot be ignored. IMRT is a treatment process involving FDA-approved medical devices, offering the hope of improved treatment outcomes with fewer complications for patients and higher reimbursement rates for hospital providers. By the end of the year 2001, there will probably be more than 75 hospitals with IMRT capabilities in place. These ions are harmful to all living cells but healthy cells possess the ability to recover from the damage over successive cycles of regeneration, provided the damage is not too severe. In contrast, tumor cells lack the ability to recover effectively, which means that repeated exposure to high-energy x-rays (or in some cases, energized electrons) will impair or kill them. For radiotherapy to be effective, radiation oncologists need a reliable source of sufficiently high-energy x-rays (the x-ray tubes used to generate x-rays for diagnostic purposes fall short). They also need a delivery system that can concentrate high-energy x-rays on tumor cells while sparing the surrounding healthy cells as much as possible. Medical Linacs The first challenge was met in the 1950s with the adaptation of linear accelerators (linacs), developed by particle physicists, to medical applications. From their early days as huge building-filling machines, today s state-of-the-art medical linacs have shrunk to room-size proportions, about 15 feet (4.5 meters) in length and nine feet (2.7 meters) in height though they re still hefty in displacement, weighing more than nine tons. Four major components make up a medical linac: an electronics cabinet or stand that houses a generator for producing microwaves similar to those used in satellite television transmission; a mobile gantry that contains the beam-producing apparatus and can be rotated around a patient; an adjustable treatment couch; and housing for the operating electronics. In addition, medical linacs must be located within specially constructed concrete treatment rooms in order to provide adequate x-ray shielding. Most medical linacs are designed to produce x-ray radiation via the acceleration of negatively-charged subatomic particles known as electrons. The electrons, which are extracted off the surface of a heated strip of metal, are propelled through a vacuum chamber by the electromagnetic field of microwaves and accelerated to nearly the speed of light, an action that greatly boosts their energy levels. After crossing a short distance (typically less than one meter or 40 inches), these energized electrons bombard a metal target, usually tungsten, causing it to emit photons (x-rays) at energies that can exceed 20 MeV. The power and intensity of such x-ray beams are more than sufficient to destroy tumors but not without posing a substantial threat to neighboring healthy cells. Any beam of photons will deliver a dose of radiation that steadily decreases in strength as the beam moves further from its source. The beam also tends to fan out as it moves away from the source. By the 1960s, medical linacs could produce a beam of x-rays at ideal energies for treating cancer, but radiation

3 oncologists needed a better method of packaging and delivering that radiation in order to avoid the unnecessary irradiation of healthy tissue adjacent to the target. The Evolution of Delivery Technology During the 1960s, radiotherapy typically involved a beam that was rectangular or square in shape and was usually directed onto a target from two to four different angles of approach. The area irradiated from each angle is called a field. Since the dosage delivered was of uniform strength across each field of radiation, the sideeffects from damage to healthy tissue surrounding a tumor could be harmful unless the dose was administered at less than optimal tumor killing levels. Marginal improvement was attained in the 1970s with 2-D radiotherapy techniques in which blocks and wedges of lead were used to shape beams to fit a relatively crude two-dimensional profile of a targeted tumor. This did spare some healthy tissue but the process was highly labor-intensive and time-consuming as blocks had to be individually cut for each beam angle used in a treatment. The heavy blocks then had to be positioned by hand for each new beam angle. This required the therapist to re-enter the treatment room for each new beam in order to make the needed adjustments. The first major breakthrough in delivery technology came in the 1980s with the arrival of 3-dimensional conformal radiation therapy (3-D CRT), a technique that, through continual refinement, is in wide use today. With 3- D CRT, high-resolution three-dimensional images of a tumor are acquired, usually through the use of computed tomography scans, and imported into a radiation treatment planning system which then performs the calculations that will shape the x-ray beam to conform to the contours of the 3-D image. Originally, the beam was physically shaped through the use of custom-molded blocks made from lead alloys which, while much easier to manipulate than the blocks of the previous decade, still had to be positioned by hand. Another significant breakthrough came in the 1990s with the development of the multi-leaf collimator (MLC) to shape the beam. An MLC consists of a computer-controlled array of up to 120 parallel, individually adjustable tungsten slats or leaves that can block the path of an x-ray beam. The MLC is attached to the head of the medical linac which generates the beam. The leaves of the MLC are used to create an adjustable aperture through which radiation beams are directed at a patient s tumor. The shape of the MLC aperture is adjusted to match the 2-D shape of the The inner workings of a medical linear accelerator. The radiation beam passes through and is shaped by a multi-leaf collimator. tumor as seen from the angle from which the beam is being delivered. By using the MLC to target precisely shaped beams from several angles, it is possible to deliver a radiation dose that closely matches the 3-D volume of the tumor. This treatment technique significantly reduces the irradiation of healthy tissue. While far more advanced than its predecessor technologies, 3-D CRT is still limited. The aperture shape is static for each beam angle so a uniform dose is delivered across the entire dimension of the treatment field, which can be several centimeters in size. When considering the entrance and exit path of the beam, this can take in more healthy tissue than is desired. This technique also relies on what radiation oncologists call forward treatment planning. This involves heavy number-crunching on the part of a medical physicist to simulate various proposed treatment schemes with numerous beam angles in a time-consuming trial-and-error search for the plan that will most likely achieve an acceptable outcome. Handling a high patient load with this technique is problematic if not impossible. The biggest breakthrough in radiotherapy would come in the 1990s with the emergence of IMRT (a concept first proposed in 1982 by Anders Brahme of the Karolinska Institute in Stockholm, Sweden).

4 IMRT: Progress in Technology and Reimbursement IMRT With IMRT, radiation oncologists for the first time have obtained the ability to divide the treatment field covered by each beam angle into hundreds of segments as small as 2.5 mm by 5 mm. Using the adjustable leaves of an MLC to shape the beam and by controlling exposure times, physicians can deliver a different dose to each segment and therefore modulate dose intensity across the entire treatment field. Consequently, the dose can be higher in the most aggressive areas of the tumor and lower in areas where the beam is near or passing through healthy tissue. With IMRT, treatment plans have become far more complex, involving daily dose delivery to hundreds and sometimes thousands of segments. For example, with as many as nine beam angles and up to 500 segments for each angle, a plan could involve 4,500 segments. Development of optimal IMRT plans using conventional manual treatment planning methods would take days. To be clinically practical, IMRT required the development of inverse treatment planning software. With this software, a radiation oncologist can prescribe the ideal radiation dose for a specific tumor as well as maximum dose limits for surrounding healthy tissue. These numbers are entered into the treatment planning program which then calculates the optimal delivery approach that will best fit the oncologist s requirements. The radiation oncologist then reviews and approves the proposed treatment plan before it is initiated. High resolution IMRT has substantially improved the control and precision of dose delivery over all previous techniques. It is possible to conform the radiation dose even more closely to the tumor volume. Physicians can concentrate higher, more effective radiation doses at the most aggressive regions of a tumor while optimizing protection and safety for surrounding healthy tissue. First Generation IMRT In its earliest iteration, an IMRT beam was shaped by a first-generation, computer-controlled multileaf collimator that provided relatively crude resolution to a small field size (maximum size was 2 cm by 20 cm). The treatment procedure was laboriously time-consuming, up to an hour per session. The patient had to be physically repositioned several times during the treatment in order to treat any but the smallest of tumors. Treatment times were cut nearly in half with the development of an IMRT delivery technique using multiple static segments. In this step and shoot delivery mode, the leaves are positioned, the beam is delivered, and then the leaves repositioned for another round of delivery until treat- Isodose distribution in color wash for Five Field IMRT plan for prostate. ment from that beam angle is completed. This sequence is repeated for each beam angle until the treatment is completed as planned. The beams are shaped by a muchimproved MLC that encompasses a 40 cm by 40 cm treatment area with a wide enough beam aperture to treat most tumors without needing to move the patient. While a decided improvement over the first-generation techniques, the step and shoot technique can still be relatively time consuming, particularly as the number of segments increase. The most recent advance in IMRT technology offers a dynamic mode or sliding window technique. In this more rapid delivery method, the beam remains on while the leaves of the collimator continually re-shape and move the beam aperture over the planned treatment area. This creates a moving beam that saturates the tumor volume with the desired radiation dose while leaving the surrounding healthy tissue in a protective shadow created by the leaves of the collimator. The moving leaves vary exposure time and dose intensity to each segment, according to the strategic determinations of the radiation oncologist s inverse treatment plan. Since computers control the MLC which determines the beam shape and coverage area, not only is there no need to physically move a patient, there is also no need for therapists to enter the room once treatment has begun. In the dynamic mode, an IMRT treatment session generally can be initiated and completed within the traditional 15- minute appointment window for radiation oncology clinics. Actual treatment duration is about ten minutes after the patient is positioned. In addition to being comforting for the patient, this rapid treatment delivery mode satisfies a key financial issue for hospitals and clinics by giving them the ability to handle high patient loads and achieve a more rapid return on their investment in an IMRT system. Earlier forms of IMRT were more time-consuming, making implementation a more daunting prospect for cost-conscious healthcare managers.

5 Clinical Results Clinical results demonstrate the enormous benefits of IMRT for patients. For example, in a study conducted by researchers at Memorial Sloan-Kettering Cancer Center in New York between 1992 and 1998, 61 patients with early stage prostate cancer were treated with 3D- CRT and 171 with IMRT to a prescribed dose of 81 Gy. They reported that 90 percent of these patients were cancer-free within three years of treatment compared to only 46 percent of 23 patients who were treated at 64.8 Gy, suggesting that a higher dose is more effective for controlling tumors. In addition, the rectal bleeding complications that resulted from the high-dose radiation treatments plunged from 17 percent in patients treated via 3D-CRT to three percent for those treated through IMRT. No wonder IMRT has been enthusiastically acclaimed by a number of leading radiation oncologists as one of the best technological developments in radiotherapy and among the greatest advancements in cancer treatment. Word about the therapeutic success of IMRT is spreading. Anecdotal reports say there has been a significant upsurge in patient requests for IMRT, but the number of hospitals offering this option has remained relatively small. Currently, only about 50 or two to three percent of all hospitals and free-standing radiation oncology centers in North America are using IMRT, and patients are beginning to seek them out via Web site listings. While it has been only five years since the technology became available for implementation, there are two reasons for the somewhat slow adoption. One is that IMRT is a paradigm shift in the delivery of radiotherapy. Hospital and clinic staff members have to devote considerable time to the development and evaluation of new treatment techniques and protocols as well as training before commencing treatment. This contributes to the other big challenge economics. Adding an IMRT program represents a costly financial investment in technology and staffing. A multi-leaf collimator. IMRT Front-End Requirements The basic requirements for IMRT include: a medical linac with a multi-leaf collimator treatment planning software with inverse treatment planning capability simulation devices and software for establishing patient positioning as well as pre-testing and refining treatment plans an adjustable patient couch a portal imaging quality assurance system of hardware and software for verifying that the beams are being delivered as planned In addition to the equipment, IMRT requires a welltrained staff of radiation oncologists, medical physicists, dosimetrists and radiation therapists. These requirements may represent a tall order. A high-end medical linac with an MLC currently costs about $1.6 million. With the addition of the software packages to run the programs, the total investment could reach $2 million. The cost of acquiring or training staff to meet the additional clinical and technical support demands can also be high. Costs can be reduced substantially if a radiation oncology department has an existing medical linac that can be upgraded to handle IMRT but will nonetheless remain formidable even at half the starting-from-scratch investment demands. Prior to the adoption of codes GO174 and GO178, hospitals offering IMRT were most likely losing money. With GO174, the daily treatment code, and GO178, the one-time charge planning code, the situation has changed, sufficient to cover the cost of implementing this important new technology. New Reimbursement Codes Upon the heels of some intense lobbying by the American Society for Therapeutic Radiology and Oncology (ASTRO)

6 Sample Reimbursement Comparisons Between IMRT and 3D-CRT Number of New Patients 1 Wage Index Bronx, NY Standard Photon Therapy Key CPT Description Total Code Code Quantity PAYMENT Payment Payment coinsurance CT Guidance for Placement of RTX Fields (TC only) 1 $275 $275 $ $ $94.51 $ Simple Simulation 2 $200 $400 $73.90 $ $14.78 $ Complex Simulation 2 $550 $1,100 $ $ $40.27 $ D Simulation 1 $3,500 $3,500 $ $ $ $ Basic Dose Calculation 10 $175 $1,750 $73.90 $ $41.52 $ Continuing Physics 8 $175 $1,400 $65.46 $ $31.66 $ Port Films 8 $85 $680 $39.18 $ $22.02 $ Complex Isodose Plan 1 $500 $500 $ $ $41.52 $ Special Teletherapy Port Plan 0 $225 $0 $ $0.00 $97.50 $ Simple Treatment Device (IJ s) 5 $250 $1,250 $ $ $69.28 $ Complex Treatment Device 11 $500 $5,500 $ $1, $69.28 $ Special Dosimetry 4 $165 $660 $73.90 $ $41.52 $ Special Physics Consult 1 $275 $275 $65.46 $83.73 $31.66 $ Special Treatment Procedure 0 $1,100 $0 $ $0.00 $ $ Complex Treatment Delivery (11-19 MeV) 38 $290 $11,020 $98.20 $4, $47.72 $1, Total $28,310 $12,123 $ $4, Table 1. Standard 3-D Treatment: Four Field with a 6 Field Boost CPT/HCPCS AVERAGE STANDARD CPT/HCPCS COMMERCIAL TOTAL PAYMENT Average TOTAL unadjusted Patients secondary insurance responsibility prior to out patient prospective payment system (OPPS) assuming 50% CCR Patient responsibility pre $5, OPPS Patient $4, OPPS responsibility Patients responsibility New IMRT Therapy CPT Description Total CPT/HCPCS AVERAGE STANDARD CPT/HCPCS COMMERCIAL TOTAL PAYMENT Code Code Quantity PAYMENT Payment Payment coinsurance CT Guidance for Placement of RTX Fields (TC only) 1 $275 $275 $ $ $94.51 $ Simple Simulation 2 $200 $400 $73.90 $ $14.78 $ Complex Simulation 2 $550 $1,100 $ $ $40.27 $ D Simulation 1 $3,500 $3,500 $ $ $ $ Basic Dose Calculation 12 $175 $2,100 $73.90 $1, $41.52 $ Continuing Physics 8 $175 $1,400 $65.46 $ $31.66 $ Port Films 8 $85 $680 $39.18 $ $22.02 $ Complex Isodose Plan 1 $500 $500 $ $ $41.52 $ Special Teletherapy Port Plan 1 $225 $225 $ $ $97.50 $ Simple Treatment Device (IJ s) 5 $250 $1,250 $ $ $69.28 $ Complex Treatment Device 12 $500 $6,000 $ $2, $69.28 $ Special Dosimetry 4 $165 $660 $73.90 $ $41.52 $ Special Physics Consult 1 $275 $275 $65.46 $83.73 $31.66 $ Special Treatment Procedure 1 $1,100 $1,100 $ $ $ $ G Complex Treatment Delivery (11-19 MeV) 38 $800 $30,400 $ $19, $ $8, GO Additional IMRT Planning 1 $700 $0 $ $ $ $ Total $49,865 $28,808 $1, $11, Patients secondary insurance responsibility prior to out patient prospective payment system (OPPS) assuming 50% CCR Patient responsibility pre $9, OPPS Patient $11, OPPS responsibility Table 2. Five Field IMRT with Seven Field Boost * These tables have been prepared for demonstration purposes only and are not intended to calculate reimbursement for a specific patient or procedure. The payment information presented was obtained from AMAC and is representative of typical reimbursement only. This information is applicable as of July 1, 2001, but will change towards the end of the year or early in 2002, when published by the AMA and the federal government. Average TOTAL unadjusted Patients responsibility

7 CODE DEFINITION CHANGES Please note the following code definition changes are only suggestions that have been submitted for CMS review. with help from American Medical Accounting and Consulting, effective January 1, 2001, the CMS approved the temporary codes G0174 and G0178. The intent was strictly to address reimbursement issues that concern the technical components associated with providing IMRT; payment levels for physician services related to IMRT were left unchanged. Another caveat is that the new codes apply only to hospitals; freestanding cancer treatment centers are not eligible. Both of these issues will be addressed effective January 1, 2002, with a new code for IMRT planning (G0178) and code will be for the technical daily treatment (G0174). Hospitals will need to change their charge masters before 3/30/2002 as the codes G0178 and G0174 will be deleted on 3/30/2002. Finally, all references to stereotactic radiotherapy multisessions (SRT) were deleted from the verbiage of code G0174, which was an error as there is no other code for SRT at this time. CMS is considering new codes for SRS and SRT next year. Currently hospitals are still using G0174 for SRT as this was the original intent and use of this code but it was inadvertently left out. The new IMRT reimbursement codes were issued under the pass-through provisions of Medicare s Outpatient Prospective Payment System (OPPS), which authorize special or increased reimbursement levels for promising new developments in healthcare technology that previous reimbursement procedures did not address. These pass-through payments are generally applicable for defined periods during a promising new technology s early stage of adoption. In the case of codes G0174 and G0178, the effective period has been left open-ended. Under the terms of the new codes, technical reimbursement for IMRT is $407 per treatment session, up from the previous ceiling of $98 for normal daily technical treatment. The new proposed reimbursement for 2002 is $ under 302. Given that a typical IMRT course of treatment may easily involve 30 to 40 daily sessions, this translates into a substantial increase in revenue and thus a solid return on the technology investment for every hospital-based radiation oncology department patient that qualifies for IMRT. The economics now look more promising for IMRT in head-to-head competition with 3D-CRT. (See Tables 1 and 2 for reimbursement comparisons between IMRT and 3D-CRT at an actual community hospital that is treating a third of its radiation oncology patients with IMRT.) As published in the Federal Register (Vol. 65, No. 219, pp ), the CMS definition for billing code G0174 reads: Intensity modulated radiation therapy (IMRT) delivery to one or more treatment areas, multiple couch angles/fields/arc, custom collimated pencil-beams with treatment setup and verification images, complete course of therapy requiring more than one session, per session.. CODE UTILIZATION Code G0174 may be charged once per session for any fixed-gantry dose delivery technique that uses an MLC system that automatically sequences field shapes and corresponding monitor unit settings. This delivery can be either dynamic or step-andshoot. Dynamic delivery is defined as changing field shapes with the X-ray beam on. Sliding-window delivery is a step-and-shoot technique that simulates dynamic treatment by moving between control points with the beam turned off. The use of superimposed-field segments is another step-and-shoot method that changes field shapes during irradiation pauses. For either step-and-shoot method, an average of at least four segments per gantry angle must be used to justify billing under code G0174. Code G0174 may be charged once per session for IMRT techniques that use a rotating-gantry dose-delivery technique with changing field shape as the gantry moves. A single sweep of the gantry with the field conforming to the outer boundaries of the target is not considered to be IMRT. Dose delivery with a physical compensator does not currently justify the use of code G0174 in the opinion of the JEC, based on HCFA s definition of this code. Future demonstration of equivalent efficacy for compensator-based IMRT would require separate consideration for coding in the future. Code G0174 can only be used in situations where the plan being implemented meets the description of code G0178 and the definition of inverse planning given above. The technical reimbursement within CPT code [Special treatment procedure (e.g., total body irradiation, hemibody radiation, per oral, endocavitary or intraoperative cone irradiation)] is not incorporated in G0174 and may be charged separately. Code G0178 may be charged for inverse treatment planning once per treatment course. Treatment of a number of separate metastases in the brain must be considered as a single planning task, and code G0178 can be used only one time. Code G0178 precludes billing for the technical component of CPT (Therapeutic radiology simulation-aided field setting; three-dimensional) and its inclusions (see the article on CPT code in the November 2000 issue of the ACR Bulletin). Patient position verification per session may be charged to code CPT [Therapeutic radiology port film(s)] per existing Carrier Medical Director policy for use of this code. Technical component billing for the following codes is incorporated in G0178 and should not be charged separately: [(Teletherapy, isodose plan (whether hand- or computer-calculated); simple (one or two parallel opposed unmodified ports directed to a single area of interest)], [Teletherapy, isodose plan (whether hand- or computer-calculated); intermediate (three or more treatment ports directed to a single area of interest)], [Teletherapy, isodose plan (whether hand- or computer-calculated); complex (mantle or inverted Y, tangential ports, the use of wedges, compensators, complex blocking, rotational beam or special beam considerations)], and (Special teletherapy port plan, particles, hemibody, total body). DOCUMENTATION The following documentation must be provided: For G0174 Permanent records of daily treatment delivery for each field, including the date, treatment unit settings and dose delivered; verification images and MLC sequence for each field; and evidence of physician review for each treatment course. For G0178 Permanent records of computer-generated inverse treatment plans, including 3-D tumor and critical structure volumes, inverse planning dosimetric or biological objectives, dose-volume histograms and dose verification; and evidence of physician review. MEDICAL NECESSITY IMRT planning and delivery are clinically warranted when one or more of the following conditions exist: The target volume is irregularly shaped and in close proximity to critical structures that must be protected. IMRT is the only option to cover the volume of interest with narrow margins and to protect immediately adjacent structures. An immediately adjacent area has been previously irradiated, and abutting portals must be established with high precision. IMRT is the only option when additional precautions for reducing the GTV, CTV or PTV margins, such as gating delivery, are used. Only IMRT can produce dose distributions that can cover extremely concave target geometries.

8 IMRT: Progress in Technology and Reimbursement The definition for billing code G0178 reads: Intensity modulated radiation therapy (IMRT) plan, including dose volume histograms for target and critical structure partial tolerances, inverse plan optimization performed for highly conformal distributions, plan positional accuracy and dose verification, per course of treatment. Those definitions were still in place as of July 1, 2001, for hospitals but are expected to change toward the end of the year, perhaps as soon as January 1, (See box on page 26 for the suggested definition changes being reviewed by CMS.) The purpose of G0174 is to provide reimbursement for the expenses associated with purchasing IMRT-related equipment. This includes an MLC that can be operated in IMRT s dynamic mode, treatment delivery software, and the necessary hardware addons such as electronic portal imaging that uses exit beam data to verify that treatments were delivered as planned. GO174 reimbursements also cover the additional staff and treatment time required for IMRT. The purpose of GO178 is to provide reimbursement for the additional expenses associated with the purchase of the software required to implement an inverse treatment planning approach. It is also aimed at covering the cost of time spent on dose verification. This code may be billed once per treatment course per treatment volume. Other codes that may be appropriate for IMRT that are not normally charged for regular treatments are special port plan, special physics consult, special treatment procedure and D simulation. Codes and will be comprehensive to G0178 (77301) with the acceptance of the new definitions by ACR/ASTRO and reimbursement increase for code G0178 in January Prognosis While the CMS adoption of these new IMRT reimbursement codes certainly paves the economic road for the diffusion of this technology by flattening out some of the economic obstacles, there are still bumps to overcome. The most obvious one is the investment in hardware and software that may be required. However, the added demands on staff and the cost of training cannot be ignored. The technology is still so new that many physicians, physicists, dosimetrists, and therapists lack clinical experience with radiation intensity modulation. With the added financial reimbursements offered by GO174 and GO178, however, IMRT training programs should proliferate. IMRT is a treatment process involving FDAapproved medical devices, offering the hope of improved treatment outcomes with fewer complications for patients and higher reimbursement rates for hospital providers. By the end of the year 2001, there will probably be more than 75 hospitals with IMRT capabilities in place, and the number is rapidly expanding. Five field IMRT Plan for prostate viewed with isodose cloud wrapping around the rectum. Ralph Young is administrative director and medical physicist at Martin Memorial Cancer Center, Martin Memorial Health Systems, in Stuart, Florida. His master s degree is from the University of Kentucky, and he has American Board of Radiology certifications in therapeutic radiological physics, diagnostic radiological physics and nuclear medicine physics. Young may be contacted at ryoung@mmhs-fla.org Bette Snyder is marketing and sales support manager at Varian Medical Systems in Palo Alto, Calif. Snyder s background in radiation oncology includes work in education, administration, billing and operations at major cancer research centers and community based hospitals. She holds a bachelor s degree in radiologic health sciences from Manhattan College in Riverdale, New York, and an M.B.A. from Fairleigh Dickenson University in Rutherford, New Jersey. Snyder may be contacted at bette.snyder@varian.com Acknowledgement The authors would like to thank James E. Hugh, III, M.H.A., seior vice president of American Medical Accounting and Consulting of Marietta, Georgia, for contributing the reimbursement-related information contained within this article. References Chui CS, Spirou S, LoSasso T Testing of dynamic multileaf collimation. Med Phys. 5: Hong L, Hunt M, Chui C, Spirou S, Forster K, Lee H, Yahalom J, Kutcher GJ, McCormick B Intensity-modulated tangential beam irradiation of the intact breast. Int J Radiat Oncol Biol Phys. 44: LoSasso T, Chui CS, Ling CC Physical and dosimetric aspects of a multileaf collimation system used in the dynamic mode for implementing intensity modulated radiotherapy. Med Phys. 10: Zelefsky MJ, Fuks Z, Happersett L, Lee HJ, Ling CC, Burman CM, Hunt M, Wolfe T, Venkatraman ES, Jackson A, Skwarchuk M, Leibel SA Clinical experience with intensity modulated radiation therapy (IMRT) in prostate cancer. Radiother Oncol. 55: The coding and reimbursement Information provided is designed to be accurate and authoritative. Neither the authors nor AHRA are liable and make no guarantee or warranty, either expressed or implied, that the information compiled is error-free. Individuals need to verify information with their Fiscal Intermediary Carriers, other third-party payers and the various directives and memorandums issued by CMS, DOJ, OIG and associated state and federal government agencies. The reader assumes all risk and liability with the use and/or misuse of the information published in this journal.