ACR Works Toward New Codes and Reimbursement for IMRT
ACR Works Toward New Codes, Reimbursement for IMRT
The following is a reprint of an article that appeared in the November/December 2001 issue of ASTROnews. The article details the American College of Radiology and American Society for Therapeutic Radiology and Oncology (ACR/ASTRO) Joint Economics Committee (JEC) successes regarding the creation and implementation of CPT® codes and coverage for two new intensity-modulated radiation therapy (IMRT) procedures. The ACR/ASTRO JEC has been monitoring and commenting on IMRT issues related to the Medicare Fee Schedule and the Ambulatory Payment Classifications (APCs) for two years.
For nearly two years, the ACR/ASTRO JEC has worked tirelessly to create new CPT® codes for IMRT and to obtain fair values on those new codes from the Centers for Medicare and Medicaid Services (CMS). Before the CPT® codes were developed, the JEC was instrumental in getting IMRT planning and delivery covered in the hospital outpatient setting under the Hospital Outpatient Prospective Payment System (HOPPS). The ACR and ASTRO continue to comment on the placement of those IMRT codes within the APCs. Specifically, the ACR and ASTRO have repeatedly requested and continue to request that CMS reclassify IMRT planning into an APC that is more comparable regarding use of resources. It is currently placed in the same APC as IMRT delivery, which is significantly different regarding resources utilized.
In early 2000, members of the JEC began working on developing CPT® codes to be used in the freestanding setting. Two codes were developed—one for IMRT planning and one for delivery—to be included in the Medicare Physician Fee Schedule. CPT® applications for the proposed codes were submitted in the summer of 2000. The new codes were approved in the fall of 2000 by the CPT® Editorial Panel, with an implementation date of January 2002.
The next task was to survey the membership on IMRT. In late 2000, ACR and ASTRO members who perform IMRT received RVS Update Committee (RUC) surveys, as part of the American Medical Association (AMA) Specialty Society RUC process. Data obtained from the RUC surveys were compiled and analyzed by ACR and ASTRO. Those findings were incorporated into recommendation forms to be presented to the RUC.
In April 2001, Drs. Michael L. Steinberg, Paul E. Wallner, James M. Hevezi and Louis Potters represented ACR and ASTRO in presenting recommendations on the two IMRT CPT® codes to the RUC. Due to the complexity of the procedure, a pre-facilitation session was scheduled. (Pre-facilitation committees consist of a small number of RUC members and are used to focus on complex codes that would likely take up an inordinate amount of time if presented to the entire RUC. The pre-facilitation committee meets with representatives of the related specialty society and asks for clarification on certain items, then writes a report either accepting or rejecting the specialty society''s recommendations.)
The pre-facilitation sessions on IMRT were grueling and exhaustive. During these sessions, the representatives were charged with the difficult task of explaining the intricacies of IMRT planning and delivery to the group of nonradiation oncologists. The first pre-facilitation session quickly surpassed its allotted time slot, and multiple facilitation sessions were necessary to fully address the IMRT codes. The pre-facilitation committee worked closely with ACR and ASTRO representatives as well as AMA and CMS staff. After much discussion and deliberation, the recommendations were successfully defended and the pre-facilitation committee wrote its report supporting ACR and ASTRO''s recommended values for IMRT planning and delivery. When the two codes were presented to the entire RUC on the final day of the meeting, the recommended values outlined in the facilitation committee''s report were accepted.
During the months since the RUC meeting, JEC representatives have continued to be in regular contact with CMS regarding IMRT. Several conference calls have been held, for example, to discuss appropriate code edits for the new IMRT codes. The JEC continues to work closely with CMS on these issues as of this writing.
Relative values for IMRT planning and delivery were published as part of the 2002 Medicare Physician Fee Schedule in early November. The JEC was pleased to learn, upon its publication, that CMS did accept the RUC''s and JEC''s recommended values for IMRT. However, as previously stated, work continues with CMS on which codes should be included as part of the IMRT codes.
Other efforts undertaken relating to IMRT include an ACR Bulletin article (April 2001) written by JEC members that further defines IMRT and outlines appropriate utilization of the two HCPCS codes currently in effect as part of the HOPPS/APCs. That article is expected to be updated to reflect the new CPT® codes. Another project that the Regulatory Subcommittee of the JEC is currently working on is developing a model policy for IMRT. Also, a new section will be added to the 2002 ACR/ASTRO Radiation Oncology Coding User''s Guide about the new IMRT codes.
For more information about ACR''s efforts concerning IMRT, please contact the department of economics and health policy at (800) 227-5463, ext. 4780.
