2D billing or 3d-CRT billing for Whole brain

[fettucine]

During my training, for even a palliative WBRT, we would scan the pt, contour the brain, globe, lens. Tilt the gantry for a non divergent beam and throw in or MLCs. All in all it would take 10-15mins. We would routinely bill this 3d-crt. In fact since getting rid of our ximatron we have been billing 3D for all non-imrt cases that we have a target contoured and generated a dvh.

Since starting my practice, my physicist informed me that I shouldn't bill 3d-crt for these plans due to the high risk of being audited. Which means no contour of brain or lens. I just wanted to see what the norm is everywhere. Principally it seems wrong to not define a target and critical avoidance structures if you have the info on a ct scan. Maybe we were billing happy in my training.

so the question is do you contour brain and lens in your whole brain cases, and if so do you look at isodose lines and/or dvh, and if yes.. do you bill this as a 3Dcrt plan?

-f8

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[deleted4401]

I have no reason to think that what you are doing is not 3D. It's volume based, you have critical structures/DVH, you are selecting an isodose line. If you got audited, you should be fine, I would guess
S

 

[fettucine]

thanks. We have an ACR surveyor coming in two weeks for a mock checkup, I'll see what he says and will update the thread.

 

[medgator]

We did that a lot towards the end of my residency. It was actually departmental policy. I've started doing that now in practice. If you are contouring a CTV (brain) and avoiding structures with MLC, how is it not billable for 3D?

 

[clinonc]

Why the trend towards outlining the brain and lens? Radiation caractogenesis takes a year at least, and the majority of patients will have died before they get the chance to develop cataract. Virtual simulation using MLCs to block the orbit is surely sufficient. Is there any evidence supporting the use of 3D CRT for WBRT?

 

[deleted4401]

I'm not sure where you practice or are from, clinonc, but that's not going to hold up here in court ... "I figured they would be dead," ... not for cataracts, not for any toxicity.

Almost all centers (>90%) use CT simulation. If you can contour the eyes/lens, brain in 10 minutes, why not do it? It's not a billing thing - I don't think people are getting rich off 3D whole brain. If you did the same thing, but billed it 2D, I'm uncertain that revenues would change in a significant way. I'm sure someone knows the cost difference and can enlighten us.

Granted - you're right, you can just angle the collimator and get off the eyes, but why not just contour them out and be sure? I don't guess, ever. I never use bony anatomy/landmarks when I have a CT. That's the point of having a CT. I have them contour the lens, and then rotate collimator, corner block at the back of the neck, and then check the axials to make sure the whole brain and cribiform plate are covered, then prescribe to 3 Gy/day to the isocenter (i.e. choosing 100% IDL).

(I also think from a billing point of view, if you use MLCs and a virtual (CT) sim, then you are now charging for 3D anyway, regardless of if you contour lens or not)

 

[BraggPeak]

The RTOG will also be opening up a protocol looking at use of IMRT to spare the hippocampus to help decrease the incidence of neurocognitive dysfunctoin following WBRT. This is based on previous single-institution data that <3% of patients fail in the hippocampus.

I wonder how much extra billing will be for the IMRT...

 

[medgator]

The RTOG will also be opening up a protocol looking at use of IMRT to spare the hippocampus to help decrease the incidence of neurocognitive dysfunctoin following WBRT. This is based on previous single-institution data that <3% of patients fail in the hippocampus.

I wonder how much extra billing will be for the IMRT...

wonder if they are going to throw hair-sparing in there while they are at it

 

[qwert]

2D billing for WBRT? I would think your department is an exception.

In fact, there is a growing experience with forward planning IMRT for whole brain in effort to spare hair and skin toxicity. Look out for abstracts at this year's ASTRO.

 

[G'ville Nole]

wonder if they are going to throw hair-sparing in there while they are at it

MIMA in Melbourne, FL offered "hair sparing" IMRT for their whole brain patients as a matter of routine. If the name sounds familiar, they're also the group that got hit for $12M in Medicare fraud.

Simul, I can give global reimbursement numbers for my region for 2D vs. 3D:

2D 3D
Plan: 71.76 160.11
Sim: 180.83 477.21
Iso calc: 75.21 149.53
Delivery: 115.21 198.07
Total(30 Gy/10fx): 1479.90 2767.55

As you can see, 3D reimburses at nearly twice the 2D rate. BTW, the same plan delivered w/ IMRT is $7643.13. I agree that no one really uses the difference b/w 2D and 3D to pad their Swiss bank accounts, but for coding purposes, if you've done the requisite work (target/normal structures, MLC, DVH, treating to IDL) you should be reimbursed accordingly.

 

[medgator]

MIMA in Melbourne, FL offered "hair sparing" IMRT for their whole brain patients as a matter of routine. If the name sounds familiar, they're also the group that got hit for $12M in Medicare fraud.

Yeah although that was the tip of the iceberg for them I'm sure, between using the special physics IMRT code on every case and billing for real-time IGRT when the MD was out the country.