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Well they are getting schooled today
Canaries in a Coal Mine
- Thread starter Gfunk6
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Well they are getting schooled today
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Zeitman speaks of canaries in mine. We labour on with our coal job. The presidential address guy proclaimed that rad onc was in best spot it has ever been!!!! The canary has been dead for a long time. We did not listen. Now we got that black lung and Trump is not helping us. We are DONE lmao
Can someone who has access summarize?
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Short Summary: The IGSRT Controversy
The editorial critiques the push for Image-guided Superficial Radiation Therapy (IGSRT) for non-melanoma skin cancer (NMSC), calling it a financially driven, medically questionable practice that mirrors the earlier misuse of electronic brachytherapy.
The Precedent (Electronic Brachytherapy)
- In the early 2010s, electronic brachytherapy for NMSC became a source of revenue for vendors and large dermatology practices.
- Dermatologists with minimal radiation training used brachytherapy codes, leading to a massive increase in services (from 4,611 to 66,577) and Medicare expenditures (from $9.6M to $121.5M) between 2012 and 2014.
- CMS recognized this aberrant utilization and significantly reduced payment for the skin-related code, resulting in a sharp drop in procedures and costs.
The IGSRT Criticism
- IGSRT uses High-Resolution Ultrasound (HRUS) for image-guidance during superficial radiation therapy (SRT) for NMSC, a cancer where local control is already excellent (> 95%) with existing modalities.
- The authors argue that the literature promoting IGSRT often lacks prospective trials, is vendor-supported, and fails to demonstrate any actual improvement in clinical outcomes or therapeutic decisions based on HRUS findings.
- Crucially, they argue that daily HRUS is clinically unnecessary. For superficial lesions, visual/palpable determination is usually adequate. Furthermore, the HRUS image and the SRT cone are not co-registered, meaning the US provides no demonstrable daily benefit for targeting.
The Financial Outcome
- Proponents sought new codes for IGSRT, aiming for high reimbursement by coding its use pre-, intra- (daily), and post-therapy.
- However, CMS assigned the new IGSRT code (77X09) a total value of 0.30 RVUs and limited its utilization to per course of therapy.
- With the proposed 2026 conversion factor, this results in an approved Medicare payment of only approximately $10 per course, a "major financial disappointment" for its proponents.
The Lesson
The editorial warns Radiation Oncologists (ROs) that associating the specialty's 77xxx code family with this oncologically inappropriate service could "taint the appropriate use of IGRT" with payers, legislators, and regulators, urging ROs to maintain credibility.
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goodbye to superficial skin radiation on custom made machines
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Oh boy. Here “I” go again. Wallner and Steinberg. What dingbats. I could say they’re the problem. But no… the problem is anyone who’d listen to them. Wallner is our specialty’s Pharisee. Certainly these guys don’t lack for hubris or know it allness.
This is not a goodbye. If any rad onc thinks this is a victory, it’s not. It is schadenfreude, but just a touch so. Freestanding radiation centers are going to be making 30-40% less per IG-IMRT patient in 2026 because of CMS changes. Derm centers will make about 25-35% less per RT patient in 2026 (could be closer to 25%). CMS changes will hit (certain pockets of) rad onc harder than derm. And the rad onc centers won’t stop doing IG-IMRT, and the derm centers won’t stop doing ultrasound IGRT skin.
Nothing changes in 2026 except the flow of money.
Let me put it a simple way: CMS gave derms 3x more per RT fraction in 2026. Of all the RT *treatment* codes, only superficial RT got a bump up in 2026. And it was a huge bump.
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Steinberg does not gets enough credit for being reprehensible. I still remember him asssuring medical
Student 7 years ago that radonc was going to be fine and that it was not oversupplied
Student 7 years ago that radonc was going to be fine and that it was not oversupplied
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Per Google...some Medicare Administrative Contractors (MACs), who manage Medicare claims regionally, have proposed draft Local Coverage Determinations (LCDs) to withdraw coverage for IG-SRT, arguing insufficient evidence of clinical value. If finalized, this could strip Medicare coverage in many states and influence private payer policies, significantly impacting compensation for this specific service.
I don't see a definitive document regarding IG-SRT, but I see references indicating cuts up to 90%. It's the IG portion that brings in the dough...bigly.
Will this be a regional decision?
Such a cut would dramatically impact practice patterns...probably for the better IMO. (As an aside, we are dealing with a national RTT shortage, to some degree exacerbated by RTTs running these superficial RT clinics for derms.)
Like discussed before, most of us (conscientious to a degree) would do IGRT on almost everything in the modern era even in the setting of case based payments. (Why not treat as little as possible...correct?). Derms will not do this...as the IGRT portion of the intervention is superfluous (we don't do it for electron tx, as it is ridiculous).
Let Wallner take the hit for the boards boondoggle, and yes, uber-wealthy boomers lecturing the young on regulatory capture is laughable... I wish they could see themselves. But, these are guys who know regulatory capture when they see it (or participate in it).
Seems like the premise is spot on.
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Reimbursement for a linac fraction for a bone met, with CBCT, at a freestanding center, nets the same amount of reimbursement, more or less, as a superficial RT fraction with US IGRT come January 1. (Because the superficial RT got such a big bump up.)
I am not sure regulatory capture is the right gestalt here. G6001 was born from 76950. The 76950 code had been used exclusively for ultrasound IGRT for prostate cancer… which was really “hot” in early 2000s but became unpopular through the years. In fact 76950 was really the first IGRT code in rad onc. Not only did prostate ultrasound IGRT not ever help anyone, it probably misaligned the target many times. Some enterprising skin guy and skin company saw a code and said let’s design tech around it and bill some stuff out. Don’t the proton places do this essentially?
Wallner and Steinberg urging ROs to remain credible given the history of the ultrasound code and other stuff in rad onc? Cmon man as Biden would say. AGAIN… Wallner and his ilk are gaslighting, clever by half, sophistic self righteous dingbats. I shudder at the fact that anyone at CMS might give him credence or listen to him.
I am not sure regulatory capture is the right gestalt here. G6001 was born from 76950. The 76950 code had been used exclusively for ultrasound IGRT for prostate cancer… which was really “hot” in early 2000s but became unpopular through the years. In fact 76950 was really the first IGRT code in rad onc. Not only did prostate ultrasound IGRT not ever help anyone, it probably misaligned the target many times. Some enterprising skin guy and skin company saw a code and said let’s design tech around it and bill some stuff out. Don’t the proton places do this essentially?
Wallner and Steinberg urging ROs to remain credible given the history of the ultrasound code and other stuff in rad onc? Cmon man as Biden would say. AGAIN… Wallner and his ilk are gaslighting, clever by half, sophistic self righteous dingbats. I shudder at the fact that anyone at CMS might give him credence or listen to him.
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Can you tell me what the bottom line will be for a derm run superficial machine that is presently treating Medicare patients via IG-SRT?
I have seen no indication that this will not be dramatically reduced (this is from derm oriented sources, including Dermatology Association of Radiation Therapy...headed by Jacob Scott 🤣)? Am I wrong? Are they wrong?
I don't know Wallner. In general, I see no reason for him to have a prominent voice at this point...however, we live in a gerontocracy. But, has any radiation oncologist spent more time with CMS (formerly HCFA) folks than Wallner over the past four decades?
In general, we have collectively done well with a coding/compensatory system that has never been rational and, frankly, has always looked ridiculous to outsiders (non radiation oncologists).
Below is a letter of appeal to Dr. Oz from a derm practice.
Make it make sense.
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Derms that do RT will take a hit. They're going to go from doing ridiculously well to very well.
CMS's reimbursement of IG-IMRT on Jan 1, 2026, versus 20 years ago (when the first kV X-ray codes hit) has given me an approximate 60%(!) hit. I still do IG-IMRT. The derms will still do US IGRT, and RT, because even after the CMS adjustments they'll make double to triple with a course of RT vs a Mohs. They'll make about $4000 per RT course after the loss of G6001, but tripling of sRT reimbursement; more like $6000 with good G6001 reimbursement whose days are now numbered.
Regarding who's wrong or right, all I can say is anyone who thinks that the ~500 dermatologists in the U.S. who run their own radiation centers will stop doing radiation after Jan 1, 2026, is delusional. That said, a company who wants to sell US-IGRT tech (Sensus e.g.) after Jan 1, 2026, is delusional too; those companies will still sell superficial machines however. I predict the machines will price at the same amount as the US-IGRT capable machines (but many of these practices don't just buy a machine, they buy a turn key service).
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Thanks for the answer.
Not sure myself if the proposed compensation number (without considering all the overhead/structural costs associated with RT) will preserve the present practice patterns. I hope not. IMO, it is exceptionally low value care...and in fact negative value relative to clinical electron beam radiation or local excision in most cases.
Gentle Cure practices in my area were billing between 15-20k for 20 fractions regimens and sending patients to us that did not get the IG portion approved. Tells you something.
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The derms:
The new superficial code is APC 5621. The new level one linac external beam code is APC 5621.
Irradiators are gonna irradiate. The reason you got a dump from Gentle Cure is they couldn't afford to treat a non-US patient; in 2026, they will suddenly be able to afford it.*
What I can't understand, and maybe never will, is that if derms can make so much more money from RT than Mohs, why doesn't every derm do RT? (I have always suspected that Mohs plus 40 Gy post op would give 99% local controls.) I could make this same sort of argument in urology... there is no reason urologists can't buy a linac (especially in non-CON states) and start rad-onc-less irradiating their own prostate cancer patients à la derm-style. Lack of needing to hire/pay for a rad onc makes irradiating financially feasible for probably many specialties although admittedly only derm has done this with gusto. I have a suspicion, per my personal crystal ball, cardiologists might try this... one day.
*EDIT: Here's what will change. Right now, the highest therapist paying places in each town are skin RT centers. These jobs get ~100 therapist applicants per job posting and pay ~20-25% above local market value. That's gonna go away, probably. They'll pay well but not insanely well. We'll see.
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Derm SRT business model relied on daily G6001 code - code gone come Jan 1?
We looked into partnering with dermatologists to offer SRT a few years ago, but the economics didn’t justify the effort unless we billed IGRT. Even then, the reimbursement differential was nowhere near the $2,000 figure you referenced. Once you factor in physics support, therapist staffing, rad onc coverage (many derms were not OK with a radonc showing up just for consults and sim), service contracts, and other overhead, the margin narrows substantially. Additionally, most dermatologists had little interest in absorbing the upfront capital costs, and while companies do offer lease arrangements, they typically take a significant percentage of collections, which further erodes profitability. Stark issues were also frequently a deterrent. With so many revenue streams available to dermatologists on the cosmetics side, many had no interesting in being involved in "risky" self-referral type arrangements.
Perhaps the most revealing part of the process, though, was that many dermatologists were—gasp—quite ethical. They felt that the majority of their cases were more appropriately treated with Mohs, and they modeled SRT income potential based on what they were already referring to radiation oncology, rather than assuming they would divert more patients to XRT once they purchased the machine.
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I definitely know some derm groups like that. It's good to hear. I have some really thoughtful, incredibly skilled Moh's surgeons in my area I'm thankful to work with.
With that said, the Gentle Cure clinic in my neck of the woods typically sends me most of their cases where the G6001 code is denied....of course that's after they ask the patients to pay for that code cash while the insurance picks up the tx charges (or at least that was my understanding of what the patient was telling me - something could have been lost in translation there)....which I'm not even sure is legal.
I imagine the places that use third party management/Gentle Cure need that G6001 code to make the pro forma work. But as TheWallnerus is mentioning, I think other well oiled 100% in house SRT practices are still going to be able to make SRT work. His comments regarding radiation therapists/staffing/salaries is correct in my experience, they pay better than rad onc clinics and *seriously this is a thing* can get them free botox/cosmetic things in house which is seen as a big perk. I've had to try to recruit against them and it's damn near impossible.
