From a Billing Perspective...

[radoncgrad2019]

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In terms of Pro fees only, how many IMRT fractions provides more billing than an SBRT course? Ie. At what point does IMRT pass SBRT? I’m sure someone has done the math before. My
Guess is somewhere around 15 frac?

 

[medgator]

It won't matter, soon enough. Do what is best for the patient

 

[radoncgrad2019]

It won't matter, soon enough. Do what is best for the patient

I agree. I’m just curious.

 

[Gfunk6]

Correct 15 fractions is where IMRT > SBRT

 

[Neuronix]

Have you ever thought that this is maybe why certain people are advocating for 15 fraction imrt or proton in the abdomen instead of 5 fraction sbrt? Nah, must be crazy talk.

 

[Chartreuse Wombat]

Kind of like how many fractionation regimens of old end in 3 or 8

 

[Neuronix]

I teach my residents this.

77427 is cpt for otv, 3-5 fraction. It is worth close to 4 professional wRVUs.

Thus all conventional fractionation is

# Fractions = x*5 or x*5+3

If it doesn't follow this rule, it probably is from a study not done in the USA.

 

[KHE88]

Does anybody bill 6 Gy x 5 breast as SBRT?
I just started doing this regimen due to the covids, and I am getting nasty looks from admin. They asked me if they could bill as SBRT and I said no.

No direct pushback, yet, but just nasty looks. I'm so over it at this point. Neuronix has a good point, I'm just going to start doing a BED calc and changing all fractionation regimens to x*5-1. We have 15 and 16 fraction breast. Why not 14? 2.8 Gy x 14. I call it "biryani fractionation"

 

[Neuronix]

There are some exceptions like 78/39 for prostate. Though the people involved with that study don't seem to use that dose anymore with some doing 80/40 or 81/45.

 

[Lamount]

Have you ever thought that this is maybe why certain people are advocating for 15 fraction imrt or proton in the abdomen instead of 5 fraction sbrt? Nah, must be crazy talk.

There is also the radiobiological argument: when facing OAR constraints of normal adjacent tumors, fractionation improves therapeutic ratio for high a/b tumors to a point (probably until about 15 fractions, then repop and lymphpenia may become more important) -this is at least why I will often choose 15 over SBRT. I will use SBRT only when I don’t have to compromise coverage.

 

[BobbyHeenan]

Does anybody bill 6 Gy x 5 breast as SBRT?
I just started doing this regimen due to the covids, and I am getting nasty looks from admin. They asked me if they could bill as SBRT and I said no.

No direct pushback, yet, but just nasty looks. I'm so over it at this point. Neuronix has a good point, I'm just going to start doing a BED calc and changing all fractionation regimens to x*5-1. We have 15 and 16 fraction breast. Why not 14? 2.8 Gy x 14. I call it "biryani fractionation"

I don’t bill as SBRT.

Shah (Cleveland clinic) said they don’t either on themednet.

*scarbrtj will point out why this should be billed as SBRT and he’s probably technically not wrong...but I don’t consider it sbrt. I don’t mandate rapid dose fall off, really easy to meet constraints, and though I do go to Linac around 90% of time pre Tx, I am 100% strict for other “real” SBRT.

I also don’t bill 25/5 rectal as SBRT but have done large meningiomas at 25/5 and billed SBRT.

*shrugs*

 

[radoncgrad2019]

wow if anyone bills 25/5 Rectal as SBRT?!

would fully side with Evivocre laughing them out of the room

 

[BobbyHeenan]

wow if anyone bills 25/5 Rectal as SBRT?!

would fully side with Evivocre laughing them out of the room

I don’t know anyone that does, but 5 Gy in 5 fractions by letter of law meets it , no?

*Oh God, I sound like scarbrtj.

 

[medgator]

I don’t know anyone that does, but 5 Gy in 5 fractions by letter of law meets it , no?

*Oh God, I sound like scarbrtj.

Technically meets criteria, but yes, would feel strange

 

[RadRadRad]

I bill livi/Florence regimen as Imrt. I only go to machine on d1 so I guess that justifies it not being sbrt.

 

[RickyScott]

really the actual price being billed to insurance is what matters. It is hard to get used to thinking this way. I am sure 5 gy x 5 imrt/3D at Cleveland clinic easily reimbursed more by insurance than sbrt at freestanding center.

 

[radoncgrad2019]

really the actual price being billed to insurance is what matters. It is hard to get used to thinking this way. I am sure 5 gy x 5 imrt/3D at Cleveland clinic easily reimbursed more by insurance than sbrt at freestanding center.

5 fraction 3D? doubt it.

 

[RickyScott]

5 fraction 3D? doubt it.

Don’t have any special insight here, but Cleveland clinic is absolute dominant in Cleveland. I doubt they negotiate a hometown discount for insurance cos and like mayo can set whatever prices they want. Anecdotally, large academic dominant systems can set negotiated rates 3 -5 others.

 

[radoncgrad2019]

‘Whatever prices they want’ seems like quite the stretch.

 

[medgator]

‘Whatever prices they want’ seems like quite the stretch.

Try again.

Don't be so naive. This isn't just an RO problem, although RO/cancer care in general does have a special niche.

 

[CptCrunch]

Does anybody bill 6 Gy x 5 breast as SBRT?
I just started doing this regimen due to the covids, and I am getting nasty looks from admin. They asked me if they could bill as SBRT and I said no.

No direct pushback, yet, but just nasty looks. I'm so over it at this point. Neuronix has a good point, I'm just going to start doing a BED calc and changing all fractionation regimens to x*5-1. We have 15 and 16 fraction breast. Why not 14? 2.8 Gy x 14. I call it "biryani fractionation"

IMRT. I think our billing people started out trying to bill as SBRT and ran into problems.

 

[scarbrtj]

By CMS definition, LCD criteria etc the 30/5 breast is SBRT. ARGUMENTS can easily be made/had as whether one should bill according to most closely matching criteria or whether one should use ones own opinion and follow ones heart etc. Private payors follow their heart and don’t allow the SBRT for 30/5.

Historically what happens is a new tx paradigm comes along which seems to fit best in a previous existing code. Later CMS comes along and redefines the code so the new tx no longer fits in the code. The in between time sows confusion.

 

[Reaganite]

The medicare LCA for for my MAC does not include breast ca as a covered diagnosis for sbrt. Your claims will probably be denied if you submit sbrt treatment codes.

 

[radoncgrad2019]

The medicare LCA for for my MAC does not include breast ca as a covered diagnosis for sbrt. Your claims will probably be denied if you submit sbrt treatment codes.

mileage may vary for scarb, but for most of us, this fight is not worth it. Bill IMRT and call it a day

 

[deleted1002574]

By dose and fractions it is SBRT.

Unfortunately, Medicare does not do a good job of actually defining it.

They ought to have a dose-fall off/IDL component, immobilization requirement, +/- respiratory management. Maybe that is what makes it SBRT?

How would you definite it?

 

[scarbrtj]

As can be referenced on the twitter some of the academic places are billing CMS for SBRT for the 30/5. If it’s expressly disallowed by a LCD/LCA obv you can’t. These can vary as we all know.

 

[scarbrtj]

if the CNS rad oncs think it's breast SBRT who are we to argue








Short answer is: debate is not settled at a scientific and federal payor level. At private payor level it's settled as far as I can tell.

 

[KHE88]

Slightly related question....

I ran into issues with evilcore denying spine SBRT for prostate oligiomet.
So I am doing psuedo-SBRT (8 fraction IMRT) as a workaround.

How would you dose this? I normally do 24/2 or 27/3 for spine SBRT.
BED10 very different for ultrahypofractionated regimens, but common theme for SBRT spine 18/1, 24/2, 27/3, 35/5 seems to be a BED3 around 120-130 Gy.

This comes out for about 44 Gy in 8 fractions (5.5 Gy/fraction). BED10 = 68.2, BED3 = 125.
Sound reasonable? I can't find any data for delivering abaltive doses to the spine in the 5-10 fraction range.
From lung, we would be talking about an 8 fraction regimen to 60 Gy, and I would not dose escalate that high in spine without some sort of solid data.

Since evicore basically doesn't approve SBRT for oligiomets, I'm wondering if anybody else has worked around it like this. My understanding is that I can't just do a 3 fraction plan and bill it as IMRT.

 

[scarbrtj]

Slightly related question....

I ran into issues with evilcore denying spine SBRT for prostate oligiomet.
So I am doing psuedo-SBRT (8 fraction IMRT) as a workaround.

How would you dose this? I normally do 24/2 or 27/3 for spine SBRT.
BED10 very different for ultrahypofractionated regimens, but common theme for SBRT spine 18/1, 24/2, 27/3, 35/5 seems to be a BED3 around 120-130 Gy.

This comes out for about 44 Gy in 8 fractions (5.5 Gy/fraction). BED10 = 68.2, BED3 = 125.
Sound reasonable? I can't find any data for delivering abaltive doses to the spine in the 5-10 fraction range.
From lung, we would be talking about an 8 fraction regimen to 60 Gy, and I would not dose escalate that high in spine without some sort of solid data.

Since evicore basically doesn't approve SBRT for oligiomets, I'm wondering if anybody else has worked around it like this. My understanding is that I can't just do a 3 fraction plan and bill it as IMRT.

You can do three fx and bill as IMRT. "Is it IMRT?" Yeah. It's also SBRT but they aren't mutually exclusive scientifically right. Just in the billing universe. Of course a biller/coder may say "that's fraud" so Bob's your uncle and you're stuck. (Whereas at another center they might allow it. In some states Blue Cross has a blanket policy that if they won't allow SBRT or IMRT in a site they will allow the practitioner to use IMRT/SBRT but bill as 3D.) I, as many of us are, am completely beholden to the billers/coders to make all decisions like this! I thought 8 times 5 Gy sounded good; maybe some of the nearby normal cells are non-conformists and are choosing to exist at slightly lower alpha/betas e.g. The sooner young rad oncs learn this the better: check all medical knowledge and ego at the door when it comes to billing/coding arguments. I make some reductio ad absurdum arguments 'round here but I still have to live in a real world lol.

 

[radoncgrad2019]

The way i see it - if we want to continue to get paid EXTRA for SBRT, which is really just slightly more work than IMRT, then it needs to remain something that is uniquely defined. Otherwise we will just get paid for 5 fractions of IMRT for ‘SBRT’.

Which I guess all of this is going away with APM?