Medicare PFS 2026 proposed rule

[Ray D. Ayshun]

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Insurance companies will not pay for two iso OA treatment. Will you do it anyway and bill just for one iso. Dilemma.

Guess so. I'll make sure it works and do the second joint 90 days later.

 

[CptCrunch]

I saw this earlier too.

"Recently, eviCore published its 2026 radiation oncology guidelines (so far only for Cigna, but historically replicated across every payer that contracts with them). The headline is simple: 77412, the code intended to represent complex delivery, is restricted to essentially three clinical situations—bone metastases, lymphoma, and non-malignant disorders. Not breast. Not lung. Not multi-isocenter head and neck. Not internal mammary coverage. Not mixed electron-photon fields. Not anything requiring active respiratory control."

EvilCore never makes sense but this makes even less sense than usual. So 8 Gy x 1 to the lumbar spine, 24 Gy x 12 for a low grade follicular lymphoma, and 3 Gy x 6 to knee OA qualifies as "complex" but not left-breast DIBH or 60-66 Gy IMRT to lung with 4D gating/tracking?

Looking at the guidelines themselves, 77412 is applicable to bone mets when treating multiple sites concurrently, mycoses fungoides (I'm presuming for total skin electron treatment), and TBI (under non-malignant section).

https://www.evicore.com/sites/default/files/clinical-guidelines/2025-11/Cigna_Radiation%20Oncology_V1.0.2026_Eff01.01.2026_Pub11.18.2025.pdf

 

[cmw021]

Is there an updated list of CPT codes for E&M, treatment planning and management, and updated RVUs? For example, updates to wRVUs for 77427, 77295/77301, 77263, etc? Or are these not significantly changed (apart from 77387-26 from 77014/G6002/G6017)

Edit: would appear that it can be found here: CMS-1832-F | CMS

 

[TheWallnerus]

Is there an updated list of CPT codes for E&M, treatment planning and management, and updated RVUs? For example, updates to wRVUs for 77427, 77295/77301, 77263, etc? Or are these not significantly changed (apart from 77387-26 from 77014/G6002/G6017)

Edit: would appear that it can be found here: CMS-1832-F | CMS

I don’t know if they will be different but I saw substantial difference in HOPPS vs PFS for the 77402/407/412

 

[cmw021]

I don’t know if they will be different but I saw substantial difference in HOPPS vs PFS for the 77402/407/412

I saw the same. I have assumed (perhaps incorrectly) that there would be little or no difference between HOPPS and PFS for professional charges (77427, 77295, 77387, etc) related to treatment planning / management. Trying to get a sense of changes in professional collections for the coming year.

 

[TheWallnerus]

I saw the same. I have assumed (perhaps incorrectly) that there would be little or no difference between HOPPS and PFS for professional charges (77427, 77295, 77387, etc) related to treatment planning / management. Trying to get a sense of changes in professional collections for the coming year.

I think that much is a safe assumption

 

[thesauce]

I saw this earlier too.

"Recently, eviCore published its 2026 radiation oncology guidelines (so far only for Cigna, but historically replicated across every payer that contracts with them). The headline is simple: 77412, the code intended to represent complex delivery, is restricted to essentially three clinical situations—bone metastases, lymphoma, and non-malignant disorders. Not breast. Not lung. Not multi-isocenter head and neck. Not internal mammary coverage. Not mixed electron-photon fields. Not anything requiring active respiratory control."

EvilCore never makes sense but this makes even less sense than usual. So 8 Gy x 1 to the lumbar spine, 24 Gy x 12 for a low grade follicular lymphoma, and 3 Gy x 6 to knee OA qualifies as "complex" but not left-breast DIBH or 60-66 Gy IMRT to lung with 4D gating/tracking?

CMS said -12 would be suitable for around 33% of cases. Evicore assumed they meant 0.33% of cases.

 

[Ray D. Ayshun]

Does 77387 presently have a wRVU value?

 

[CaesarRO]

It's presently 0.7, going down to 0.68 because of the 2.5% "efficiency adjustment" which is applied across the board

 

[emt409]

As I understand it, SGRT was lumped in with all other IGRT like CBCTs. Departments who heavily invested in SGRT with the false assurance that it will be spared in this rule are not happy. SGRT vendors are now advertising using it for motion management to bill level 3 complex treatment reimbursement (CPT 77412).

Never let a bad rule stop a good grift.

Jokes on them, that’s what I use it for anyway!

 

[thesauce]

I am beginning to digest just what a practice-killer these coding changes are going to be. Even running efficiently, it would be nearly impossible to take this kind of a hit. We are definitely going to see some centers shutting down.

 

[BobbyHeenan]

I am beginning to digest just what a practice-killer these coding changes are going to be. Even running efficiently, it would be nearly impossible to take this kind of a hit. We are definitely going to see some centers shutting down.

I think if you've been barely in the black it's lights out.

What I think is going to happen is if it's a borderline call about keeping the lights on, we are going to see a lot of places using surface guidance on about every case and just going level 3's for VAST majority of cases to make their numbers work.

 

[TheWallnerus]

I think if you've been barely in the black it's lights out.

What I think is going to happen is if it's a borderline call about keeping the lights on, we are going to see a lot of places using surface guidance on about every case and just going level 3's for VAST majority of cases to make their numbers work.

Kind of a drinking seawater when you are stranded at sea move. Will relieve the thirst but hasten the death.

I think this was born of indifference coupled with lack of knowledge by ASTRO or ACR or whoever was at the table toward freestanding reimbursement. Hospital is going generally to be fine.

I wish academics and hospital based were more aware. Lally is on YouTube explaining how we are all winning or forestalling disaster with the billing and coding changes. Ignorance is bliss.

 

[CaesarRO]

Didn't they adjust the freestanding practice expense changes to be more favorable?

 

[BobbyHeenan]

Kind of a drinking seawater when you are stranded at sea move. Will relieve the thirst but hasten the death.

I think this was born of indifference coupled with lack of knowledge by ASTRO or ACR or whoever was at the table toward freestanding reimbursement. Hospital is going generally to be fine.

I wish academics and hospital based were more aware. Lally is on YouTube explaining how we are all winning or forestalling disaster with the billing and coding changes. Ignorance is bliss.

Didn't they adjust the freestanding practice expense changes to be more favorable?

I think it may take a year before we all know for sure...but despite the ASTRO and Lally optimism, other offline knowledgeable voices are suggesting cuts that could have big impacts.

I am not well educated on freestanding...but on the hospital side internally our knowledgeable folks are thinking we will see a six digit plus decline in overall technical fee revenue at most of our hospitals. Agree with sentiment we will "be fine" as in not closing, but the belt is going to tighten.

 

[TheWallnerus]

Didn't they adjust the freestanding practice expense changes to be more favorable?

Yes, much like Rose adjusted herself to let Jack be a little less in the freezing water

 

[thesauce]

This cut is catastrophic. It is about 7 years' worth of cuts all at once and Evicore is grifting harder than anyone else in trying to push the envelope even further.

 

[Ray D. Ayshun]

Interesting new setup to evicore guidelines fo 1/1/26 with respect to treatment delivery codes.

https://www.evicore.com/sites/default/files/clinical-guidelines/2025-11/Cigna_Radiation%20Oncology_V1.0.2026_Eff01.01.2026_Pub11.18.2025.pdf

Also:

Does refractory to conventional methods simply mean it still hurts after ibuprofen?