Medicare PFS 2026 proposed rule

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BobbyHeenan said:
Bridge was saying they are assuming CMS is estimating that 77412 will be around 30% of cases. I wonder if mechanisms will be in place to "flag" outliers?
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Nah. We will see much more than 30% utilization. And CMS will just keep lowering the 77412 reimbursement. That’s our system for ya: if you use it, you lose it.
 
BobbyHeenan said:
Bridge was saying they are assuming CMS is estimating that 77412 will be around 30% of cases. I wonder if mechanisms will be in place to "flag" outliers?
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Not hard for CMS to do. Like the old qui tam cases where every case getting special physics or treatment procedure lead to some big time payouts
 
TheWallnerus said:
Nah. We will see much more than 30% utilization. And CMS will just keep lowering the 77412 reimbursement. That’s our system for ya: if you use it, you lose it.
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Yeah that may happen too.

I suspect we will see private insurers have prior auth for usage of image guidance/77412, but medicare with no prior auth will be the wild west. Everyone using SGRT on every case and up-billing to 77412.

No way BCBS or United going to pay 77412 for free breath lung or breast, right?
 
BobbyHeenan said:
Yeah that may happen too.

I suspect we will see private insurers have prior auth for usage of image guidance/77412, but medicare with no prior auth will be the wild west. Everyone using SGRT on every case and up-billing to 77412.

No way BCBS or United going to pay 77412 for free breath lung or breast, right?
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Not just SGRT gets 77412 though

Doesn’t breast tangents with electron SIB to cavity seem like the most incredible idea ever… and now I can do field in field and bill it as IMRT!

Sacha Baron Cohen Lol GIF by The Tonight Show Starring Jimmy Fallon
 
BobbyHeenan said:
Bridge was saying they are assuming CMS is estimating that 77412 will be around 30% of cases. I wonder if mechanisms will be in place to "flag" outliers?
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CMS will utilize it's usual playbook:

1. Have a defined split between 77402:77407:77412 in the final rule which is 5%:60%:35%
2. The will closely observe the percentage distribution of these codes individual tax IDs in 2026
3. If there are a "few" pockets of overbilling, CMS will weaponize third party auditors. The directive: "We encourage you to find fault because if you do, CMS charges a penalty and you get a cut. If you find no malfeasance then you don't get paid"
4. If overbilling is rampant it has several levers to pull (a) "encourage" ASTRO to better define what CMS views as legit, (b) devalue the code in 2027, or (c) *rare* devalue the code in 2026

Anytime CMS "adjusts" codes, it is an absolute boon for corporate grifters. On the one hand, they can monetize the byzantine knowledge of compliance and on the other hand the are bounty hunters paid by CMS to extract payment from offenders.
 
TheWallnerus said:
Not just SGRT gets 77412 though

Doesn’t breast tangents with electron SIB to cavity seem like the most incredible idea ever… and now I can do field in field and bill it as IMRT!

Sacha Baron Cohen Lol GIF by The Tonight Show Starring Jimmy Fallon
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Oh we're definitely about to see some creative treatment planning.
 
OTN said:
Does this mean multi-iso osteoarthritis treatment will be reimbursed at the absolute highest level?
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Looks like it! Can someone say "weaponized compliance."
 
OTN said:
Does this mean multi-iso osteoarthritis treatment will be reimbursed at the absolute highest level?
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Mr. Smith, are you SURE we don't need to treat your other knee as well? It looks like it's bothering you. May as well do it.
 
The vast majority of my OA patients receive treatment to more than one joint at a time.
 
Question, are insurance companies planning to reimburse 77387 when billed with new delivery codes?
77402 is defined:


Radiation treatment delivery, Level 1 (eg, single electron field, multiple electron fields, or 2D photons), including imaging guidance, when performed)
 
A_DeMichele said:
Question, are insurance companies planning to reimburse 77387 when billed with new delivery codes?
77402 is defined:


Radiation treatment delivery, Level 1 (eg, single electron field, multiple electron fields, or 2D photons), including imaging guidance, when performed)
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Including technical aspect of image guidance

I predict if people just bill 77387 it might get denied or not pay

Make sure it’s always 77387-26

EDIT: 77402, 407, 412 are technical only codes (implying just the technical part of 77387 is bundled)
 
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Question:

For those of us on pure RVU models we don't benefit at all from the changes in the technical delivery codes. It's purely a hit to IGRT.


Normally we distinguish between Complex Isodose, 3D and IMRT in treatment planning.

Why wouldn't the insurance companies continue to push back on indications for 3D and IMRT etc purely from a planning code perspective?
 
CaesarRO said:
Question:

For those of us on pure RVU models we don't benefit at all from the changes in the technical delivery codes. It's purely a hit to IGRT.


Normally we distinguish between Complex Isodose, 3D and IMRT in treatment planning.

Why wouldn't the insurance companies continue to push back on indications for 3D and IMRT etc purely from a planning code perspective?
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Insurance may still do that...but planning charges are wwwaaayyy less than delivery charges. But yes, it may be a double-whammy of prior auth - fighting for BOTH planning charges and technical charge levels.
 
BobbyHeenan said:
Insurance may still do that...but planning charges are wwwaaayyy less than delivery charges. But yes, it may be a double-whammy of prior auth - fighting for BOTH planning charges and technical charge levels.
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Planning for a 5 fraction IMRT will cost more than delivery of 5 fractions of IMRT… come 2026
 
TheWallnerus said:
Planning for a 5 fraction IMRT will cost more than delivery of 5 fractions of IMRT… come 2026
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This is easy math

IMRT plan goes from $1700 to $1900 in 2026

An IG-IMRT fraction goes from $500 down to $300-$330

Physician wRVUs overall get a bump up on a 5 fx IG-IMRT regimen

Whoever owns the technical is going to see a noticeable downward ding for 5 fx IG-IMRT; much of this ding was pre-2026 baked in on HOPPS side, but not for freestanding
 
This may be a simple question and I am just big dumb. The MPFS determines RVU values for professional codes and that is finalized (~5-5.5% haircut across the board).

As I understand it the MPFS also determines technical reimbursement for freestanding facilities, so those changes are also finalized. Is that correct? But, it's the OPPS rule that determines technical reimbursement for hospital based systems which has not been released for CY2026?

The proposed rule for OPPS had 77407 and 77412 both being reimbursed at APC class 5622 ($275.34). For those of us that are hospital based, if that sticks in the final rule, does it really matter whether you do intermediate or complex treatment if they reimburse the hospital the same amount?
 
HolySmokes said:
This may be a simple question and I am just big dumb. The MPFS determines RVU values for professional codes and that is finalized (~5-5.5% haircut across the board).

As I understand it the MPFS also determines technical reimbursement for freestanding facilities, so those changes are also finalized. Is that correct? But, it's the OPPS rule that determines technical reimbursement for hospital based systems which has not been released for CY2026?

The proposed rule for OPPS had 77407 and 77412 both being reimbursed at APC class 5622 ($275.34). For those of us that are hospital based, if that sticks in the final rule, does it really matter whether you do intermediate or complex treatment if they reimburse the hospital the same amount?
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Without googling I was sure 77412 was 5623 (and in fact ASTRO was trying to get 77407 to 5623)?

I was a bit purposefully imprecise above because, again as I was sure, “IMRT” delivery could be reimbursed in a couple different ways in 2026 (and non IMRT treatments could get reimbursed twice what IMRT gets).

BIG EDIT: Actually I think I am wrong and you are right. But only for hospitals. This makes no sense but does in fact seem to be what has happened. Hospitals got super screwed?

image.jpg
 
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TheWallnerus said:
Without googling I was sure 77412 was 5623 (and in fact ASTRO was trying to get 77407 to 5623)?

I was a bit purposefully imprecise above because, again as I was sure, “IMRT” delivery could be reimbursed in a couple different ways in 2026 (and non IMRT treatments could get reimbursed twice what IMRT gets).
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The MPFS did weight the PE portion of the three treatment codes to correspond to APC 5621, 5622, and 5623, but that's only applicable for freestanding practices? That doesn't necessarily say what the OPPS rule for direct reimbursement of the codes in a hospital setting will be, right?

1763136425104.png

This is the table from the addendum of the proposed OPPS rule.
 
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HolySmokes said:
The MPFS did weight the PE portion of the three treatment codes to correspond to APC 5621, 5622, and 5623, but that's only applicable for freestanding practices? That doesn't necessarily say what the OPPS rule for direct reimbursement of the codes in a hospital setting will be, right?

View attachment 411661
This is the table from the addendum of the proposed OPPS rule.
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It appears you are right

TLDR is that at least come 1/1/26 freestanding gets reimbursed about $600 for 77412 and hospitals get about $300
 
TheWallnerus said:
It appears you are right

TLDR is that at least come 1/1/26 freestanding gets reimbursed about $600 for 77412 and hospitals get about $300
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I'm not familiar with freestanding reimbursement....are folks still modeling this as a cut as compared to prior rates on the technical /global side ?
 
Ray D. Ayshun said:
So on 1/1, 77385 goes to 77407, and more importantly, 77014 and g6002 become 77387. What are people planning to do with this information on 12/31?
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Both IMRT and non IMRT become 77407

It’s a nuanced (almost boringly so) discussion

I could give my opinion as to what you should do with this info but specifically on 1/1, do your best guess interpretations… and then wait for somebody else to tell us what we REALLY should do during that first quarter of year
 
77407 doesn’t require pre-auth, just bill it; 77387 does, but you already have IGRT pre-auth on file
 
So nobody's planning to change auth requests until 1/1? Even for patients simmed in December and starting in January. Just switching the codes and hoping for the best? This in itself is a brilliant way to make a cut to radonc. The January confusion alone will cost us 1-2%
 
Ray D. Ayshun said:
So nobody's planning to change auth requests until 1/1? Even for patients simmed in December and starting in January. Just switching the codes and hoping for the best? This in itself is a brilliant way to make a cut to radonc. The January confusion alone will cost us 1-2%
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Like Ademichele said, in general 77407 doesn't require prior auth... however, who knows, it could starting Jan 1. And there will be fraction limits at play, etc. Best thing to do is prior auth for any/all codes if patient starting tx after Jan 1.

There WILL be confusion.
 
77412 is going to be very closely audited, rationed, and eventually its inevitable overuse will be weaponized against us. On paper, use of certain modalities such as SGRT, CyberKnife, MRI-Linacs, etc. automatically qualify for this code. However, insurers will want exacting clinical justifactions (e.g. just because you have the technology, 77412 doesn't automatically apply).

EvilCore is already planning to deny every single one of these out of hand. It will be an uphill battle. Get ready for 100-page appeals packaged like doctoral disserations only to have a nurse reviewer "Cheryl from Nebraksa" to write "not medically necessary" in 11 words.
 
Gfunk6 said:
77412 is going to be very closely audited, rationed, and eventually its inevitable overuse will be weaponized against us. On paper, use of certain modalities such as SGRT, CyberKnife, MRI-Linacs, etc. automatically qualify for this code. However, insurers will want exacting clinical justifactions (e.g. just because you have the technology, 77412 doesn't automatically apply).

EvilCore is already planning to deny every single one of these out of hand. It will be an uphill battle. Get ready for 100-page appeals packaged like doctoral disserations only to have a nurse reviewer "Cheryl from Nebraksa" to write "not medically necessary" in 11 words.
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This distinction matters not to us hospital employed docs. It's all 77407 all the time for me til retirement. (kinda kidding, but in all seriousness, I barely give a **** about the tech changes).
 
Ray D. Ayshun said:
This distinction matters not to us hospital employed docs. It's all 77407 all the time for me til retirement. (kinda kidding, but in all seriousness, I barely give a **** about the tech changes).
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I mean … it could matter. If you do MR Linac or surface guidance, or two isocenters, and don’t bill for it… expect to get accused of fraudulent underbilling by somebody. And usually the call comes from inside the house.

SURELY all of us have the experience of wanting to use IGRT, it getting denied, and then being told we couldn’t do the IGRT on the patient (because we couldn’t bill it)?
 
TheWallnerus said:
SURELY all of us have the experience of wanting to use IGRT, it getting denied, and then being told we couldn’t do the IGRT on the patient (because we couldn’t bill it)?
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Absolutely, yes. But who knew the answer to this problem was that IGRT for everyone gratis! Problem solved.
 
TheWallnerus said:
I mean … it could matter. If you do MR Linac or surface guidance, or two isocenters, and don’t bill for it… expect to get accused of fraudulent underbilling by somebody. And usually the call comes from inside the house.

SURELY all of us have the experience of wanting to use IGRT, it getting denied, and then being told we couldn’t do the IGRT on the patient (because we couldn’t bill it)?
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I'll follow the rules with respect to motion management etc, and I'll do 2 iso for my bilateral knee OA. this tech code change means slightly more brain space for me.
 
OPPS final rule has been release: https://public-inspection.federalregister.gov/2025-20907.pdf

77402 and 77407 retain APC 5621 and 5622 as proposed, but 77412 was increased to 5623.
Payment rate for 5621 and 5623 are slightly decreased ($107 --> $105 and $600 --> $568, respectively) but 5622 was increased pretty substantially ($275 --> $397).

So routine 3D treatments reimburse more by ~$125/fraction while routine IMRT will reimburse less by ~$203/fraction. With some 3D treatments also getting the complex treatment code (multiple iso palliative, DIBH breast) that should help offset some of the losses but I still expect an overall small net decrease in technical revenue.
 
If Evicore or others come up with the actual 77412 written policy, pls share!
 
A_DeMichele said:
If Evicore or others come up with the actual 77412 written policy, pls share!
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I didn't read this thoroughly, but it looks like Evicore is putting out a written policy and *shocker* it looks like a disaster.

radiationeconomics.substack.com

Mission Accomplished? Not Even Close.

The CPT overhaul means nothing if UM vendors redefine complexity out of existence.
radiationeconomics.substack.com radiationeconomics.substack.com
 
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?
 
Gfunk6 said:
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?
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Yeah this all seems very strange.

With regard to bone I was thinking it meant for these cases where we palliatve a few sites at once.
But the lymphoma and "non malignant disorders" is baffling.
 
Ray D. Ayshun said:
I'll follow the rules with respect to motion management etc, and I'll do 2 iso for my bilateral knee OA. this tech code change means slightly more brain space for me.
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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.
 
BobbyHeenan said:
I didn't read this thoroughly, but it looks like Evicore is putting out a written policy and *shocker* it looks like a disaster.

radiationeconomics.substack.com

Mission Accomplished? Not Even Close.

The CPT overhaul means nothing if UM vendors redefine complexity out of existence.
radiationeconomics.substack.com radiationeconomics.substack.com
Click to expand...
Wow looks like freestanding is going to be decimated

This was so hard to predict I think I ihave only said it about ten times here already since late summer
 
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