Medicare PFS 2026 proposed rule

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To make a pro forma you need to know what the proposed rate for 77412 and 77407 are on the MPFS (non-facility), and the rates for APC codes 5622 and 5623 (facility). I haven't seen these. Where are Jordan's numbers coming from? Those rates could theoretically be adjusted so the only people getting screwed are the docs on RVUs.
 
alwaysbeIMRTing said:
To make a pro forma you need to know what the proposed rate for 77412 and 77407 are on the MPFS (non-facility), and the rates for APC codes 5622 and 5623 (facility). I haven't seen these. Where are Jordan's numbers coming from? Those rates could theoretically be adjusted so the only people getting screwed are the docs on RVUs.
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They are putting out numbers for those cpt codes, but I too am not clear where they are getting them.
 
alwaysbeIMRTing said:
To make a pro forma you need to know what the proposed rate for 77412 and 77407 are on the MPFS (non-facility), and the rates for APC codes 5622 and 5623 (facility). I haven't seen these. Where are Jordan's numbers coming from? Those rates could theoretically be adjusted so the only people getting screwed are the docs on RVUs.
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CPT1/
HCPCS		ModStatusNot Used for Medicare PaymentDESCRIPTION
Work
RVUs2
Non-
Facility
PE
RVUs2		NA
Facility
PE
RVUs2		NAMal-
Practice
RVUs2
Total Non-Facility RVUs2
Total Facility RVUs2		Global
77402ARadiation tx delivery simple 0.00 2.69 2.69NA 0.02 2.71 2.71XXX
77407ARadiation tx delivery intrm 0.00 6.43 6.43NA 0.04 6.47 6.47XXX
77412ARadiation tx delivery complx 0.00 14.37 14.37NA 0.08 14.45 14.45XXX
This is from the addenda. Did not see the APCs listed.

ASTRO just sent these two summaries out:
PFS: https://www.astro.org/ASTRO/media/ASTRO/Daily Practice/PDFs/2026MPFSProposedRuleSummary.pdf
OPPS: https://www.astro.org/ASTRO/media/ASTRO/Daily Practice/PDFs/2026HOPPSProposedRuleSummary.pdf

They continue to push for site neutrality similar to ROCR. Any thoughts on their motivation?
 
Wildcat321 said:
CPT1/
HCPCS		ModStatusNot Used for Medicare PaymentDESCRIPTION
Work
RVUs2
Non-
Facility
PE
RVUs2		NA
Facility
PE
RVUs2		NAMal-
Practice
RVUs2
Total Non-Facility RVUs2
Total Facility RVUs2		Global
77402ARadiation tx delivery simple 0.00 2.69 2.69NA0.02 2.71 2.71XXX
77407ARadiation tx delivery intrm 0.00 6.43 6.43NA0.04 6.47 6.47XXX
77412ARadiation tx delivery complx 0.0014.3714.37NA0.0814.4514.45XXX
This is from the addenda. Did not see the APCs listed.

ASTRO just sent these two summaries out:
PFS: https://www.astro.org/ASTRO/media/ASTRO/Daily Practice/PDFs/2026MPFSProposedRuleSummary.pdf
OPPS: https://www.astro.org/ASTRO/media/ASTRO/Daily Practice/PDFs/2026HOPPSProposedRuleSummary.pdf

They continue to push for site neutrality similar to ROCR. Any thoughts on their motivation?
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Thank you.

That suggests HUGE difference between 77412 and 77407.

ASTRO suggesting not a huge cut....but it still seems to me all of hte projections will depend upon whether your IMRT cases now are considered intermediate or complex in 2026 and if a VisionRT usage is enough to make them complex.
 
The ASTRO document seems to suggest the APCs for 77407 and 77412 are the same ($275.34). Does the difference in PE RVUs above matter if the payment is the same? I genuinely don't understand how most of this works.
 
I think there is a typo in the ASTRO document.

CMS is proposing 77407 in APC 5622 (level 2) and 77412 in APC 5623 (level 3), not both in 5622.
ASTRO is asking for 77407 in APC 5623 and 77412 in APC 5624 (level 4).

If ASTRO is successful in getting these bumped up a level, it would put IMRT treatment delivery back around where it was under 77385 and 77386, which were APC 5623. With the redefinition of 77407, most IMRT would now fall under it, which would drop IMRT payments to level 2.

Hopefully they can make the argument that a >50% cut for the service indicates that CMS has not grouped these correctly.
They have also rightfully identified that the efficiency cuts to the RVUs for the professional codes are arbitrary. I am not going to get my hopes up that they will undo that. And of course the usual whining about supervision and in-person 77427 for comprehensive exam (who does that?)
 
HolySmokes said:
The ASTRO document seems to suggest the APCs for 77407 and 77412 are the same ($275.34). Does the difference in PE RVUs above matter if the payment is the same? I genuinely don't understand how most of this works.
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I see these two tables....different rates....

1752694527196.png


1752694637321.png


Also, in case anyone wants to riot....

1752694571772.png
 
HolySmokes said:
These rates look the same to me between the two tables?
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I haven't read it all, just skimmed it, but on the first table it has the Level 3 radiation therapy as APC 5623 but on the second table it has Level 3 as a 5622.
 
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The wRVU for G6017 is currently zero, so I'm guessing no. However, it looks like you will be able to bill 77412 for it. I'll leave it to someone else to figure out the global payments for 77412 in freestanding vs. G6015+G6017. You will bill 77387 -26 anyway for physician image review.
 
alwaysbeIMRTing said:
The wRVU for G6017 is currently zero, so I'm guessing no. However, it looks like you will be able to bill 77412 for it. I'll leave it to someone else to figure out the global payments for 77412 in freestanding vs. G6015+G6017. You will bill 77387 -26 anyway for physician image review.
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In the hospital outpatient setting, we just recently started billing G6017 for 3D cases that we are using SGRT but not using IGRT (primarily breast). I'm wondering if these would qualify as 77387-26 (without image review). The vision RT folks have been sending out recent emails to that effect.
 
Interesting. Can you bill G6017 for any form of DIBH? Wouldn't any form of DIBH qualify and intrafraction motion tracking?

I have never treated DIBH without IGRT. So if you are treating DIBH, then you would already have a 77387 -26 for reviewing the kV or CBCT (unless you could bill 2 on the same treatment).
 
cmw021 said:
In the hospital outpatient setting, we just recently started billing G6017 for 3D cases that we are using SGRT but not using IGRT (primarily breast). I'm wondering if these would qualify as 77387-26 (without image review). The vision RT folks have been sending out recent emails to that effect.
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alwaysbeIMRTing said:
Interesting. Can you bill G6017 for any form of DIBH? Wouldn't any form of DIBH qualify and intrafraction motion tracking?

I have never treated DIBH without IGRT. So if you are treating DIBH, then you would already have a 77387 -26 for reviewing the kV or CBCT (unless you could bill 2 on the same treatment).
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LIke CMW, we are billing G6017 on cases where we use vision RT but don't use CBCT. This ends up being DIBH L breast cases mostly for us. We are getting paid for it (on pro fee side) as well in majority of cases though some have required peer to peer for private insurers.

I too am waiting for clarification, but I was thinking at first glance in these types of situations you will be able to bill 77387-26 in the new guidelines.
 
just wanted to provide staffing levels recommended by abr. Most radoncs are seeing around 4-5new patients a week which would equate to less than 10 on beam. ( and we know its worse with Pareto distribution such that the median is closer to or below 4)

This is less than 20 hours a week of clinical responsibility. Too bad we can’t just take on more patients to make up for the loss in reimbursement. I would be willing to work 25-30 hrs…





accreditationsupport.acr.org

Personnel: Radiation Oncology (Revised 7-9-2024)

Revision History Role Personnel Requirements/Recommendations Medical Director Each program must have a medical director who is a radiation oncologist as described below. He/she is responsible for oversight of the department, includi...
accreditationsupport.acr.org accreditationsupport.acr.org
 
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BobbyHeenan said:
LIke CMW, we are billing G6017 on cases where we use vision RT but don't use CBCT. This ends up being DIBH L breast cases mostly for us. We are getting paid for it (on pro fee side) as well in majority of cases though some have required peer to peer for private insurers.

I too am waiting for clarification, but I was thinking at first glance in these types of situations you will be able to bill 77387-26 in the new guidelines.
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Aren't you billing G6002 in these cases also? With G6002 gone, you would be billing 77387 -26 for the image review leaving you no way to bill for the SGRT. However the bump from 77407 to 77412 the SGRT buys you should be way higher than the reimbursement for 77387 -26.
 
alwaysbeIMRTing said:
Aren't you billing G6002 in these cases also? With G6002 gone, you would be billing 77387 -26 for the image review leaving you no way to bill for the SGRT. However the bump from 77407 to 77412 the SGRT buys you should be way higher than the reimbursement for 77387 -26.
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'I only bill G6002 for daily kv Orthogonal image guidance. I don't typically take daily orthogonal DIBH images with vision RT so I wouldn't bill G6002.

I believe at this time you can only bill for one type of image guidance, even if doing multiple (CBCT or kv orthogonal or surface guidance), so you can't combine codes.
 
Can we get an executive summary of how bad we're getting hit on the professional side?
 
Mandelin Rain said:
Can we get an executive summary of how bad we're getting hit on the professional side?
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A lot is in flux....take it for what it's worth (free), but from what I gather I think you're looking at 1-5% cut if you're just billing/collecting professional fees.

If you do a ton of CBCT image review you're going to take a bigger hit (I think wRVU will go from something like 0.84 to 0.70) more than others.
 
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Mandelin Rain said:
Can we get an executive summary of how bad we're getting hit on the professional side?
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Magic 8 ball says 5% minimum, 10% maximum income hit year over year if your contracts don't change (and astro isn't successful at clawing back the efficiency adjustments to all the 772xx and 773xx codes).
 
alwaysbeIMRTing said:
Interesting. Can you bill G6017 for any form of DIBH? Wouldn't any form of DIBH qualify and intrafraction motion tracking?

I have never treated DIBH without IGRT. So if you are treating DIBH, then you would already have a 77387 -26 for reviewing the kV or CBCT (unless you could bill 2 on the same treatment).
Click to expand...
I'm not certain about G6017 for DIBH. We have not done that historically, but our billers are on the more conservative side.

We have started billing G6017 for 3D breast specifically because we do not bill for IGRT for these patients. For L DIBH, we are doing daily MVs (not kVs or CBCT, similar to how Bobby outlined), and we do not bill G6002. So for years, we have not billed any form of IGRT/SGRT for these patients. We recently changed that with G6017 using SGRT (Identify vs Align RT, depending on which machine). We have collected pro fees with this approach.

Agree also with what Bobby said above- cannot bill G6017 alongside IGRT (CBCT or kV).

My hope is that in 2026 we will bill 77387-26 for all IGRT, including our SGRT patients that aren't being imaged with kV or CBCT, though its not entirely clear to me at this point if that's possible. I'm concerned about the interpretation from our overly conservative billers...
 
BobbyHeenan said:
We are getting paid for it (on pro fee side) as well in majority of cases though some have required peer to peer for private insurers.
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We are new to this in our department. I haven't pushed back on p2p's for fear of patient delays - as I posted above we've not collected previously for years despite routinely using alignRT so currently just happy to get something rather than nothing.

What is your medical necessity justification for G6017 SGRT approval for peer to peers? Are the decisions often overturned? Cases limited to Left sided DIBH, or are you doing R sided tangents / prone / etc?
 
cmw021 said:
We are new to this in our department. I haven't pushed back on p2p's for fear of patient delays - as I posted above we've not collected previously for years despite routinely using alignRT so currently just happy to get something rather than nothing.

What is your medical necessity justification for G6017 SGRT approval for peer to peers? Are the decisions often overturned? Cases limited to Left sided DIBH, or are you doing R sided tangents / prone / etc?
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Right now it’s really only DIBH whole breast cases.

I’ve had to do two peer to peers and they were both approved.

I’ve had about 6 other cases over last year that were paid for.

We too are only now billing it last year or so.
 
alwaysbeIMRTing said:
Aren't you billing G6002 in these cases also? With G6002 gone, you would be billing 77387 -26 for the image review leaving you no way to bill for the SGRT. However the bump from 77407 to 77412 the SGRT buys you should be way higher than the reimbursement for 77387 -26.
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Yes but if you are pro fee only, this is a loss
 
G6017 is confusing me. It's got zero wRVUs and it's not in the PFS lookup. But apparently it does not have a technical component. How are you getting paid billing pro fees for this? I've never seen a pro code that can be billed by the physician that doesn't have any wRVUs. Does medicare pay it or only commercial payors?
 
alwaysbeIMRTing said:
G6017 is confusing me. It's got zero wRVUs and it's not in the PFS lookup. But apparently it does not have a technical component. How are you getting paid billing pro fees for this? I've never seen a pro code that can be billed by the physician that doesn't have any wRVUs. Does medicare pay it or only commercial payors?
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we started getting paid in 2025 by Medicare. Some but not all insurers started paying if you get prior with. Probably still a minority of private payers but I’d have to check on that.
 
So the rationale for reducing the wRVUs on cone beam review to 0.7 from 0.85 with the switch from 77014 to 77387 is that you will also bill this code for kV review instead of G6002, which had a wRVU value of 0.39. So while you will be getting paid less for cone beam review, you will be getting paid more for kV review. From the ASTRO and ACRO discussion on youtube, it is claimed that this weight of 0.7 (which medicare is already proposing to reduce to 0.68 with the 2.5% cut to all pro codes, which is insane since it is a new code) represents the average weight of CBCT vs. kV use in the typical practice.

I just ran my most recent numbers. I was 91% CBCT and 9% kV (I don't treat a lot of breast and a lot of lung, prostate and H&N). If I were to use the new code at the new valuation, this would result in an 13.4% decrease in wRVUs. In other words, the proper valuation of 77387 should be 0.81, not 0.7, and definitely not 0.68. To get a value of 0.7, you would need a CBCT/kV ratio of 67% to 33%. Curious if anyone besides a breast subspecialist is actually anywhere close to this? Whoever advocated for this ratio on our behalf really screwed us.
 
I ran the numbers for the past few years. My CBCT vs. kV ratio varies between 88%-98% each month averaging around 94-95%. I am aware of some clinics that CBCT every treatment as a policy whether or not they get paid for it. I would encourage everyone to run their own numbers and provide this feedback to the professional societies if you have any voice there. I do not.

The wRVU for the new code should not really be much different from the old code at 0.85. 0.68 is way, way too low and represents an actual huge cut, not just an equitable accounting for kV vs. CBCT usage as claimed.
 
alwaysbeIMRTing said:
I ran the numbers for the past few years. My CBCT vs. kV ratio varies between 88%-98% each month averaging around 94-95%. I am aware of some clinics that CBCT every treatment as a policy whether or not they get paid for it. I would encourage everyone to run their own numbers and provide this feedback to the professional societies if you have any voice there. I do not.

The wRVU for the new code should not really be much different from the old code at 0.85. 0.68 is way, way too low and represents an actual huge cut, not just an equitable accounting for kV vs. CBCT usage as claimed.
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Yes. I would like to see the data where they "weighted" it to "increase" the Kv imaging (G6002).

I am like you - if doing IGRT, i do about 85% CBCT, only 15% ortho kV's.

I don't do CBCT on every case.

This isn't some "leveling out" of image guidance by upping G6002 and decreasing 77014 CBCT.... It's a cut.

On that podcast, ASTRO/ACRO folks didn't put up any fight about this and instead tried to explain how it wasn't really a cut. Which IMO is wrong. It's a cut.
 
I don't think that the fact that you get to 0.7 by weighting G6002 (0.39) at 0.333 and 77014 (0.85) at 0.667 is a coincidence. Somebody advocating for us spitballed that the average clinic is about two thirds cone beam and one third kV based on zero data.
 
Ok to wing it and use back of the napkin math when it comes to reimbursements and residency expansion, but we have to wait for decades worth of evidence to do obvious things like hypofractionate for dcis 🙄
 
alwaysbeIMRTing said:
I don't think that the fact that you get to 0.7 by weighting G6002 (0.39) at 0.333 and 77014 (0.85) at 0.667 is a coincidence. Somebody advocating for us spitballed that the average clinic is about two thirds cone beam and one third kV based on zero data.
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on 17.5k wRVUs last year my billing department billed G6002 7 times and 77014 3,551 times...
 
RSAOaky said:
on 17.5k wRVUs last year my billing department billed G6002 7 times and 77014 3,551 times...
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I just looked at some of our data across multiple centers last year after you posted this. Yeah we were like 200 G6002's versus five digit 77014's.

Commentary on this is complete BS - "you're getting a bump on kv orthogonal imaging"

I thought were were closer to 10-15% G6002 but we're like you and alwaysbeimrt'ing.
 
TheWallnerus said:
With prostate fiducial matching kV orthog matching shows less systematic and random error versus CBCT matching, although one can argue if the differences are clinically meaningful.
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I'll take kV with fiducials over Cbct without any day of the week. Obviously the best will be both esp for evaluating the rectum and bladder filling.

Fiducials are just more reproducible and less prone to error at the rectal interface
 
How is much is this gonna impact the rad onc median salaries? And what’s the likelihood it gets finalized?
 
If you are salaried, your salary is set by your local market supply and demand, not reimbursement rates. Residency expansion is more of a threat to you than CMS cuts.
If you bill on your own or get paid per RVU, you are looking at a 5-10% decrease in your income if nothing else changes.
If you bill globally (collect both the professional fee and the facility fee because you own the facility and have staff to pay), this could be a lot worse if the IMRT delivery coding snafu isn't sorted out.
 
allseasons said:
How is much is this gonna impact the rad onc median salaries? And what’s the likelihood it gets finalized?
Click to expand...

That's incredibly hard to predict.

I think some changes will occur over this next 60 day comment period, but my prediction is that these image guidance codes merging into one code (and being a cut) will stay.

The BIG question is on the technical side what the $/fraction will be for 3D/IMRT and "advanced" IMRT. If those take big cuts it will IMO have some downstream compensation impact and may throw some further turmoil in market....smaller free standing centers that treat in the teens are going to have a really hard time getting by. Less centers means less jobs which will put pressure on the market.
 
alwaysbeIMRTing said:
If you are salaried, your salary is set by your local market supply and demand, not reimbursement rates. Residency expansion is more of a threat to you than CMS cuts.
If you bill on your own or get paid per RVU, you are looking at a 5-10% decrease in your income if nothing else changes.
If you bill globally (collect both the professional fee and the facility fee because you own the facility and have staff to pay), this could be a lot worse if the IMRT delivery coding snafu isn't sorted out.
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Exactly. For 80%+ of us, the doubling of residency spots had a much larger impact on salaries and job availability than cms. Even with the cms cuts, we still have more rvus than neurosurgery, thoracic surgery, ortho etc. supply and demand. Quite simply, Astro betrayed its members.
 
There are large academic systems in the us that have this as part of their business model -- catering to arab royalty who show up on global express jets with suitcases full of cash. Kind of like how MGM and Caesars make the bulk of their profits from ~100 or so Chinese clients who play $100k hands of baccarat.
 
alwaysbeIMRTing said:
There are large academic systems in the us that have this as part of their business model -- catering to arab royalty who show up on global express jets with suitcases full of cash. Kind of like how MGM and Caesars make the bulk of their profits from ~100 or so Chinese clients who play $100k hands of baccarat.
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Special non resident/fellow floors/suites at Mayo and CCF
 
When we were in residency a bunch of us tried to create a business model of a linac on a cruise ship.

Old people who like to cruise. Check
Medical toursim. Check
Don't have to shield the hull. Check
Kills fish who swim around the ship that you can scoop up for food. Check
Register ship in Panama and bypass all US medical regulations. Check
No insurance, cash only. Check

Animated GIF
 
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