Medicare PFS 2026 proposed rule

[alwaysbeIMRTing]

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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.

 

[BobbyHeenan]

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.

They are putting out numbers for those cpt codes, but I too am not clear where they are getting them.

 

[Wildcat321]

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.

CPT1/ HCPCS	Mod	Status	Not Used for Medicare Payment	DESCRIPTION	Work RVUs2	Non- Facility PE RVUs2	NA	Facility PE RVUs2	NA	Mal- Practice RVUs2	Total Non-Facility RVUs2	Total Facility RVUs2	Global
77402		A		Radiation tx delivery simple	0.00	2.69		2.69	NA	0.02	2.71	2.71	XXX
77407		A		Radiation tx delivery intrm	0.00	6.43		6.43	NA	0.04	6.47	6.47	XXX
77412		A		Radiation tx delivery complx	0.00	14.37		14.37	NA	0.08	14.45	14.45	XXX

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?

 

[BobbyHeenan]

CPT1/ HCPCS	Mod	Status	Not Used for Medicare Payment	DESCRIPTION	Work RVUs2	Non- Facility PE RVUs2	NA	Facility PE RVUs2	NA	Mal- Practice RVUs2	Total Non-Facility RVUs2	Total Facility RVUs2	Global
77402		A		Radiation tx delivery simple	0.00	2.69		2.69	NA	0.02	2.71	2.71	XXX
77407		A		Radiation tx delivery intrm	0.00	6.43		6.43	NA	0.04	6.47	6.47	XXX
77412		A		Radiation tx delivery complx	0.00	14.37		14.37	NA	0.08	14.45	14.45	XXX

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?

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.

 

[HolySmokes]

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.

 

[alwaysbeIMRTing]

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?)

 

[BobbyHeenan]

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 see these two tables....different rates....

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

 

[HolySmokes]

I see these two tables....different rates....

View attachment 406673

View attachment 406675

These rates look the same to me between the two tables?

 

[BobbyHeenan]

These rates look the same to me between the two tables?

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.

 

[HolySmokes]

I think there is a typo in the ASTRO document.

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.

I see now, thanks for helping clarify.

 

[yesmaster]

I see these two tables....different rates....

View attachment 406673

View attachment 406675

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

View attachment 406674

UW and MDA will get paid tons eventually for treating a handful of billionaires and insurance executives with protons for arthritis and stage 1 breast cancer. Expert “thought leaders.” Community practices will make up for it with volume and AI.

 

[drowsy12]

‘Community practices will make up for it with volume and AI.’


Fairy tale much?

 

[TheWallnerus]

Has anyone else heard that director of health policy at ASTRO was fired today

Please understand I’m as sure of this rumor as I am of what IMRT reimbursement will look like in 2026

 

[Tigerstang]

G6017 - sad to see it go

 

[cmw021]

G6017 - sad to see it go

Might this (SGRT) still be billable as 77387-26?

 

[alwaysbeIMRTing]

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.

 

[cmw021]

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.

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.

 

[alwaysbeIMRTing]

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).

 

[BobbyHeenan]

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).

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.

 

[RickyScott]

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…

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

 

[alwaysbeIMRTing]

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.

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.

 

[BobbyHeenan]

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.

'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.

 

[Mandelin Rain]

Can we get an executive summary of how bad we're getting hit on the professional side?

 

[BobbyHeenan]

Can we get an executive summary of how bad we're getting hit on the professional side?

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.

 

[alwaysbeIMRTing]

Can we get an executive summary of how bad we're getting hit on the professional side?

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).

 

[cmw021]

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).

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...

 

[cmw021]

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.

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?

 

[BobbyHeenan]

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?

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.

 

[Tigerstang]

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.

Yes but if you are pro fee only, this is a loss

 

[alwaysbeIMRTing]

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?

 

[BobbyHeenan]

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?

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.

 

[alwaysbeIMRTing]

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.