Advertisement - Members don't see this ad
This year's coding change has been an absolute fiasco.
Here are the major issues that I see that were preventable:
1) They should not have had a predicted ratio for 77402, 77407, 77412. The right ratio is the ratio you are treating with. If you have a breast practice, there are going to be many left sided patients and numbers will be higher. If you are doing prostate without fiducial tracking, your numbers will be lower. Even predicting for the population and estimating puts us in a weak position. The right number will be a future number. The work it takes to get from 77407 to 77412 is significant (authorization, documentation, P2P, extra time on table) is not some vast amount that people are going to get rich from.
2) They did not make it a point to have practices discuss these changes with their payor. We are getting absolutely clobbered as the crosswalk was done incorrectly and we are trying to fix this. Our largest payor is paying us basically Medicaid rates. And, we don't even get that low for Medicaid patients! Michigan has a rule that if you are faculty, you get paid Medicare rates for Medicaid. This should have been discussed up front that the payment delivery needed to match what it was before plus the allowance for IGRT. There were forward looking people that did this proactively.
3) The discussions about LDRT and multi-isocenter treatment should have been done quite early on instead of spring 2026. This is a humongous issue. If you are treating multiple isocenters, then you should be compensated for the time on the table. The argument of benign vs malignant is not valid - the whole point of this exercise in coding changes was to make it treatment dependent, not disease dependent.
4) Active motion management should have been given a defined definition, instead of what is happening where the payors are defining it for us. Evicore should not be able to say that AMM = respiratory motion only. They are not the deciders. We should have been the deciders.
5) Society leadership made it a point that prior auth would be less of an issue because the codes were technique agnostic. This is obviously not the case, with anyone dealing with United Health Care, Evicore and other payors. I have more auth issues in 2026 versus pre-2026 and the margin of gain is significantly lower.
6) The society completely bungled their calculations and anyone with half a brain knew that with the loss of IGRT technical revenue, even if all else remained same, we were getting a significant haircut. How could this happen? These are supposed to be smart people doing the analysis. Even my substack posts said this a long time ago. It made zero financial or mathematical sense.
7) It is a surprise to no one that has been in the field for >10-15 years that freestanding is taking a much more severe hit than the hospitals. We are getting crushed. Yet, we are the minority and continually shrinking. No one is society leadership actually gives a **** about freestanding. The society CEO is purportedly a freestanding guy. If so, where has he been during this nightmare? He should have a large microphone. I don't think anyone knows or care what he does. It is no different than it was with the prior CEO.
8) Finally, the original sin was not discussing these coding changes over the last 2-3 years during their development. It was an afterthought to push ROCR eventually. This was malignant neglect on the part of the societies. They were doing all this negotiating about the changes in a small, dark conference room and until mid-to-late 2025, we had no idea what was happening. The communication arm of the societies are either grossly incompetent or purposefully secretive in order to get to case rates.
I don't believe ROCR will be better. "Stability" "Technique agnostic" "Taking out of hands of CMS" - these are just buzzwords. They mean nothing. If we are getting case rates, there will be continuous downward pressure from the feds and from CMS. It is much easier to shave a few bucks off of one number than it is to do that to multiple codes. There will be no mechanism for increased costs of labor/technology and inflation. The same organ that would pass this law would be able to either reduce the payments or abolish it if/when it fails, and this false sense of stability will fade quickly.
I have not heard a coherent and affirmative case for ROCR other than buzzwords, fear and bullying that "it will get worse". All it does it gets worse. Why do you think this "worse" will be less bad than what CMS gives us? At least CMS is transparent that they are trying to decimate us. I'd love to hear a strong steelman argument for ROCR. I have not read or heard one that isn't flimsy and easy to poke holes in. And, if you remove protons and PPS exempt hospitals and allow industry to be involved in our certification, isn't this just community doctors bearing the burden of "payment reform"?
I have zero trust left in their recommendations for what we should do. From reducing our IMRT use, to telling us to not do X fractions, to create a system where fancy hospitals charge way more but are considered cost-effective b/c they shave a few treatments off, to allowing proton centers to misinform the public, to pretend that this coding change was not that bad - they have not been stewards of the profession or patients or the physicians that provide these services. If you have trust in the societies, ask yourself "why?". Ask what have they done for you lately. Have they been honest? Have they been correct? When mistakes have been made, do they own them or revise history? Are their course corrections or more of the same? I can barely think of any society that has done more harm to their specialty than ours. And yet, people still go back. From slides of a talk, 850 people quit our society from 2020-2025. I am presuming they are mostly American physicians and of ~5000 practicing physicians, that is a lot. They are starting to do everything they can to have people re-join. They get on committees and realize nothing actually changes, nothing gets done and the whims and desires of the elite continue to be what the society desires. It must be disheartening, the people that thought things were going to improve, when in reality it was the same bike with a new coat of spray paint.
Young folks - take high paying jobs, don't worry about academic advancement - barely anyone is doing anything of value - they are just RVU grinders like the rest of us. Get a long contract that is guaranteed and not completely tied to productivity. Understand billing and coding. Fight auth hard. Always take the P2P and appeal if there is time. Trust no one about the future of the specialty, particular those that are entrenched academics that are divorced from the reality of community cancer care. Think for yourselves. Ask questions. If the answer doesn't make sense, ask it again until you get one that does or chalk it up to yet another person that doesn't really understand the issues at hand. "Trust us" should be heard as "We are f*cking you over".
Here are the major issues that I see that were preventable:
1) They should not have had a predicted ratio for 77402, 77407, 77412. The right ratio is the ratio you are treating with. If you have a breast practice, there are going to be many left sided patients and numbers will be higher. If you are doing prostate without fiducial tracking, your numbers will be lower. Even predicting for the population and estimating puts us in a weak position. The right number will be a future number. The work it takes to get from 77407 to 77412 is significant (authorization, documentation, P2P, extra time on table) is not some vast amount that people are going to get rich from.
2) They did not make it a point to have practices discuss these changes with their payor. We are getting absolutely clobbered as the crosswalk was done incorrectly and we are trying to fix this. Our largest payor is paying us basically Medicaid rates. And, we don't even get that low for Medicaid patients! Michigan has a rule that if you are faculty, you get paid Medicare rates for Medicaid. This should have been discussed up front that the payment delivery needed to match what it was before plus the allowance for IGRT. There were forward looking people that did this proactively.
3) The discussions about LDRT and multi-isocenter treatment should have been done quite early on instead of spring 2026. This is a humongous issue. If you are treating multiple isocenters, then you should be compensated for the time on the table. The argument of benign vs malignant is not valid - the whole point of this exercise in coding changes was to make it treatment dependent, not disease dependent.
4) Active motion management should have been given a defined definition, instead of what is happening where the payors are defining it for us. Evicore should not be able to say that AMM = respiratory motion only. They are not the deciders. We should have been the deciders.
5) Society leadership made it a point that prior auth would be less of an issue because the codes were technique agnostic. This is obviously not the case, with anyone dealing with United Health Care, Evicore and other payors. I have more auth issues in 2026 versus pre-2026 and the margin of gain is significantly lower.
6) The society completely bungled their calculations and anyone with half a brain knew that with the loss of IGRT technical revenue, even if all else remained same, we were getting a significant haircut. How could this happen? These are supposed to be smart people doing the analysis. Even my substack posts said this a long time ago. It made zero financial or mathematical sense.
7) It is a surprise to no one that has been in the field for >10-15 years that freestanding is taking a much more severe hit than the hospitals. We are getting crushed. Yet, we are the minority and continually shrinking. No one is society leadership actually gives a **** about freestanding. The society CEO is purportedly a freestanding guy. If so, where has he been during this nightmare? He should have a large microphone. I don't think anyone knows or care what he does. It is no different than it was with the prior CEO.
8) Finally, the original sin was not discussing these coding changes over the last 2-3 years during their development. It was an afterthought to push ROCR eventually. This was malignant neglect on the part of the societies. They were doing all this negotiating about the changes in a small, dark conference room and until mid-to-late 2025, we had no idea what was happening. The communication arm of the societies are either grossly incompetent or purposefully secretive in order to get to case rates.
I don't believe ROCR will be better. "Stability" "Technique agnostic" "Taking out of hands of CMS" - these are just buzzwords. They mean nothing. If we are getting case rates, there will be continuous downward pressure from the feds and from CMS. It is much easier to shave a few bucks off of one number than it is to do that to multiple codes. There will be no mechanism for increased costs of labor/technology and inflation. The same organ that would pass this law would be able to either reduce the payments or abolish it if/when it fails, and this false sense of stability will fade quickly.
I have not heard a coherent and affirmative case for ROCR other than buzzwords, fear and bullying that "it will get worse". All it does it gets worse. Why do you think this "worse" will be less bad than what CMS gives us? At least CMS is transparent that they are trying to decimate us. I'd love to hear a strong steelman argument for ROCR. I have not read or heard one that isn't flimsy and easy to poke holes in. And, if you remove protons and PPS exempt hospitals and allow industry to be involved in our certification, isn't this just community doctors bearing the burden of "payment reform"?
I have zero trust left in their recommendations for what we should do. From reducing our IMRT use, to telling us to not do X fractions, to create a system where fancy hospitals charge way more but are considered cost-effective b/c they shave a few treatments off, to allowing proton centers to misinform the public, to pretend that this coding change was not that bad - they have not been stewards of the profession or patients or the physicians that provide these services. If you have trust in the societies, ask yourself "why?". Ask what have they done for you lately. Have they been honest? Have they been correct? When mistakes have been made, do they own them or revise history? Are their course corrections or more of the same? I can barely think of any society that has done more harm to their specialty than ours. And yet, people still go back. From slides of a talk, 850 people quit our society from 2020-2025. I am presuming they are mostly American physicians and of ~5000 practicing physicians, that is a lot. They are starting to do everything they can to have people re-join. They get on committees and realize nothing actually changes, nothing gets done and the whims and desires of the elite continue to be what the society desires. It must be disheartening, the people that thought things were going to improve, when in reality it was the same bike with a new coat of spray paint.
Young folks - take high paying jobs, don't worry about academic advancement - barely anyone is doing anything of value - they are just RVU grinders like the rest of us. Get a long contract that is guaranteed and not completely tied to productivity. Understand billing and coding. Fight auth hard. Always take the P2P and appeal if there is time. Trust no one about the future of the specialty, particular those that are entrenched academics that are divorced from the reality of community cancer care. Think for yourselves. Ask questions. If the answer doesn't make sense, ask it again until you get one that does or chalk it up to yet another person that doesn't really understand the issues at hand. "Trust us" should be heard as "We are f*cking you over".
