Image-guided radiation therapy (IGRT) or target localization is not something new to radiation oncology. Starting in the early 1950s in Canada, radiation oncologists have used this early form of guidance procedure called port films to position the patient. These port films located anatomy using multiple gantry angle images taken by a linear accelerator with megavoltage. Although the image clarity was good enough for positioning, it lacked the sophistication of current target localization systems in millimeter accuracy which is crucial when treating the patient.
A common misconception of the general public and some payers is that IGRT is actually the treatment. IGRT is a localization procedure using advanced equipment prior to the treatment ("inter-fraction") or during the treatment ("intra-fraction"). The radiation oncologist and clinical staff use the IGRT system to locate the tumor and then position the patient to deliver optimal dose distributions to the tumor. The IGRT technique allows avoidance of critical structures such as liver, spinal cord, and optic nerves. A unique coordination between the radiation oncologist and the highly trained therapists allows cancer centers to treat specific areas with high radiation doses while sparing normal tissue. This allows for accuracy that few had only 10 years ago.
ExacTrac® an IGRT system. image/courtesy of Brainlab
Many research centers, teaching facilities, and advanced cancer centers were leaders in developing and utilizing IGRT procedures for many years prior to them becoming commercially available. Port films for tumor localization were the first basic positioning system (AMA CPT-4 code 77417).1 The clinical staff, with orders from the physician, will take several images from each gantry angle position that represents the beam that will be directed to the tumor. These port films would then be reviewed by the treatment staff and approved by the radiation oncologist.
Know the codes
An ultrasound procedure code (76950) was revised in 2001 to represent "ultrasound guidance for placement of radiation therapy fields" and was the next IGRT code to be commercially used. 76950 is an IGRT procedure that uses ultrasound and is ordered and performed by the staff and/or radiation oncologist.
The supervision level assigned by the Centers for Medicare and Medicaid Services is "general," meaning the physician can order but does not need to be present. The "general" level of supervision as defined by CMS reads: "Procedure must be performed under the general supervision of a physician. General supervision means the procedure is furnished under the physician's overall direction and control, but the physician's presence is not required during the performance of the procedure. Under general supervision, the training of the non-physician personnel who actually perform the diagnostic procedure and the maintenance of the necessary equipment and supplies are the continuing responsibility of the physician."2
Consequently, if the physician ordered and directed the procedure, the technical portion may be charged; however, unless the physician participates in the ultrasound procedure, the professional component should not be charged.
CPT code 76370 (CT guidance for the placement of radiation therapy fields) was deleted in 2006 when the definition was converted to a new code, 77014 (computed tomography guidance for placement of radiation therapy fields), with the same definition as 76370. The procedure was originally described as "CT on rails" where an actual CT was parallel with the accelerator and the patient was moved via a rail system to be imaged then immediately treated. Years later, the CT system became part of the linear accelerator.
77014 can be a confusing CPT code because it represents two totally separate procedures. The first one is the CT for planning, which is ordered by the radiation oncologist and performed after the clinical simulation set up for the physics-planning computers. This procedure is a technical-only charge and can be researched back to the AMA clinical vignettes since 1991.
When IGRT is performed during treatment, this same code is used with the treatment codes when a CT is used for target localization. This is ordered by the physician and then performed by the therapists prior to treatment. Once the therapists have completed the CT procedure making the appropriate shifts, the physician will review these in near real time prior to the next treatment.
Anytime there is a major discrepancy, the therapists will stop and call the physicians to the console for review prior to treatment to determine the major issue with the localization. Supervision Level 2 applies:3 "Procedure must be performed under the direct supervision of a physician. Direct supervision in the office setting means the physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed."
A stereoscopic kilovoltage (KV) imaging system was introduced as a localization standard, but there was no code to represent the procedure. In January 2005, CMS accepted the request of American Medical Accounting and Consulting Inc. (AMAC) and assigned HCPCS code C9722.
Since this was a "C" code, only hospitals could use this HCPCS code. In 2006, CPT code 77421 (stereoscopic X-ray guidance for localization of target volume for the delivery of radiation therapy) was developed and HCPCS code C9722 was deleted. The CPT code 77421 KV or megavoltage (MV) is used with an electronic portal imaging device (EPID) unit which uses MV and normally is used with some type of implanted markers. The same ordering and documentation is required as discussed with CT above.
Since 2007, this code clearly stated that the physician must review the images or shifts "prior" to the treatment. In spring 2010, society documentation stated it can be reviewed by the radiation oncologist prior to the "next" treatment. Supervision Level 2 applies (see above definition).
A new target localization code, 0197T (intra-fraction localization and tracking of target or patient motion during delivery of radiation therapy-e.g., 3-D positional tracking, gating, 3-D surface tracking-each fraction of treatment) was published in 2009 as an AMA Class III CPT code.4 A complete definition and clinical vignettes were later published by the AMA in 2010. This code was introduced in 2008 but effective for reporting in 2009. 0197T may be used for several different types of procedures.
Category III code coverage and reimbursement is established via the various CMS Local Coverage Determinations (LCDs) so the coding applications remain variable in different parts of the country. The recognition of 0197T as a reportable event has gained acceptance by many providers and payers and will likely become a standard Category I CPT code in the future.
The Class III CPT code 0197T can be used for gating using a system to allow for organ motion (not breath holds) for lung and abdominal areas. This code also is for intra-fraction where, in one case, electronic transponders are inserted in and/or near the tumor allowing for non-imaged tracking of the tumor location. This also can be accomplished with 3-D surface tracking. The recording of the tracking and motion must be ordered by the physician and performed by the clinical staff and documented.
Clearing up confusion
One area of confusion in the radiation oncology community was how to use the new target localization procedures (76950, 77014, 77421, and 0197T) and code them correctly. Even the government was confused. Guidance codes have a technical component (TC) and a professional component (PC = modifier 26), with the exception of port films. According to CMS, if the physician does not complete his review during or after the procedure, the TC may be charged but not the PC. For IGRT and target localization procedures, guidance can be performed using markers, the tumor, or bony anatomy.
(Click image to view larger photo.)
Clinical staff can confuse payers by using vernacular specific to a manufacturer's name for a device-for example, the onboard imager (OBI). Clinicians will refer to the IGRT procedure as OBI when the actual OBI is capable of performing KV images, CT images, and fluoroscopy. The previously listed CPT procedure codes follow the federal supervision guidelines and the "technical" portion is regulated by these guidelines.
Port films, CPT code 77417, are technical codes and have no professional component or payment associated with them. The compensation for the radiation oncologist is considered to be included in the professional management code-for example, 77427 (radiation treatment management, five treatments). The radiation oncologist orders the port film procedure. The therapy staff performs and documents the procedure and selects the appropriate CPT code, 77417, for reporting. Port films may be ordered and performed many times during the course of treatment by the radiation oncologist as medical necessity dictates. Once the films are produced, the physician will review them and sign off on the film. The Medicare regulations concerning this particular procedure allow reimbursement for one film per week.
All IGRT procedures must be charged under the "rendering physician" who was present in the cancer center that day. The above table is an example of payment for the IGRT and target localization codes. Please note the outpatient prospective payment system (OPPS) for hospitals "packages" the codes and the status indicator code is "N." This means you must bill the procedure, and the additional value is added into the treatment codes when combined on the same claim. If all hospital-based cancer centers stopped billing these IGRT and target localization procedures with the treatment, the payment rates for treatment delivery would drop dramatically. The treatment delivery codes approved for IGRT and target localization are 3-D conformal treatment codes 77413-77416 and IMRT 77418.
1. All AMA class 1, 2, and 3 codes are copyrighted and property of the American Medical Association. All rights reserved.
2. CMS. www.cms.gov/manuals/downloads/clm104c13.pdf and www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx
3. CMS. Supervision level description:
1. Procedure must be performed under the general supervision of a physician. General supervision means the procedure is furnished under the physician's overall direction and control, but the physician's presence is not required during the performance of the procedure. Under general supervision, the training of the non-physician personnel who actually perform the diagnostic procedure and the maintenance of the necessary equipment and supplies are the continuing responsibility of the physician.
2. Procedure must be performed under the direct supervision of a physician. Direct supervision in the office setting means the physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed.
3. Procedure must be performed under the personal supervision of a physician. Personal supervision means a physician must be in attendance in the room during the performance of the procedure.
9. Concept does not apply.
4. Category III codes are established by the AMA as temporary codes for emerging technology services and procedures and are released semi-annually by the AMA. Codes in this section may or may not receive a Category I CPT designation and are converted or archived no later than five years from the first publication date.
James E. Hugh III, MHA, CHBME, ROCC®, is senior vice president of American Medical Accounting and Consulting Inc. (AMAC®), Marietta, Ga.