Reimbursement for new RT lags behind implementation

ABSTRACT: Health policy expert cites challenges in placing a monetary value on new radiation-based medicine.

HOUSTON-Advanced applications, such as image-guided radiation therapy (IGRT) and

stereotactic body radiotherapy (SBRT), are being rapidly deployed in radiation oncology. But securing reimbursement rates for these sophisticated technologies is a sluggish process, according to a presentation at the 2008 American Association of Physicists in Medicine (AAPM) meeting.

New devices in the market include tumor tracking, surface tracking, respiratory gating, and 4D radiotherapy, said Najeeb Mohideen, MD, a radiation oncologist who co-chairs the Health Policy Committee for the American Society of Therapeutic Radiation and Oncology (ASTRO), and serves as a liaison between AAPM and ASTRO.

“Most new devices are launched without dedicated codes,” Dr. Mohideen said during his talk, where he outlined the process and challenges of the valuation of new technology codes. “It takes time, data, and a significant effort to garner new codes, influence coverage policies and technology assessments, and drive appropriate payment.”

The bane of bundling

While technological advances in treatment delivery-eg, intensity-modulated radiotherapy (IMRT), IGRT, proton beam therapy-may be highly effective, they are also expensive. This poses a dilemma for the radiation oncologist who is expected to deliver quality care while reining in costs. As an example, Dr. Mohideen cited the combined OPPS [outpatient prospective payment system] and Medicare Part B payments for IMRT (CPT 77418), which ballooned from $318 million in 2003 to $820 million in 2006.

Even when new CPT codes are issued (for IGRT, for example), they may be bundled into hospital APCs [ambulatory payment classifications] rather than paid separately.

“Prior to 2003, we only had a code for ultrasound-based IGRT,” Dr. Mohideen told ONI. “We now have codes for stereoscopic x-ray-based, ultrasound-based, and CT-based IGRT. In addition, we also have codes for SBRT. However, to reign in the costs, Medicare has bundled procedures like IGRT, into existing APC codes for treatment delivery in the hospital outpatient setting.”

Slow progress

The path to reimbursement for new codes is a complex one, said Dr. Mohideen, who practices at Northwest Community Hospital in Arlington Heights, Illinois. Every approved medical procedure is described by a 5-digit CPT code that the American Medical Association develops, owns, and maintains, he said.

In order for new-code approval, the AMA’s CPT editorial committee requires a clear presentation on the new medical procedure, evidence of its value, and how it differs from existing procedures.

The valuation of new and revised CPT codes is based on recommendations to CMS from the AMA and the Specialty Society Relative Value Scale Update Committee (RUC).

Dr. Mohideen explained that in the Medicare Physician Fee Schedule, physician work is valued on a relative scale that takes into consideration procedure time, intensity, and effort. The technical reimbursement is based on the valuation of nonphysician clinical labor (medical physicists, dosimetrists), supplies, and equipment costs. The process to obtain a new code-from CPT application to RUC valuation and eventual payment-can take up to 2 years, Dr. Mohideen said.

New technology reimbursement is also stymied by lack of published data (see “Proton beam RT not exempt from evidenced-based medicine,” ONI, July 2008).

As in other specialties, Dr. Mohideen said, radiation oncologists should gear up for increased scrutiny: Stringent review comes before and after new CPT codes are assigned. Issues to keep in mind are utilization rates, the technology’s impact on work, and cost-effectiveness, as well as long-term outcomes and quality. Dr. Mohideen warned that payers are looking at new technology outcomes to see if they demonstrate superiority over conventional, less expensive alternatives.