Reimbursement for the CyberKnife and TomoTherapy Systems
In the United States and around the world, healthcare providers that purchase capital equipment, such as the CyberKnife® and the TomoTherapy® Systems, generally rely on government and/or private third-party payors for reimbursement. Examples of these types of payors in the United States include Medicare, Medicaid, private health insurance plans and health maintenance organizations, which reimburse all or a portion of the cost of treatment, as well as related healthcare services. In other parts of the world, government health ministries or private health insurance companies typically develop payment rates for radiosurgery and radiation therapy, which vary by country, patient diagnosis and other factors. Regardless of geographic location, Accuray has a team of specialists available to answer your reimbursement questions, which typically involve the following three components:
In the United States, there are currently no national coverage determinations (NCD) in place under Medicare for CyberKnife or TomoTherapy treatment. Coverage criteria for treatment with the CyberKnife and TomoTherapy Systems are outlined in local coverage determinations (LCDs) or, in the absence of a formal policy, treatment is covered as long as it is considered reasonable and necessary. The most common indications covered by Medicare in local coverage determinations for robotic and non-robotic radiosurgery are primary and metastatic tumors in the brain, spine, lung, liver, kidney, pancreas, adrenal gland, prostate and other cancers in the setting of recurrence following conventional radiation. 3D conformal and intensity-modulated radiation therapy (IMRT) are generally covered for cancers of head and neck, lung, breast, prostate, brain, spine, liver, pancreas, kidneys, ovaries, bladder and other cancers appropriate for treatment with conventional fractionation.
Commercial payor coverage policies vary. Most cover robotic and non-robotic radiosurgery for tumors in the brain, spine and lung. Other indications, such as renal, liver, prostate and pancreatic cancers, are also covered by some national and local commercial payors. 3D conformal and IMRT are typically covered by commercial payors for the indications covered by Medicare.
Internationally, coverage for radiosurgery and radiotherapy varies from country to country.
In the United States, the codes that are used to report robotic radiosurgery treatment delivery are healthcare common procedural codes (HCPCS) G0339 for the first fraction and G0340 for fractions two through five. It is important to note that non-robotic systems can provide SRS/SBRT treatments; however, it would not be appropriate to use the robotic SRS/SBRT HCPCS codes (G0339/G0340). Instead, hospitals would use HCPCS code G0173 (Linear accelerator based stereotactic radiosurgery, complete course of therapy in one session) or G0251 (Linear accelerator based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, maximum five sessions per course of treatment) and freestanding centers would use Current Procedural Terminology (CPT) code 77372 (Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; linear accelerator based) or 77373 (Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions).
IMRT delivery is billed under Current Procedural Terminology (CPT) code 77418 (Intensity modulated treatment delivery, single or multiple fields/arcs, via narrow spatially and temporally modulated beams, binary, dynamic MLC, per treatment session). 3D conformal delivery is billed under Current Procedural Terminology (CPT) code 77413 (Radiation treatment delivery, 3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 6-10 MeV).
Both HCPCS and CPT codes are valid codes for payment under Medicare and are recognized by commercial payors for use in the hospital outpatient and freestanding center sites of service. Other codes are used to report treatment planning, dosimetry, treatment management, and other procedures routinely performed for treating radiosurgery or radiotherapy patients. Internationally, coding varies by each country.
In the United States, the majority of CyberKnife and TomoTherapy procedures are performed in the hospital outpatient department. Medicare payment for CyberKnife and TomoTherapy procedures delivered in the hospital outpatient setting is developed by the Centers for Medicare and Medicaid Services (CMS), which calculates rates based on costs submitted by hospitals to perform outpatient procedures. Payment for treatment with the CyberKnife and TomoTherapy Systems is also available in the freestanding center setting. The primary treatment delivery codes for robotic radiosugery (G0339 and G0340) are carrier priced under Medicare and vary when compared to the payment rates for these same procedures delivered in a hospital outpatient setting of care (parity, higher and lower). Medicare payment for IMRT and 3D conformal delivery in the freestanding center site of service are set nationally by CMS but are adjusted to account for geographic variations. Unlike in the hospital outpatient setting, imaging with IMRT and 3D conformal is paid separately, in addition to the codes billed for treatment planning, delivery, and management.
Commercial payors typically base payment on a percentage of billed charges, or on contracted rates, and may benchmark prices based on a percent of Medicare rates. State Medicaid programs develop payment policies independently and both coverage and payment will vary from state to state. Internationally, payment varies by each country.
Additional Reimbursement Support
If you would like additional reimbursement information (US or markets outside the US) for robotic radiosurgery or IMRT, please contact Accuray’s Patient Access Department at the following e-mail address: firstname.lastname@example.org. To ensure that our reimbursement experts from around the world provide you with accurate reimbursement information, please make sure to include in your e-mail the name of the country where the patient will receive treatment.