Best Practices for SGRT Billing

I’m Sally Eggleston. I work for Radiation Business Solutions. I’ve probably talked to quite a few of, if not you, somebody in your system. We assist Vision RT’s customers with reimbursement questions and payer problems. We’ve been in the business over 22 years with radiation oncology. It is our passion. It’s what we do. We’re a full revenue cycle, but we like to help people. We own and operate and manage centers also, so we understand the pains and what you guys go through on every day, and radiation oncology is really at a very important time right now. So one of the things you will hear me preach is continue to fight and work with these payers.

Just a small disclaimer: your practice is your practice. You need to do what you feel right and document the heck out of everything. So this is what happened to us in 2026. These are the descriptors. When you look at 77412, it specifically says there are different caveats. There’s either multiple isocenters, or the single isocenters with active motion management, which is what a lot of what we’re talking about today, or total skin, or mixed electron photon. So one of the things that I’m going to talk about here shortly is about the fact that there are so many variables that are in there. And this is the payment rate that we’re looking at. The top is the Medicare physician fee schedule, which would be freestanding, and below that would be the hospital outpatient. And you can see that there are definitely discrepancies in there, and that’s one of the things that we’ve got to get addressed.

Probably one of the surprisingly biggest issues that we hear people talking about is this 77387, and I don’t really understand it, but hospitals and coders are really having a problem with that from the standpoint of, they don’t understand it. They don’t believe it’s still billable. They think it is packaged in the treatment delivery, which it is on the technical side, but it’s not on the professional side. Your physicians should be billing the 77387 if they are doing anything such as cone beam CT, SGRT, and looking at images, stereoscopic, any of those. So, if you’re having issues with your system or somebody with that, please reach out to us because that is craziness for our physicians to not get RVUs and payment for that code on a daily basis.

So some of the common questions we see are that, can we do it? Yes, you can. Let’s get that one going. Active motion management: whenever those CPT codes had the new descriptors, the first thing we did was look at what the AMA’s and the CPT definition was, and if you read that, it clearly states surface guidance in there. It says, example: intra-fraction motion, surface guidance to monitor the target or organs at risk during the breathing cycle. Example: it minimizes organ motion, allows more accurate delivery to mobile targets. It’s a technique that can provide gating using the body surface contouring as a surrogate for internal target motion, using the surface as a surrogate for internal motion. So that solidified to a lot of people like Dr. Jones and to us as we read it, that surface guidance is in the descriptor. It accounts for active motion management. It is billable under the 77412.

I’m not going to talk a lot about medical necessity because Dr. Jones did an amazing job with that. That is always the case. Documenting medical necessity from the physician’s standpoint—I can’t tell a physician how to treat a patient. None of us can in here. Only a radiation oncologist makes that decision. So it is up to them to document why they are doing active motion management with whatever technology they’re utilizing, and in this case, SGRT, through Vision RT. So, those orders must be in there, and a lot of this when it comes to commercial payers, is about that documentation and what you say to get your authorization, and we’ll talk a little bit about payer issues in a minute. So it does need to be patient-specific. You can have a rather canned paragraph, but dropped in patient-specific information is strongly encouraged.

And the patient must be monitored during beam-on. Surprisingly, we still get asked that question, too. So it’s not about setup, it’s about monitoring during beam-on, and we just had the conversation; that was straight from Emilio from ASTRO, who is really championing on the coding side for all of us that surface guidance does qualify for active motion management under 77412. There’s that question over and over again. Yes, it does. It’s one of several. So that’s the other thing, right? I’m on an island here. It’s not just one technology, it’s more than one. They’re very clear with that. But Vision RT definitely hits the mark.

And this utilization question continues to come up. You just heard what Dr. Jones’ was. And the way the utilization—the reason that comes up—is because in the proposed rule and in the final rule, there were percentages of how much percent of the Level One, Level Two, and Level Three treatment delivery that was expected. And they do that because they have to do that because there’s just one bucket of money for everything under the Medicare physician fee schedule, and they have to allot these dollars of how they think it will work, and that’s how they decide on payment. And that’s why we saw payment fluctuation from the proposed rule to the final rule.

So those percentages are in there because of that, but does that mean that’s what you should do or where you should be or that you should worry about that? And our response to that is always no. And when I read that 77412 descriptor, how would they even know if you were a center in a rural area who treated 50% of their patients with bone mats that have more than one isocenter versus you doing surface guidance, active motion management, right? A payer’s not going to know that. CMS is not going to know that. So their data mining of utilization is going to be all over the place strictly because of the wording in that descriptor. So, keep that in mind. It’s difficult whenever there has to be a decision tree for you to make for your therapist to figure out what code it should go to, right? At the very beginning, that’s what we utilized. It worked well, but that’s craziness, right? That’s where we end up having to do.

We do have resources for Vision RT customers to help you on the authorization side, appealing a claim. Radiation oncology has to stick together right now. This is not the time to roll over or allow your physician to say, “EviCore, I don’t want to do a peer-to-peer.” This is not the time to do that. We’re really at a crux here. It’s not just the freestanding centers that are feeling this, but hospitals also. So it is definitely the time to band together.

When it comes to these codes, it’s difficult, and somebody asked the question, have you got any Medicare denials? Medicare is going to pay you most of the time for whatever code you send through. They don’t know what you did. It is an honor system, right? Which is why you document thoroughly. It’s why you put everything out there. Make sure that you’ve ordered medical necessity and you’ve documented what you’ve done. If Medicare does anything, it’s on the back end and they may say, they periodically look at a center and say, “We need 10 medical records to prove that you did this.” CERT audits and those type things.

When it comes to the commercial payers, different story. So because in the freestanding centers we had been utilizing G-codes for over 10 years, right? We’d been using G-codes for a long time. So in November, we’re calling commercial payers and saying, “We want to make sure you’re prepared. We’re going to not be billing these G-codes.” These are old CPT codes. They’re not new. I used these a million years ago. Dr. Tannahill’s talk really spoke to me yesterday because I’ve been saying that for a long time. We’re totally flipping back to the old school days, right? So when you have CPT codes that have been on a commercial payer’s fee schedule for a really long time, they just keep lowering what that payment rate is. And so what happened come January, yeah, they’re processing your new CPT codes, but the rate is really low. So there’s been a lot of battles to fight. There’s been updating your fee schedules.

The Medicaids, and I kind of laugh about this, and I’m not poking fun at ACRO, don’t think I am, because we work with ACRO and ASTRO to make sure that they are advocating on our behalf all the time. They put this list up on a webinar that they had last week. There were some duplicates on there. Well, this is how many payers and the states that they had been working with. We’re a revenue cycle company that has been in the business for 22 years. So we looked at our system. We had 741 payers in there. That’s a lot, right? So, this has been our problem. Freestanding centers, a lot of times, don’t have the manpower to go to those commercial payers, make sure the fee schedules get updated. Hospitals don’t pay attention, frankly. Right? So, sorry, but that’s the reality of the revenue cycle side in a hospital. And it’s really important right now for hospitals to be adjusting their charge master with these codes. Because that utilization, what the cost is, goes to Medicare, and we got to make sure we have that part right.

So there’s still a lot of work to be done. Every Medicaid in the United States has got a letter from ASTRO and ACRO and from us, and any place we have a client, we’re sending letters to the governors, to state officials, because Medicaids are state-run, and they’re not wanting to pay for these codes because they don’t know what to do with it. I’m not quite ready for questions. I just wanted to throw out, ASTRO did have a town hall Wednesday night. It was supposed to last an hour and a half. It just lasted an hour 15 minutes. It was pretty low-key. They explained what happened, what they’ve been doing, everything from their Hill day last week to working with payers to trying to get a fix or a change. I’ll be blunt, it doesn’t look promising. And the reason being because come July, our proposed rules are going to come out, and it’ll be interesting to see where our payment rates lie there. They did say very specifically, because somebody asked, “Are prostate patients 77470 level two?” The answer was yes. And then another physician on ASTRO chimed in and said, “But we need to keep in mind that if they have the technology and can provide active motion management, that they are 77412.” That came out of their mouths. Everybody heard it. Unfortunately, there was at the max, 110 people on that Zoom call, which is very disappointing to me for this industry. There again, now’s the time. We’ve got to band together. We’ve got to advocate.

The other thing that they stated on there was that they will be putting out a policy, but it probably will be the summer, which is rather unfortunate that we get the policy July, August. I figure they’re probably waiting a little bit for the proposed rule to come out there, too. But that was the latest and greatest from them. It solidifies what we and Vision RT have been telling their customers. That goes right along with what Dr. Jones said. If you have the medical necessity from the physician, you’re documenting it, then bill your 77412, your level three.

On some payer notes, UHC, they’re difficult. That’s just all there is to it. They are still wanting to deny a lot of prostate and brains, and we’re talking about getting the authorization up front. But they definitely deny for the first level, and you have to move on and keep fighting, which you can have a bit of success. eviCore did publish guidelines, so they become pretty clear. They consider peer-to-peer outside of anything that’s not on their covered diagnosises. ASTRO worked with them in early January on that, and most of the time, we can get 77412 approved outside of their diagnosises today. Carelon, which is a radiation benefit management company, all body areas are okay for 412, but based on individual plan guidelines, so you may have to argue some of those. Evolent denies head and necks, and their medical director told us that they have been instructed to deny prostate. So I don’t know, Dr. Jones, if you’re seeing that with any payers that Evolent is their benefit management company.

So we do have struggles, and some of these you are having to do peer-to-peers, your physicians are, but there again, don’t give up the fight. Keep after it, because it’s vital at this point in time. We’ve made strides with this 412 since January, I feel like, and ASTRO is helping along with that. So we don’t want to go backwards from that standpoint.

This transcript was generated using AI. If you note any issues, please email us at secretary@sgrt.org.