IGRT Supervision Guidelines Clarification:

On February 8, 2008, the Centers for Medicare and Medicaid Services (CMS) updated its manual instructions for the Outpatient Prospective Payment System (OPPS) through Transmittal 82 (Change Request 5946). Included in the update were instructions regarding coverage of outpatient therapeutic services furnished incident to a physician’s service. The updated coverage requirements have been controversial because they appear to be more restrictive than the requirements specified in long-standing Medicare regulations. They also have created confusion related to the requirements for physician supervision of diagnostic tests.

The purpose of this article is to clarify the CMS requirements related to the physician supervision of Image Guided Radiation Therapy (IGRT) in hospital outpatient departments and physicians’ offices. The CPT codes describing IGRT include 76950, 76965, 77417, 77421 and 77014. CMS guidance for the Outpatient Prospective Payment System (OPPS) that was issued through Transmittal 82 (Change Request 5946) did not change the physician supervision requirements for these IGRT codes. 

All the IGRT codes are considered diagnostic tests subject to the physician supervision requirements in the Code of Federal Regulations at 42CFR §410.32(b)(3). These requirements apply in both hospital outpatient departments and physicians’ offices. The regulation defines the levels of physician supervision for diagnostic tests as shown below. The IGRT codes assigned to a given level are listed in parentheses.

• 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. (76950 Ultrasonic guidance for placement of radiation therapy fields, 77417 Therapeutic radiology port film(s))
• Direct Supervision - means the physician must be present 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. (77014 Computed tomography guidance for placement of radiation therapy fields)
• Personal Supervision - means a physician must be in attendance in the room during the performance of the procedure. (76965 Ultrasonic guidance for interstitial radioelement application, 77421 Stereoscopic X-ray guidance for localization of target volume for the delivery of radiation therapy)

As shown above, CMS believes that codes 76965 and 77421require personal supervision. It remains the position of ASTRO that these codes should be subject to direct supervision and ASTRO continues to work with CMS to bring about the necessary changes in policy. In the meantime, ASTRO wants radiation oncologists to be aware of the current supervision requirements and to understand that services furnished without the required level of supervision are not covered under Medicare.