ROCR FAQs

Education
 

What is ROCR

The ASTRO-proposed Radiation Oncology Case Rate (ROCR) program represents a legislative initiative to reverse disastrous Medicare payment trends that are expected to continue. ASTRO believes ROCR represents the best chance to secure long-term rate stability and continue to deliver cutting-edge care to our patients close to home.

Check out this article and recorded webinar to learn more.
 

How has ROCR changed since it was first introduced in May 2024? 

Revisions to the ROCR Act are the product of feedback and discussions with stakeholders throughout the radiation oncology community, as well as the active input of our Congressional champions. HP/GR leaders and staff have been heavily engaged in these complex discussions, working to secure support for ROCR from the radiation oncology community. Below is a list of the key enhancements, which we believe will build that consensus:

• Clarifying exclusions.
• Matching the process for including previously excluded services to the inclusion process for new technology, including language ensuring sufficient reimbursement for newly included services.
• Extending the period from 10 to 12 years before new tech or excluded services could potentially be included into the base rates.
• Creating a transitional payment period for adaptive radiation therapy to ensure billing can continue until a new code is developed.
• Enhancing accreditation through increased incentive payments, new quality standards, and a revised exemption for limited resource practices.

In particular, the revisions strengthen ROCR's accreditation component, enhancing a radonc-driven approach to quality in sharp contrast to the costly, flawed, largely irrelevant MIPS program. The new "limited resource" exemption, to be defined by the Secretary with stakeholder input, narrows the broad "small practice exemption" and better ensures that the exemption applies only to those clinics that truly need additional support. Of note, more than half of all ASTRO/APEx accredited centers are single-linac centers, demonstrating that may small practices have the resources and capacity to achieve accreditation, even without financial incentives. These practices, and others like them, should receive a greater reward for their commitment to quality and safety. New quality standards will help ensure that technical capabilities are consistent with clinical utilization and will be developed through a transparent and inclusive process with stakeholder input to ensure balanced recommendations.

Where can I find more information about ROCR?

ASTRO’s website has a variety of tools including several webinars, policy and technical documents. Practices are encouraged to review these materials and submit questions.

Providing Feedback
 

Is there an opportunity for public comments?

Yes, ASTRO welcomes feedback on ROCR! We want to hear about the model's potential impact on your practice and the patients you care for. Please submit comments. 

Is there a timeline for ROCR?

With the March 2025 reintroduction, it is ASTRO's goal to secure passage of the ROCR Act before the end of the year. Once enacted, there will be a one-year planning period in which CMS will promulgate regulations related to implementation. During that time, the radiation oncology code set will be frozen to ensure a smooth transition from the existing payment system to ROCR. ROCR then will be effective one year after the enactment date, ideally in 2027.

Ins and Outs
 

Why are proton therapy, brachytherapy and radiopharmaceuticals not included in ROCR?

Proton therapy treatment delivery codes (77520-77525) are currently not valued under the Medicare Physician Fee Schedule. Payments for proton therapy services are instead determined regionally by each Medicare contractor and vary significantly. Additionally, the volume of traditional Medicare patients treated with proton beam therapy is lower than other modalities. These factors make it very challenging to appropriately value the service within an episode-based payment model.

The delivery of brachytherapy and radiopharmaceuticals are also lower volume services, but they are valued under the Medicare fee schedule. However, the current rates undervalue the services delivered. Therefore, including these services in an episode-based payment model based on recent reimbursement data would only exacerbate current concerns regarding the undervaluation of these services.

These and other radiation therapy services could be included in the model in future years as increased utilization and stable pricing develop.

Can you explain the provision that allows adaptive to be billed with a modifier? 

Currently, there is not a CPT Code associated with Adaptive Radiotherapy (ART), and therefore CMS has not valued this service. ASTRO recognizes that use of ART is growing, and we believe that the work involved should be separately billable as part of ROCR to encourage continued use of the technology when it is medically necessary. In the revised ROCR Act, a transitional payment is established that allows for a separate payment for ART using a modifier both of which will be determined by the Secretary of HHS. Below is the list of code eligible for the appended modifier:

• 77295 - 3-dimensional radiotherapy plan, including dose volume histograms
• 77300 - Basic radiation dosimetry calculation, central axis depth dose calculation, TDF, NSD, gap calculation, off axis factor, tissue inhomogeneity, factors, calculation of non-ionizing radiation surface and depth does, as required during course of treatment, only when prescribed by the treating physician
• 77301 - Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specifications
• 77338 - Multi-leaf collimator (MLC) devices for intensity modulated radiation therapy, design and construction per IMRT plan
• 77334 - Treatment devices, design, and construction; complex (irregular blocks, special shields, compensators, wedges, molds or casts)
• 77293 - Respiratory motion management simulation

The transitional period will end when a CPT code is established for ART. Twelve years after the establishment of a CPT code for ART, consideration could be given to incorporating ART into ROCR case rates, but with significant stakeholder input and adequate valuation.

Is there a timeline for when new technology will be included in ROCR case rates?

It is critical that there be sufficient opportunity for new technology and services to mature in the radiation oncology marketplace before inclusion in ROCR case rates. Beginning on the date that a Category 1 CPT code is assigned to new technology, there will be a 12-year period in which the services is paid fee-for-service. After that 12-year period, new technologies will only be considered for inclusion in ROCR if there is broad clinical evidence, market penetration, and stakeholder consensus for including the new technology in ROCR case rates.

Why are PPS Exempt Cancer Hospitals excluded from ROCR?

In 1983, Congress established an exemption from the Inpatient Prospective Payment System for cancer hospitals that met three criteria: 1) be designated as a comprehensive cancer center (CCC), 2) be organized primarily for treating and researching cancer, and 3) show that at least 50% of its total discharges had a principal diagnosis of cancer or other neoplastic disease. Today, 11 PPS-exempt Cancer Hospitals (PCH) exist.

In 1999, the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act (BBA) passed requiring the Secretary of Health and Human Services to determine Outpatient Prospective Payment System (OPPS) payments for cancer hospitals based on their pre-BBA payment amount. So, while PCHs are not expressly excluded from the outpatient PPS, they receive transitional outpatient payments (TOPs) to maintain their pre-BBA payment amounts.

Because the PPS Exempt Cancer Hospitals are PPS Exempt and paid outside of the MPFS and the OPPS, they are effectively part of a unique Medicare payment system and cannot be included in other payment programs, such as ROCR.

Does ROCR apply to freestanding centers?

ROCR applies to both freestanding and hospital outpatient-based radiation oncology departments. The case rates associated with ROCR are based on historical hospital outpatient rates, rather than freestanding rates, that have seen significant declines in recent years.

Savings
 

Why does ROCR have to generate savings? Hasn’t radiation oncology been cut enough over the last decade?

Congress is operating under pay-as-you-go rules, making it challenging to pass any legislation that does not reduce federal spending, particularly in the health care policy space. Therefore, to secure Congressional support, ROCR will have to demonstrate a modest amount of savings to the federal government.

In ROCR, ASTRO estimates savings to be less than what is likely to happen if current payment and hypofractionation trends continue. How does this agree with the ASTRO Work Force Study which predicts RVU stability in future years?

Both ROCR and the Work Force Study considered the same hypofractionation assumptions. However, the ROCR analysis includes impact assessments of all payments, not just work RVUs. The Work Force analysis only considered work RVUs. ASTRO’s analysis indicates that aggregate payments inclusive of professional and technical payments will decline through 2030, owing to greater sensitivity of technical payments due to hypofractionation.

What are the national case rates based on?

The national case rates are based on the M codes for the professional component (PC) and the technical component (TC) of each of the 15 disease sites for the RO Model that CMS issued in the 2022 MPFS final rule. Under the RO Model, CMS determined that HOPPS rates were more accurate for radiation oncology services, so the Agency based the M codes on HOPPS data. ASTRO replicated the methodology and found that those case rates were reasonable and trended them forward to 2024 for ROCR.

How will ROCR ensure stable payments into the future? What stops CMS from pushing back?

ROCR’s set base rates and inflationary updates will help ensure stable payments in future years. By making ROCR law, CMS will have much more limited authority than it does currently under the MPFS and HOPPS to adjust radiation oncology payment rates. As long as radiation oncology participates in Medicare, the specialty will be subject to government decision making on health policy, requiring constant advocacy.

Episode of Care
 

How does ROCR handle incomplete courses of care? For example, if a treatment plan is developed and the patient starts receiving treatment but then passes away before the last treatment is administered?

A ROCR case rate is paid at two points during the course of treatment. The first half of the payment is made when both the treatment plan and the first treatment delivery take place. The second half is paid at the end of the course of treatment or at 90 days, whichever comes first. In circumstances in which a patient is unable to complete treatment, the full case rate (both payments) will still be paid. However, the ROCR case rate will not be paid when the treatment plan is completed but the patient is never treated. The work associated with cases that are never treated will be paid FFS.

What other disease sites are paid like this? 

The ROCR concept builds off previous payment reform initiatives, such as the End Stage Renal Disease (ESRD) Prospective Payment System (PPS). Under the ESRD PPS, federal law requires a bundled payment to ESRD facilities (including drugs, labs, supplies, and capital costs) for renal dialysis services furnished to Medicare beneficiaries for ESRD effective Jan. 1, 2011. Correlations can also be drawn between ROCR and other Center for Medicare and Medicaid Innovation (CMMI) episode-based payment models, such as the Better Patient Care Initiative Advanced and the Comprehensive Joint Replacement Models.

How would ROCR deal with multiple treatments within a 90-day episode? For example, a metastatic case where several palliative sites may be treated over a short period of time. 

The ROCR case rates for bone metastasis and brain metastasis cases are inclusive of payments made for all services during a 90-day period, including services for treatment of multiple sites at different times during the 90-day episode timeframe. The case rate payment therefore represents a blended average of single-site and multiple-site palliative episodes and would provide reimbursement when multiple sites are treated during the 90-day period.

Payment Methodology and Billing
 

How does ROCR prevent future cuts?

ROCR is designed as a separate payment program under traditional Medicare. As a separate payment program, ROCR is designed to live in perpetuity, but has flexibility to shift services in and out of the program through rebased and revised payment methodologies. The model is rebased at five-year intervals. However, a guardrail will be implemented through statute that prevents the rebased rates from decreasing by more than 1% in any one rebasing period, effectively stabilizing future payments.

Would ROCR give practices the flexibility of submitting charges for consultation and simulation if both were done on the same day? 

All evaluation and management (E/M) codes associated with the initial consult would continue to be paid FFS. Simulation services are included in the ROCR case rate.

ROCR generates savings off the Technical Component payments? Won’t that make it less desirable for hospital-based practices?

While ROCR does generate the bulk of its saving from TC payments given the large proportion of radiation therapy services payments made up by TC payments, the reductions in TC revenue likely are less than what is expected if current hypofractionation trends continue. Hospital settings are already seeing declines in TC revenue as a result of hypofractionation, which likely will become more significant unless a new payment program like ROCR is implemented.

Will practices still have to bill CPT codes along with ROCR M codes as part of the claims submission process?

As part of ROCR implementation, CMS will outline the claims submission process. It is likely that CMS will seek to monitor ROCR by requiring the submission of CPT codes, in addition to M codes. This was the plan under the RO Model, and we anticipate there will be a similar requirement under ROCR as well.

How are payments for professional and technical services split?

Professional services and technical services are paid separately under ROCR. Similar to the RO Model, ROCR includes a Professional Component (PC) and Technical Component (TC) payment for each of the 15 disease sites. 
The PC and TC base rates are based on the M Code rates that CMS established in the 2022 Medicare Physician Fee Schedule (MPFS). Those rates were based on radiation oncology payment data under the Hospital Outpatient Prospective Payment System (HOPPS) between 2017-2019 and trended forward to 2024. The Centers for Medicare and Medicaid Services (CMS) uses HOPPS data because the Agency recognizes that the payment data under HOPPS better represents the cost associated with delivery of radiation therapy.

A geographic price cost index (GPCI) adjustment is made to the case rates to account for variation in costs. Below are charts detailing the PC and TC base rates for practices located in the New York City suburbs and in Alabama for each disease site:

*It should be noted that these rates do not include recent changes to the payment methodology including the extension of the discount factor over a period of ten years, rather than five, and the revised accreditation incentives. 

How would you handle payment for the initial code, but the patient receives no treatment or treatment terminates after the first fraction?

For those cases in which a course of treatment is planned but there is no treatment delivery, services that are provided will be paid under the current fee for service payment system. However, cases in which a treatment plan is developed, and one fraction of the treatment is delivered trigger the ROCR case rate, the first bundled payment will be issued. The second portion of the ROCR case rate will be issued even if the patient does not complete treatment.

Would there be a way to bill for different treatment planning for the same treatment service? For example, 3-D vs. IMRT treatment planning for SBRT on CyberKnife vs. traditional linac?

ROCR is modality agnostic so you will not be able to bill for different types of treatment planning associated with SBRT. The cost associated with different types of planning services are already included into the case rate for each related disease site.

Health Disparities and Quality Care
 

What triggers the HEART Payment and how will it be implemented?

A Health Equity Achievement in Radiation Therapy (HEART) payment of $500 is added to the Technical Component payment when a Medicare beneficiary affirmatively responds to the following question:

• In the past two months, has a lack of reliable transportation kept you from medical appointments, meetings, work, or from getting things needed for daily living?

Practices will use a Z-code to trigger the HEART payment. The HEART payment will not duplicate other transportation benefits provided under Medicare or Medicaid and will be subject to program integrity rules to prevent abuse.

ROCR incentivizes practice accreditation. Which accreditation standards meet this requirement and will my practice need to complete accreditation before ROCR launches?

In the first three years, ROCR provides a 1% update to the Technical Component payment for practices that either have accreditation or are actively working toward accreditation. The ASTRO APEx Program, the ACR Radiation Oncology Accreditation Program, and ACRO Accreditation Program would meet this requirement. After the first two years, the ROCR methodology applies a -2.5% reduction to the technical component payment for practices that are not accredited by one of the three accrediting bodies.

Practices with limited resources, as defined by the Secretary, will receive a 0.25% increase to their technical payments if they complete an audit that demonstrates attainment of quality standards. These same practices will not be penalized if they do not pursue an audit.

Other
 

If this fails what are the long-term consequences from CMS and the AMA RUC?

Radiation oncology will continue to advocate with CMS and Congress for fair Medicare payment policies for radiation therapy services, regardless of the outcome of ROCR. Additionally, ASTRO will continue to work with our valued partners at the AMA, including through the CPT and RUC process, and across the House of Medicine to support fair payments for all physician services, including the development and valuation of existing and new radiation therapy services.

However, it is expected that radiation therapy will experience continued payment cuts due to anticipated changes to the value of key radiation oncology treatment delivery codes and modifications to the Practice Expense methodology which are expected in this summer's MPFS proposed rule. Providers must understand what may be coming:

• Financial Implications: Shifts in reimbursement rates, which could affect the financial stability of practices, particularly those in underserved areas.
• Operational Adjustments: If reimbursement rates do not adequately reflect the cost of treatment, some practices may struggle to offer certain services, potentially limiting patient access to the latest advances in radiation therapy.

These policy changes in combination with CMS' focus on policies designed to support primary care and other health care services at the expense of capital-intensive specialties like radiation oncology will exacerbate the unstable rate setting environment that radiation oncology has experienced over the last decade. For these reasons, ROCR serves as an opportunity to secure rate stability and protect access to care.