# Current Practices in, Reimbursement Opinions About, and Clinical Indications of Adaptive Radiation Therapy: Results From the American College of Radiation Oncology Survey

## TL;DR

This survey explores how radiation oncologists use adaptive radiation therapy and their views on billing and reimbursement for this treatment.

## Contribution

The paper presents the first published survey on ART clinical practices and reimbursement opinions in the U.S.

## Key findings

- Most respondents believe ART should be reimbursed more than standard treatments.
- A majority support the creation of a new billing code for ART.
- ART is used across various treatment types and is perceived as more complex than standard therapy.

## Abstract

Introduction: Adaptive radiation therapy (ART) is generally defined as adjusting radiation dose delivery based on changes observed in the tumor or surrounding normal tissues during the course of treatment. Improvements in dosimetry with ART have been widely reported in the literature, in addition to the increased costs attributed to increased physician time and capital investment. ART utilization has been steadily rising, now with multiple available treatment platforms, but there is no generally accepted guideline for proper billing and reimbursement. No specific billing code for ART is currently available. Considering the heterogeneity of billing practices and limited published data on utilization trends, the American College of Radiation Oncology (ACRO) Government Relations and Economics Committee developed a survey to understand current clinical and billing practices while gauging the opinions of the community about appropriate reimbursement.

Methods: A two-part 21-item questionnaire was developed by ACRO and distributed amongst its members who are practicing attendings. The first section was intended for all attendings, including non-users of ART, and focused on opinions surrounding reimbursement, while the second section was meant only for ART-users, focusing on current billing practices and clinical utilization. Responses were collected between January 27, 2025 and April 1, 2025 and responses are reported with frequency counts and percentages.

Results: A total of 123 responses were collected, 51 were ART-users. A majority of respondents felt that a new billing code for ART should be developed (n=106; 87.8%) and a majority of respondents (n=101; 82.1%) either agreed or strongly agreed with the statement “Adaptive RT treatments should be reimbursed more than standard RT treatments.” Users are treating the full spectrum of disease with ART and using it for standard fractionation, hypofractionation and Stereotactic Body Radiation Therapy (SBRT). Attending physicians were almost universally involved in daily contouring for target volumes (n=46; 93.9%). Most users felt that their ART cases are generally more complex compared to non-ART cases (n=41; 83.7%) and proceeded with adaptation due to either changes in tumor volume (n=44; 89.8%) or changes in organs-at-risk (OARs) (n=40; 81.6%). Billing practices varied among ART-users and many respondents were unaware of which billing codes were being utilized (n=29; 59.2%).

Conclusion: This survey represents the first published material on the current clinical landscape and reimbursement practices of ART. ART is being used in many different ways and while current billing and clinical practices vary, the general opinion within the radiation oncology community is that ART should be reimbursed more than standard radiation treatments and we could benefit from the development of a unique billing code.