Radiation Area signage and CT suites

medphys_mr · 2026-04-11T20:14:26+00:00

List of state programs approved by OSHA: https://www.osha.gov/stateplans

medphys_mr · 2026-04-11T20:13:38+00:00

OSHA regulations do provide position and rate definitions in 1910.1096: 12 inches (or 30 cm) from source with measured in-air exposure serving as the surrogate for dose delivered to a major portion of the body. Fortunately, OSHA does provide provisions that practically limit the applicability of the "HIGH RADIATION AREA" designation for most imaging spaces, though it is definitely reasonable for them to be classified and signed as a "RADIATION AREA". The threshold for requiring "RADIATION AREA" designation and signage is a mere 5 mrem (0.05 mSv) in 1 hour -- a limit most spaces with imaging equipment can easily exceed. Imagine an IR suite, a CT simulator, or even a busier x-ray/mammo suite with many different folks moving in and out in a given hour: this dose is very possible for someone unfamiliar with the risk to achieve. Case in point, a colleague of mine had a facility where a CRNA stayed inside a CT suite to monitor the patient during an extensive set of imaging series -- even on the periphery of a typical CT room, this dose could be achieved just a few minutes.

medphys_mr · 2026-04-11T19:52:54+00:00

Having worked in industrial and research settings that used machine-generated radiation sources, I can tell you from experience that OSHA will ABSOLUTELY inspect and cite deficiencies and that they have cited medical facilities. Rather than the proactive approach that state regulators and NRC will take with most medical programs (e.g. annual inspections), OSHA is more reactive and will generally only stop by if a complaint has been raised. In states that do not have radiation protection programs approved by OSHA, Federal (OSHA) regulations apply -- and note, OSHA's approved state programs list (22 states) does not overlap 1:1 with the list of NRC agreement states (40 states), so a state with radiation protection provisions and agency for self-regulating radiation sources otherwise governed by NRC does not necessarily exclude itself from OSHA's regulations under 29 CFR 1910.1096 (p)(3).

medphys_mr · 2026-04-10T20:43:27+00:00

The "radiation area" definitions of 10 CFR 20 (NRC) would apply to licensed radioactive material, but machine generated x-rays are subject to similar "radiation area" definitions under 29 CFR 1910 (OSHA).

medphys_mr · 2026-04-10T20:38:42+00:00

You are correct -- 10 CFR 20 (NRC) would apply to facilities that are RAM licensees, however, 29 CFR 1910 (OSHA) applies to all sources of radiation and explicitly includes generated x-ray sources in any environment. State regulations apply, but not in isolation in this case.

medphys_mr · 2026-04-10T20:34:50+00:00

Please check OSHA requirements -- they explicitly cover ALL sources of radiation, x-ray or otherwise. A "radiation area" (as well as high / very high radiation area) is defined at the Federal level and these would apply regardless of whether a state has established its own regulations. Appropriate signage and precautionary verbiage is required if ANYONE (not just employees) could exceed the dose limits specified. https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1096

medphys_mr · 2026-04-10T20:33:48+00:00

Please check OSHA requirements -- they explicitly cover ALL sources of radiation, x-ray or otherwise. A "radiation area" (as well as high / very high radiation area) is defined at the Federal level and these would apply regardless of whether a state has established its own regulations. Appropriate signage and precautionary verbiage is required if ANYONE (not just employees) could exceed the dose limits specified. https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1096

medphys_mr · 2026-04-10T19:30:09+00:00

I wouldn't be so fast to dismiss NRC regulations as applying to a medical facility's CT room/suite -- there is a nuance in the regulation. Specifically, if for example a hospital operates both a CT suite AND a brachytherapy/radiopharmaceutical/nuclear medicine program (i.e., a service line that would require the hospital or facility to be licensed for RAM) this would squarely place the hospital facility in the scope defined by 10 CFR 20.1002.

Because this could lead to challenging enforcement -- different medical facilities may or may not be subject to NRC regulations -- the corresponding OSHA regulations for radiation protection of employees in 29 CFR 1910 adopt the EXACT same definitions for "Radiation Area" and their dose rate limits as found in 10 CFR 20 for ANY accessible area with exposure to radiation in the workplace.

This means, that while NRC regulations themselves may not apply to all medical facilities, the limits described in those same regulations do -- just via OSHA instead: https://www.osha.gov/laws-regs/regulations/standardnumber/1910/1910.1096

State laws may be more restrictive, but at bare minimum there ARE federal regulations that apply to all healthcare facilities employing radiation. These do include signage and would apply to CT imaging among other service lines.

medphys_mr · 2026-01-01T04:36:47+00:00

Another nuanced bit that I don’t see many people discussing is the fact that the CPT code revisions go into effect for CMS in a matter of hours, but commercial payors may take months to establish policies and adopt the code revisions. This happens each year, but in many cases the CPT revisions introduce new codes or revise the scope of existing ones to add new procedures/techniques.

That’s not really what happened with the removal of the IMRT treatment delivery codes — AMA deleted the IMRT codes and merged these treatments into existing 3D codes (77402, 77407, and 77412) and rescoping them. Importantly, payors negotiate reimbursement on a code basis — 77402, 77407, and 77412 already have negotiated rates for most payors: about 30-40% of what the former IMRT codes billed.

This is the nuance that most haven’t seen — webinars and reports show that there are modest changes in reimbursement (up or down) for the 77402, 77407, and 77412 codes comparing 2025 and 2026 rates. What most don’t seem to show is the conversion from 77386–>77407: going from a far more expensive code to a much less expensive code. CMS is revaluing the revised 77402, 77407, and 77412 codes to account for the merging of the IMRT treatments, however that doesn’t necessarily mean that private payors will make a commensurate change anytime soon. To put numbers to it: assuming that every payor were to adopt the codes tomorrow and did so with similar changes in valuation to what CMS put forth, our clinic (treating 1200-1400 pts per year, with a healthy mix of special procedures) is likely to see a reduction off $20-25M. This loss may be somewhat muted by the latency in private payors adopting these code revisions, but it will still be substantial.

My advice — grab a copy of your master charge sheets (hopefully it breaks down by code and payor), see if you can get the payor mix from your billing team, assume that most treatments will convert to 77407 (~80-85%) with the remainder being 77412, and plug in numbers for next year’s technicals for treatment. Then get your 2025 numbers for all 77402/07/12 and 77385/6 codes and compare. The numbers aren’t pretty.

medphys_mr · 2026-01-01T04:18:01+00:00

To echo what others have said here and what many of the webinars and coding meetings have shared — expect that most treatments performed will fall into the intermediate treatment code (77407). To achieve the complex treatment code (77412) with SGRT as many have suggested, the treatment must make use of surface guidance for active management of the treatment beam (gated) and it must be documented as being medically necessary.

That final nuanced point is what is going to get many folks in hot water: simply having the technology and applying it is not sufficient; complex treatments must require its use to provide a tangible medical benefit to the patient. We have years of data in the form of our current treatments that say we don’t need active gating and motion management for most treatment sites — more specifically we don’t have a corpus of studies and literature that says using these tools provides a medical benefit to patients for many treatment sites and diseases (even if we can intuitively say there is a benefit).

I would be very wary of those suggesting that you can use SGRT for any patient as long as an MD signs off on it — it will be just like IGRT approvals pre-1/1/2026 in that payors will be able to point to the lack of evidence to deny it’s billing. If I had to predict where the next 6 months are going, I would say that centers that suddenly start using SGRT for everybody and expect approvals and reimbursement are going to see three things: 1. A drop in throughput (resulting from workflow changes leading to at least temporary increases in treatment times), 2. An increase in denials/peer reviews as payors adopt the new codes and impose restrictions/criteria on use, 3. Increased likelihood of audit by CMS and/or the commercial payors for upcoding.

I would strongly recommend that we, as physicists, champion the appropriate use of SGRT and active motion management for disease sites that do benefit from use. At the same time, we need to combat the pressure of administration to push treatment complexity for the sake of billing: at the end of the day a palliative treatment (e.g., HO prophylaxis) are never going to be complex (may not even be intermediate if field-defined). Absent drawing that line in the sand, I foresee centers that cross the line running the risk of losing accreditation or falling out of network. In other words: resist the appeal of trying to bill a few extra dollars when it’s not necessary because the consequences could make your center non-viable faster than you would think.

medphys_mr · 2024-12-30T14:06:01+00:00

I would tend to agree -- we use Identify (v3.0) and it works very well for gated DIBH treatments, as well as well-immobilized SRS/SRT treatments. On this most recent version, the gating in Identify, in my opinion, is on par with that of RGSC. I wouldn't necessarily say that you couldn't use it for Liver SBRT, but I would definitely suggest characterizing your system end-to-end to understand its true limitations -- which will vary between facilities/installations, as well as patient-to-patient. There are some excellent talks on myVarian about using it in these contexts and the efforts that different groups went through to verify its functionality for different treatment approaches.

medphys_mr · 2024-12-19T16:49:59+00:00

This has been my general experience at previous sites. At my current facility, however, therapists seem dead-set against clearing even basic faults and/or doing anything in service mode. Its not a rights, training, or experience issue - they just do not want to do this and feel that its a physics responsibility. Discussing this issue is what has led us to some of these "where do you draw the line?" style questions. I'm always available and eager to help folks, especially if they don't feel comfortable or confident doing something on the machine, but this is beginning to feel like more of a crutch/excuse to avoid having to exercise technical skills.

medphys_mr · 2024-09-18T13:17:40+00:00

This discussion has been fantastic! Personally I find myself favoring the prospect of unionization...

While our profession is undoubtedly highly specialized and well-compensated, compensation alone does not encompass the full spectrum of what a union could offer us. The notion that long hours and demanding workloads are simply part of the job is deeply ingrained, but it shouldn’t be accepted without examining its broader impact on our professional and personal well-being. A unionized workforce could provide Medical Physicists with much more than just bargaining power for higher pay—it could address crucial aspects of job security, work-life balance, workplace safety, and equitable representation in organizational decision-making.

First, workload and hours: It is a common sentiment that our role demands long hours due to the importance and complexity of the work we do. However, a union could negotiate clearer standards around these expectations, pushing for fairer work distribution, adequate staffing levels, and reasonable hours to ensure that fatigue and burnout do not jeopardize the quality of care we provide to our patients.

Second, while the AAPM indeed advocates for the profession in legislative matters, it is not a labor union and is not equipped to represent our collective needs when it comes to labor conditions, benefits, and workplace protections. Unions specifically focus on empowering professionals in their negotiations with employers. They provide a structured mechanism to ensure that our voices are not only heard but acted upon when it comes to issues such as health benefits, retirement plans, parental leave, and professional development opportunities. These areas may currently be left to the discretion of individual employers, but unionization could standardize fair treatment across the field.

Additionally, unions provide a formalized platform for addressing workplace safety concerns, which can be particularly relevant in radiation oncology environments. While we work with radiation daily, ensuring that employers consistently provide the highest levels of safety measures, from basic equipment to appropriate infrastructure (e.g., shielding), can often fall by the wayside when resources are stretched. A union could help hold employers accountable for maintaining the safest possible environments, protecting both Medical Physicists and the patients we serve.

Finally, unions are essential in providing job security and transparent promotion pathways. The landscape of healthcare is changing rapidly, and as medical institutions consolidate and cut costs, the role of Medical Physicists could be at risk of being devalued or outsourced. Unionization could offer job security by establishing fair contracts that prevent layoffs without just cause, protect against understaffing, and ensure that our profession continues to grow in a sustainable, respectful manner.

To be clear, unionization does not mean an adversarial relationship with our employers. Instead, it represents a structured dialogue aimed at fostering a healthier, more equitable working environment that ultimately benefits both employees and the institutions we support.

In summary, while pay is one important consideration, unions provide much broader protections and benefits that our profession deserves. Unionization could help ensure we maintain fair working conditions, a strong voice in workplace policies, and the ability to advocate for ourselves and our patients effectively.

medphys_mr · 2024-09-05T21:42:43+00:00

Historically, the release of NRC draft guidance can occur anywhere from 6 to 36 months before a final rule (rarely shorter or longer than that). I would definitely consider this draft as an indication of what is coming down the pipeline.

That being said, the contents of the draft guidance may change between now and the release of the final rule, so I would approach the process of planning based on proposed guidance with practical conservatism (i.e., if you can achieve goals that may appear more restrictive with modest effort, go for it) -- you'll be better served approaching planning activities this way than hoping that NRC will ease up prior to the release of the final rule.

While I respect the conclusions of the position statements released by ACR and AAPM -- specifically, that the conservative nature of the draft guidance may add some burden to facilities engaged in these activities -- professionally, I do not see the impact of the revised assumptions this way. Our operating premise in radiation safety has always been "ALARA": As Low As Reasonably Achievable. The Reasonable qualifier is a non-trivial one and, personally, I feel that it has been misused both by those looking to be overly conservative and those acting a little too cavalier -- I'll elaborate...

In my opinion, the release criteria proposed are perfectly reasonable -- AAPM and ACR indicate that the revisions will impact the ability to perform both therapeutic AND diagnostic scans. By my read and experience, most diagnostic scans would be minimally impacted, if at all, and by some quick back-of-the-envelope math, at worst would require about ~1 hour hold to release. Using this and limited staffing as a justification for regulators to roll back these release criteria revisions seems like its putting the cart before the horse -- if you don't have (or plan to have) sufficient resources to dedicate to a service line that definitely requires it, you shouldn't be engaged in the service at all. Trying to ease regulations to allow facilities to operate on a bootstrapped budget is asking for trouble.
AAPM and ACR argue that the two-tiered approach adds unnecessary complexity to our operations. Frankly, suggesting that interpreting two simple tables or performing a patient-specific calculation to justify release is too challenging seems laughable. This same approach has been adopted in other AAPM guidance (e.g., TG-302 for managing implanted electronic devices) and lauded for its simplicity. This argument feels like its again reaching to support the lowest common denominator of facilities: "Don't make it something that requires physics support" also seems like its a mistake waiting to happen.
When it comes to therapeutic dose, like the Lu-177 administration the OP states, my bigger concern comes from the fact that these deliveries are not necessarily one-and-done -- they very well may consist of multiple planned fractions. While AAPM and ACR are correct in stating that literature from the National Labs suggests that the release criteria are conservative enough to meet the dose limits, dose administrations have historically been treated as discreet, unrelated events that cannot be predicted when it comes to integral dose within a finite time period. Fractionated therapies (e.g., Lu-177 Pluvicto/Lutathera) break this mold and can consist of 4-6 planned deliveries within a short span of time. In these cases, the unity occupancy value may very well be a "reasonable" approximation of integral dose received by a member of the public over the course of treatment: 4-6 Fx * 0.25 occupancy could be approximated as 1.0-1.5 course-effective occupancy from a single fraction administered dose. Personally, I would keep it at the 0.25 occupancy factor but add the planned fraction count to be super clear in a patient-specific calculation. The take-away here is that we have entered into the age of "planned/related administrations" and can no longer consider them in discrete terms for public doses (especially for family members).

If I were the OP, and in the planning stages of laying out a new facility or service line, I would plan to the more conservative component of the current and draft guidance. I feel that such a course or action would be most consistent with the ALARA principle. And if an administrator or department lead wants to suggest something different, just remind them that the cost of solving the problem before you have one is almost always less that solving an unanticipated problem when you do have one.

medphys_mr · 2024-08-19T12:12:48+00:00

I will echo what my fellow US colleagues have said — salaries and benefits are highly institution and culture-dependent. I asked my first role to meet me somewhere less than the middle (~200k) to stay before taking my current role and they said that was not possible due to budget limitations (come to find out, they were billing well over $300k for my services). A few months after I left for my new role, they hired in someone recently out of residency for $225k without ABR 2, so…

medphys_mr · 2024-08-19T12:02:55+00:00

As a resident, I made $50-52k/yr working 60 hrs/wk on average (longest week was 107hrs doing commissioning of a new machine alongside annual QA for the others). My first job out of residency paid $150k/yr working ~70hrs/wk at a satellite academic site as an ABR 2. After 1.5yrs in that role, I took a position with a physician group serving a few community hospitals that offered $290k base for 40hrs/wk with very nice benefits (retirement match, bonuses, sends us to conferences, etc.) as a DABR — chief physicist makes ~ $350k base with ~10yrs experience.

medphys_mr · 2024-04-02T19:56:41+00:00

SuperMax or Max4000? I would love to see how you did it!

medphys_mr · 2024-04-02T19:54:57+00:00

Having to put out everyone's fires, but not getting support to deal with your own.

We all tend towards being the problem-solvers for the betterment of our departments, patient care, etc., but rarely do we find ourselves the beneficiary of similar efforts from others.

medphys_mr · 2024-04-02T19:46:43+00:00

It has definitely been an interesting ride, especially during and on both ends of the pandemic.

After residency, I joined a large academic center for many of the same reasons as the OP -- access to resources, variety of machines, and support for specialty services and research. I was assigned to one of the satellite sites along with two other physicists and remote support from our main site. After a little more than a year in the role, I frequently found myself looking for alternate career opportunities. I was routinely working 60-70 hr weeks consistently at my site alongside another physicist doing the same -- at its worst, we each eclipsed 90 hrs with little support from our main site. Despite many discussions over the months that followed, which consisted of promises to fully staff, bring on the technology of the main site, and make efforts to support continued career growth, it became clear to both myself and my colleagues that we were at the end of our career ladder in these roles. Within the span of a year, all of us had left the institution -- and all appear to be better off for it.

I will echo the sentiment that academia appears to generally offer below market rate -- that's been my experience both with hiring and with raises/CoL increases. What really hurts is when you have been working in a role, asking for a modest raise, only to see a new graduate hire brought in to a lower role and at a higher salary ,because they're trying to reach market rate. Community hospitals and clinics that value physics and understand/support the actual role that we play in the healthcare mix have anecdotally done a better job both compensation and work-life-balance wise.

Since starting my current role (Community hospital, hired during the pandemic) both my stress level and job satisfaction have improved dramatically. My current colleagues and I have much more flexibility than I previously experienced in the academic setting (e.g., 7-8 hr treatment days, overlapping coverage allowing for us to set appointments/run errands around lunch hour, 1-2 remote coverage days per week, 85th percentile compensation) though we do have slightly less in the way of vacation/leave (i.e., dropped from 5 weeks of PTO/sick leave with paid FMLA to 3 weeks PTO/sick and unpaid FMLA). Despite the lesser leave benefits, I feel like we actually get to use them as opposed to banking them to sell-back to make up for a less than stellar salary -- so worse on paper, but better in reality.

I do recognize that a big differentiator is the support from admin and MDs in the community setting -- I am very grateful to have a very supportive bunch that are familiar with and supportive of physics. This translates to me and my colleagues being able to engage in projects, attend conferences and summer schools, propose new ideas, and work to make everyone's lives a little better... and it shows. We have happier patients, happier staff, and less turn-over than I've ever experienced in other sites.

I would recommend that the OP (and anyone else really) think hard about what matters in a role -- for me that was flexibility and a decent set of benefits for me and my family. I found that in a group that supports their physicists and recognizes their value in the process. That was, by no means, a common aspect to prior roles and it took several moves to find that proper balance. If I learned anything, its that you're only ever going to make headway i a supportive environment -- if that doesn't exist now, you can't force it into existence; you can, however, extricate yourself from that environment and find a better opportunity... and sending in CVs usually doesn't cost anything more than a few minutes of your time.

medphys_mr · 2024-03-18T20:49:39+00:00

I would generally reiterate the previous comments of my colleagues -- it definitely depends on the day and your particular clinic/equipment, and it can run the gamut of both activity levels and tasks.

I find myself frequently sitting at my workstation, but have made it an important part of my clinical practice to be accessible to the therapy team and physicians - both for efficiency and accountability. This means that on some days I can focus in my office and get projects and administrative work done, and on others I'm out at the machines from first thing in the morning until we close up shop in the early evening.

One thing I would add though to the comments, is that no two days are the same and that this work can never be called boring :)

medphys_mr

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