Medicare Compliance & Reimbursement

But use this one code sparingly, if ever.

There are many moving parts to radiation treatment management coding. From knowing the difference between the codes and the services they describe to knowing what needs to be documented, there’s a lot to consider.

To help, we’ve put together this handy guide for you to consult whenever you have to report this important part of a patient’s cancer treatment. And we’ve added a note of caution for you to bear in mind before you bill one of the codes.

Take Note of These Radiation Treatment Management Codes

All told, there are seven CPT^® codes that represent radiation treatment management:

• 77427 (Radiation treatment management, 5 treatments)
• 77431 (Radiation therapy management with complete course of therapy consisting of 1 or 2 fractions only)
• 77432 (Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session))
• 77435 (Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions)
• 77469 (Intraoperative radiation treatment management)
• 77470 (Special treatment procedure (eg, total body irradiation, hemibody radiation, per oral or endocavitary irradiation)
• 77499 (Unlisted procedure, therapeutic radiology treatment management)

The codes differ according to the type of radiation treatments the patient receives, the anatomic location toward which the treatments are directed, and the number of treatments documented.

CPT^® codes 77427 and 77431 describe management of radiation therapy delivered into the body from an external source (as opposed to brachytherapy, which is delivered internally). Code 77469 also describes external radiation therapy, but unlike 77427 and 77432, the code describes management of radiation delivered intraoperatively in instances where a surgeon finds it difficult to remove a patient’s entire tumor with surgical intervention.

The stereotactic radiation therapy (SRT) treatment management codes, 77432 and 77435, describe a type of radiation therapy in which the provider delivers a few very high doses of radiation to small, well-defined tumors inside the body. The two codes describe the treatment management of the different anatomic locations treated, with 77432 describing management of SRT delivered to tumors in the brain and 77435 describing stereotactic body radiation therapy (SBRT).

You can use 77470 to describe several kinds of radiotherapy, in which the provider manages the irradiation treatment to the patient’s whole body (or, in the case of hemibody radiation therapy, half). Again, this can be performed externally or internally using endocavitary irradiation, where radiation is delivered directly to the tumor within a body cavity, such as the rectum.

Last, 77499 is an unlisted procedure code, which allows you to report a radiation therapy procedure for which there is no specific CPT^® descriptor available. However, you will rarely, if ever, use this code. “I’ve never used an unlisted CPT^® code in oncology, and their use is not typical at all,” says Stephanie Thebarge, CPC, CPCO, CPMA, CPPM, CPB, CEMC, CHONC, compliance manager at New England Cancer Specialists in Scarborough, Maine.

Remember the Documentation Elements

There are four elements to 77427/77431, according to the American Society for Radiation Oncology (ASTRO), though these elements apply to all the codes in the 77427-77499 range.

They are:

• A minimum of one examination of the patient by the physician for medical evaluation and management;
• Review of port films;
• Review and changes to dosimetry, dose delivery, and treatment parameters; and
• Review of the patient’s setup (www.astro.org/Daily-Practice/Reimbursement/Practice-Management-Resources).

CPT^® guidelines agree, adding the examination should include an “assessment of the patient’s response to treatment, coordination of care and treatment,” and a “review of imaging and/or lab test results with documentation … for each reporting of the radiation treatment management service.”

Important: The patient examination element is required to report the treatment management codes, while the other three elements are typically included but do not need to be documented each week.

Know How to Document 77427/77431 Units

As the code descriptor says, five fractions, or treatment sessions, equal one unit of 77427. But what happens when the treatment is less than five or when the treatment extends beyond five fractions?

When the treatment goes beyond five fractions, the Centers for Medicare & Medicaid Services (CMS) and other payers that follow Medicare guidelines tell you that “if … there are three or four fractions beyond a multiple of five, those three or four fractions are paid for as a week,” according to the Medicare Claims Processing Manual (www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c13.pdf). This means Medicare will pay for six or seven fractions with one unit of 77427; you can then bill for eight or nine fractions with two units of 77427 and so on.

If the treatment only includes one or two fractions, you will use 77431 as the code descriptor states, “with a complete course of therapy consisting of 1 or 2 fractions only.” Very rarely will the treatment consist of only three or four fractions.

Use 77470 With Caution — If At All

According to AMA guidelines, you should report 77470 when your provider uses extra cognitive planning time and effort that goes above and beyond the complex clinical treatment planning described by 77263 (Therapeutic radiology treatment planning; complex).

“In this special treatment procedure, the radiation oncologist uses imaging, advanced radiation physics and special dose calculations to deliver radiotherapy treatment,” according to Kristen Taylor, CPC, CHC, CHIAP, associate partner at Pinnacle Enterprise Risk Consulting Services. “Special treatment procedure documentation should include notation of the additional effort and work required, but cases requiring radiation and chemotherapy do not automatically warrant use of 77470,” Taylor cautions.

Code 77470 is not routinely charged for any radiation service. When your claim does merit 77470, you should only bill it on the date documented in the medical record. As CPT^® states, “77470 assumes that the procedure is performed 1 or more times during the course of therapy, in addition to daily or weekly patient management.” Because the explanation states “1 or more times during the course of therapy,” if you do use 77470, you should only submit it once.

Bruce Pegg, BA, MA, CPC, CFPC, Managing Editor, AAPC