Oncology & Hematology Coding Alert

Edits dissolve for dosimetry and 3D planning; new ones apply to IMRT services.

With the approaching New Year, resolve to list the changes and updates that can impact your practice in 2017. The 2017 National Correct Coding Initiative (CCI) Policy Manual for Medicare Services was released on November 17, 2016, on the CMS website. The CCI annual update for 2017 brings two key changes likely to impact your radiation oncology coding:

1. The policy manual is now updated for the change in the edit between codes 77300 and 77295.
2. You should prepare to face a fall in services considered separately billable with a course of IMRT planning and treatment.

You can access the manual at: https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html?redirect=/nationalcorrectcodinited/.

You Can Bill Dosimetry with 3D Planning

The first update of note in the CPT^® 2017 manual is for the procedure to procedure (PTP) edit for column one CPT^® code 77295 (3-dimensional radiotherapy plan, including dose-volume histograms) and column two CPT^® code 77300 (Basic radiation dosimetry calculation, central axis depth dose calculation, TDF, NSD, gap calculation, off axis factor, tissue inhomogeneity factors, calculation of nonionizing radiation surface and depth dose, as required during course of treatment, only when prescribed by the treating physician). CCI has now corrected the edit in the manual in Chapter 9, Section F (Radiation Oncology), Subsection 14.

What did the edit mean? The edit between CPT^® codes 77300 and 77295 implied the listed calculations were not billable with the 3D planning code.

Recap of the journey of this edit: In the letter dated March 1, 2016, Niles R Rosen, MD, Medical Director, CCI confirmed to the American College of Radiology (ACR), American Society of Radiation Oncology (ASTRO) the edit would be deleted in the third quarter CCI release on July 1, 2016, with a retroactive date of January 1, 2016. You can access this CCI response at: http://www.acr.org/~/media/ACR/Documents/PDF/Economics/astroacr030116_77295w77300 (2).pdf.

Policy manual update: the policy manual has now been updated for 2017 though the edit was deleted in the PTP files around the middle of this year. The statement supporting 'basic dosimetry calculations to be part of the 3D plan and hence not separately billable' has now been deleted. The PTP files and the manual are now aligned for this change.

Welcome change: This update is a welcome change as payers will now have lesser chances of making an error on this edit for submitted claims.

"This will allow practices to bill for appropriately documented dosimetry calculations performed on the same date as the 3D planning, says Kristen Taylor, Managing Director; Pinnacle Enterprise Risk Consulting Services, LLC. "Work with your providers to ensure appropriate documentation and review occurs for the dosimetry calculations."

Beware Date of Service Edits with IMRT Treatment

Another important update in the 2017 CCI policy manual is for the simulation codes.

Manual speak: In chapter 9, section F.15, the manual clearly specifies the increased billing edits for IMRT courses of treatment. According to the manual, "CPT^® codes 77280-77290 (simulation-aided field settings) should not be reported for verification of the treatment field during a course of intensity modulated radiotherapy (IMRT) treatment."  

What does this mean? You now have a new edit between the simulation codes and IMRT treatment. The services are no longer billable together. The manual has now listed the CPT^® codes 77280-77290 as not billable for verification of the treatment field during a course of IMRT treatment.

Already in practice: According to ASTRO, codes 77280 (Therapeutic radiology simulation-aided field setting; simple)-77290 (Therapeutic radiology simulation-aided field setting; complex) should not be reported on same date of service for IMRT planning, i.e., code 77301 (Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specifications). "ASTRO does state these simulation-aided field setting codes may be performed and billed, as medically necessary, during the course of IMRT treatment," Taylor says.

You can read the ASTRO directive on: https://www.astro.org/uploadedFiles/Main_Site/Practice_Management/Reimbursement/IMRT MP.pdf.

What can you expect in 2017? Additional edits seem likely. For example, may see codes 77280–77290 with a direct date of service edit with IMRT treatment codes 77385, 77386, G6015 and G6016. "Practices need to remain vigilant in their denial review to determine if additional edits have been implemented," Taylor says. "Documentation is the key to appropriate reimbursement. Work with your physicians to ensure documentation of medical necessity for additional simulation-aided field settings during the course of treatment. This could include significant change in the treatment field or surrounding viable tissue."