Oncology & Hematology Coding Alert

Documenting thoroughly will get oncologists reimbursed for all stages of radiation treatment planning and will help them avoid audits.

I was looking at the charts of one physician and told him, If I were an auditor, I would be getting all your simulation money back because of poor documentation, says Cindy Parman, CPC, CPC-H, principal and
co-founder of Coding Strategies Inc., a Dallas, Ga.-based coding consulting firm.

The clinical treatment planning process includes interpretation of special testing, tumor localization, treatment volume determination, treatment time/dosage determination, choice of treatment modality, determination of number and size of treatment ports, selection of appropriate treatment devices and other procedures.

Coding and Documenting the Planning

There are three procedure codes for planning:

77261 (simple therapeutic radiology treatment
planning) Simple planning requires a single treatment area of interest encompassed in a single port or simple parallel opposed ports with simple or no blocking.
77262 (intermediate) Planning requires three or more converging ports, two separate treatment areas, multiple blocks, or special time constraints.
77263 (complex) Planning requires highly
complex blocking, custom shielding blocks, tangential ports, special wedges or compensators, three or more separate areas, rotational or special beam considerations, combination of therapeutic modalities.

Proper documentation of radiation treatment planning requires radiation oncologists to reflect accurately the number of treatment areas, ports and blocks in the patient record.

Simulation Codes

There are five codes for simulation 77280-77299. As Parman explains, prior to beginning a course of treatment, a simulation is completed to determine the size and location of the initial treatment ports, which are designed to direct the radiation at tumor areas and protect critical tissue. Parman says most simulation cases call for 77290 (complex; simulation of tangential portals, three or more treatment areas, rotation or arc therapy, complex blocking, custom shielding blocks, brachytherapy source verification, hyperthermia probe verification, any use of contrast materials) or 77295 (three-dimensional; computer generated three-dimensional reconstruction of tumor volume and surrounding critical normal tissue structures from direct CT scans and/or MRI data in preparation for non-coplanar or coplanar therapy. The simulation utilizes documented three-dimensional beams eye view volume-dose displays of multiple or moving beams. Documentation with three-dimensional volume reconstruction and dose distribution is required). This is due to the complexity of todays simulations, but many radiation oncologists fail to provide the correct documentation. They often neglect to make the detailed notations about the simulation that justify using 77290 or 77295.

What payers are noticing is documentation that does not show physician participation, says Parman. Radiation oncologists should keep detailed simulation notes. A simulation note, completed and signed by the radiation oncologist, should document physician participation. The simulation note should include the following:

The date the simulation was completed;
The reason for the simulation, such as initial
simulation, block check or subsequent simulation;
A summary of the procedure, including
patient position, identification of field location and critical structures blocked or considered;
A description of any mobilization designed
and/or customized; and
A summary of use of fluoroscopy and contrast.

Roberta Anne Strohl, RN, MN, AOCN, a clinical specialist with radiation oncology at the University of Maryland in Baltimore, agrees that physicians often fail to document the complexity of their work. We do all this sophisticated work, and its not documented, Strohl says. It goes back to making sure everything you do
is documented.

Physicians also need to ensure that their notes are clear and easy to understand, Parman says. Dictate your notes as if you are explaining to someone who doesnt understand radiation oncology, because chances are if youre audited, they [the auditors] wont.

If a simulation is performed on the treatment unit rather than a simulator, a charge for a simulation should be made. There are two types of charges:

1. Same-day charges. Charges for port films taken the same day should not be made if the simulation is performed on the treatment unit. Physicians or facilities cannot bill for these procedures because the port films are considered part of the simulation charges.

2. Separate-day charges. If the port films are taken on a later date to verify that the fields are properly aligned, the port films may be billed by the facility. The facility would bill 77280-77299.

Simulations may be performed on different occasions during the course of radiation therapy to monitor the treated tumors changing size, but only once per setup procedure, Parman says. A simulation should be charged each time fields are added or changed during a course of therapy.

Documentation is essential. All changes in the treatment field require documentation. Each simulation billed must have its own simulation note, which should be included in the patient record, Parman says.

Physicians should append the simulation code with modifier -26 (professional component) to report physician services if the simulation is performed in a facility not owned by the radiation oncology physician group. Physicians may not use modifier -26 if his or her group owns the treatment facility, employs the staff and is responsible for the facilitys operating costs. Instead, they should bill the code without a modifier.

Additional billing errors occur when billing for three-dimensional simulations (77295), Parman says. The tendency is to buy a 3-D simulator and use it for everything. As more radiation oncology practices purchase three-dimensional simulators, billing for their use becomes more common. But, Parman warns, if you bill for their use, you have to be able to prove (and have documented) medical necessity. Radiation oncologists billing for 3-D simulations need to show that the tumor volume is irregular, that the tumor is close to structures that must be protected, or that the tumor cant be detected clearly by other imaging procedures.