Oncology & Hematology Coding Alert

With more than $900 possible per procedure, keeping these codes straight is crucial

Can't keep track of what -high-intensity- means or what -remote afterloading- refers to when coding high dose rate (HDR) brachytherapy? Our experts teach you how to identify all the components of 77781-77784 and apply them correctly every time based on what you see in your documentation.

The codes: Four CPT codes specifically describe remote afterloading high- intensity brachytherapy:

- 77781--Remote afterloading high-intensity brachytherapy; 1-4 source positions or catheters

- 77782--... 5-8 source positions or catheters

- 77783--... 9-12 source positions or catheters.

- 77784--... over 12 source positions or catheters.

Analyze Each Code Element

Our experts explain each component of the descriptors for 77781-77784, showing you the services your physician should document for you to report these codes.

-Remote afterloading-: HDR brachytherapy uses a single high-intensity radioactive material supplied through one or more catheters by a special machine, says Cindy Parman, CPC, CPC-H, RCC, co-owner of Coding Strategies Inc. in Powder Springs, Ga., president of the American Academy of Professional Coders National Advisory Board, and presenter of -Brachytherapy: Radiation From the Inside Out- at the national Academy conference.

Remote afterloading refers to the radioactive material being applied by the machine after the catheters are inserted.

-High-intensity brachytherapy-: Brachytherapy involves the placement of encapsulated radioactive material, often cesium, iridium, or cobalt, in or near tumor tissue. HDR material delivers radiation at a rate of 10 cGy to 100 cGy per minute, Parman says. Low dose (LDR) delivers the same dose per hour.

HDR requires less patient treatment time and can be performed as an outpatient service, making it increasingly more popular with patients than LDR, Parman says.

Note: HDR treatments involve radiation sources that are used over and over for multiple patients. Payers include the cost of this sort of source in the HDR treatment codes, meaning that even if your freestanding center supplies the material, you shouldn't charge separately for it (Nov. 1, 2002, Federal Register). Hospitals may report C1717 (Brachytherapy source, high dose rate iridium 192, per source) under Outpatient PPS.

-Source positions or catheters-: The final element of codes 77781-77784 is based on the number of source positions or catheters the oncologist uses, Parman says:

- 77781--... 1-4 source positions or catheters
- 77782--... 5-8 source positions or catheters
- 77783--... 9-12 source positions or catheters
- 77784--... over 12 source positions or catheters.

For HDR brachytherapy, a physician places small catheters in and around the tumor area. During treatment, the catheters connect to the HDR machine, which inserts the radioactive source.

While another physician may insert the catheters, the oncologist is the one in charge of the radioactive sources, says Becky Sweat, CPC, coder and business services coordinator with Wake Forest University Health Services in Winston-Salem, N.C.

Why? In most states, the radiation oncologist is specially trained to handle radioactive material, says Michael A. Ferragamo, MD, FACS, assistant clinical professor at the State University of New York, Stony Brook School of Medicine.

The radiation oncologist generally has a Nuclear Regulatory Commission (NRC) license, as well.

Bring It All Together

Here's how to apply the HDR codes to a MammoSite example.

Example: A breast cancer patient returns for HDR treatment following insertion of a single balloon catheter by the oncologist when he excised her tumor. The oncologist treats the patient with HDR brachytherapy twice a day for five days. For the first day, report the following for the HDR treatment, Parman says:

- Treatment 1: 77781

- Treatment 2: 77781-58-76 (Staged or related procedure or service by the same physician during the postoperative period; Repeat procedure by same physician).

For days two through five, report the following:

- Treatment 1: 77781-58

- Treatment 2: 77781-58-76.

Rationale: The patient has only one catheter, making 77781 the appropriate HDR code choice.

You may report HDR for each treatment, and appending modifier 76 defines the separate nature of each treatment. Modifier 58 lets payers know the treatment is a preplanned follow-up service.

Some payers may prefer that you report two units of 77781 each day instead, so be sure to track your payers- specific preferences.

Note: While you may separately report a number of other radiology codes with HDR (such as 77263, Therapeutic radiology treatment planning; complex and 77290, Therapeutic radiology simulation-aided field setting; complex), you should NOT report 77427 (Radiation treatment management, five treatments) with HDR. ACR and ASTRO maintain that 77427 is only appropriate for external beam therapy radiation management, Parman says. As always, individual payer guidelines take precedence, so follow your local policies, she says.