Oncology & Hematology Coding Alert

When billing for treatment management in radiation oncology, practices should report 77427 (radiation treatment management, five treatments) for five fractions at a time, which describes five treatment sessions. Often, however, the number of fractions completed does not equal five or a multiple of five. To bill for three or four leftover fractions, again use 77427. 
 
For example, if nine fractions were completed prior to the end of a patient's radiation treatment, 77427 would be reported twice, once for the first five fractions and a second time for the remaining four.
 
According to Jim Hugh, director of Atlanta-based AMAC, a coding and billing consulting firm, radiation oncology practices commonly make three mistakes:
 

Billing for one or two remaining fractions using 77427;
 

Using 77431 (radiation therapy management with complete course of therapy consisting of one or two fractions only) for each of the remaining fractions;
 

Allowing payers to steer them away from the proper use of 77427.

How to Use 77427
  
 
Radiation treatment management represents the professional services of the physician managing a course of radiation therapy. Clinical treatment management is the ongoing management of a course of radiation therapy using any energy of photon-beam or high-energy particle source.
 
Radiation treatment management is reported in units of five fractions or treatment sessions regardless of the time in which the services are furnished. The services do not need to be provided on consecutive days, says Margaret Hickey, MS, MSN, RN, OCN, CORLN, and independent coding consultant based in New Orleans. Code 77427 includes the ongoing supervision and care of the patient during the entire course of radiation therapy by the radiation oncologist. Each fraction consists of physician services that typically include:
 

Review of and revision of treatment plan;
 

Port film or portal verification image review;
 

Chart and dosimetry review, including dose delivered to date and treatment parameters;
 

Treatment setup and positioning evaluation, review immobilization devices, block placement;
 

Care of infected skin, special care of ostomy site;
 

Medical prescription writing;
 

Nutritional counseling, fluid electrolyte management;
 

Telephone calls to or from the patient; and
 

Pain management.

These services are provided to the patient as part of radiation treatment management and should not be billed separately from 77427.
 
According to CPT guidelines, multiple fractions representing two or more treatment sessions furnished on the same day may be counted separately as long as there has been a distinct break in therapy sessions, and the fractions are of the type that would usually be furnished on different days.
 
Under these guidelines, radiation oncology practices should wait until at least five fractions have been completed before reporting 77427. Practices should not bill for those that are scheduled but not yet performed.
 
Hyperfractionated Radiation Therapy

On the other hand, hyperfractionated radiation therapy is usually about half a daily dose of radiation therapy given twice daily and is not the type of treatment usually delivered on different days. Therefore, most payers consider two hyperfractions to be equal to one fraction. Consequently, 10 hyperfractions should be performed before 77427 is reported. Some payers allow 77427 to be billed for five hyperfractionated doses if the radiation oncology practice can prove the hyperfractions were related to separate therapy sessions and not the usual treatment given in one day. Documentation should include information in the progress notes that the radiation oncologist examined the patient within each of the five hyperfractions.

As mentioned earlier, 77427 is reported if there are three or four fractions beyond a multiple of five at the end of a course of treatment. But if one or two fractions beyond a multiple of five are left over, they should not be reported separately.
 
Some radiation oncology practices incorrectly assume that since they are allowed to bill for three or four leftover fractions, they can also bill for one or two. Because three or four leftover fractions can be billed separately and not one or two, payers can balance payment of 77427 when not all five fractions were completed against fractions that must be absorbed by radiation oncology practices.
 
"It all evens out over the course of a year," Hugh says.
 
77427 Versus 77431

Don't confuse 77427 with 77431. Radiation therapy management (77431) refers to complete therapy management and includes fewer than three sessions (one or two fractions). Code 77431 is typically used to report a full course of treatment, not leftover fractions. However, if the patient's entire treatment course consists of only one or two fractions, the physician can bill 77431 ensuring that the number of fractions is documented.
 
Radiation therapy management also includes follow-up patient visits within 90 days of the completion of radiation therapy. Most payers will not allow separate reimbursement for follow-up visits inside 90 days of the patient's last radiation treatment. If a patient is seen during this period, the radiation oncology practice should either not bill for the E/M service or list it as "no charge." 

Poor advice from payers also causes radiation oncology practices to misuse treatment management codes. Hugh says practices are sometimes told to use 77431 for each leftover fraction or to bill 77427 for each fraction. "CPT guidelines are fairly straightforward, and billing any other way is fraud," Hugh says. "If you are told to bill differently, get it in writing, otherwise once your insurer finds out that you have been billing incorrectly they are going to ask for their money back."