Oncology & Hematology Coding Alert

When a particularly difficult case of cancer is treated with a regimen of chemo-therapy and radiation, the radiation oncologist providing the treatment planning may be inclined to code 77470 code 77470 (special treatment procedure [e.g., total body irradiation, hemibody irradiation, per oral, endocavitary or intraoperative cone radiation]). This code recognizes the clinical management by a physician for a patient receiving special procedures. In this case, however, it would usually be more accurate to bill for normal radiation treatment planning or the actual procedure.

The special treatment code, 77470, is commonly reimbursed by payers, but can easily be misused. If you can document that special treatment planning was used, you should have no problem getting paid, says Carl Bogardus, MD, FACR, president of Cancer Care Network, a billing and coding consulting firm in Midwest City, Okla. Yet, the rules associated with the code are confusing and lack clear direction, he adds.

According to Medicare regulations, 77470 covers the additional physician effort and work required for the special procedures of hyperfractionation, total body irradiation, per oral or transvaginal cone use, brachytherapy, hyperthermia, combination with chemotherapy or other combined modality therapy, stereotactic radiosurgery, intraoperative radiation therapy, and any other special time-consuming plan.

The code is normally used along with other radiation treatment management codes, such as 77427-77432 and 77499. In addition to the reimbursement for these codes, 77470 carries a 2.09 RVU for physicians, which translates into about $80.

For example, 77470 can be used when treating children with radiation therapy, because of the extra time and planning it takes to prepare a child, says Jim Hugh, MHA, senior vice president with AMAC, a reimbursement and billing firm based in Atlanta that serves radiation oncology practices and hospitals.

Two other examples are:

Total body irradiation (TBI),
Hemibody irradiation (HBI), per oral, endocavitary or intraoperative cone irradiation.

TBI requires the delivery of radiation throughout the body, while HBI focuses on half the body. Like radiation to specific sites, total body and hemibody irradiation fall under the radiation treatment delivery codes, 77401-77417; clinical treatment planning, 77261-77263; and simulation, 77280-77295. Both procedures require an extensive amount of planning to ensure the proper dose is delivered and that damage to major structures is avoided; therefore, Medicare allows the use of 77470 to be billed with the appropriate planning, simulation and radiation treatment codes.

This code should not be used to simply account for extra time used, warns Cindy Parman, CPC, CPC-H, principal and co-founder of Coding Strategies in Dallas, Ga. It should be used under the following circumstances:

1. Proton therapy. Append it to the listed treatment planning code when proton therapy is used as the main course of therapy, or as adjunct to other types of radiation.

2. Complex treatment planning. You may report this code in addition to conventional treatment planning that is complex, 77263 (therapeutic radiology treatment planning; complex). This applies to clinical treatment planning that requires highly complex blocking, custom shielding blocks, tangential ports, special wedges or compensators, three or more separate treatment areas, rotational or special beam considerations and a combination of therapeutic modalities.

3. Other procedures. In addition to the above, the following are allowed by many insurers: hyperfractionation, certain brachytherapy procedures such as prostate seeds, stereotactic radiosurgery, intensity modulated radiation therapy (IMRT), retreatment of the same site, concurrent multiple site treatment, treating a site abutting a previously treated site, and concurrent chemotherapy.

4. Separately identifiable service. If a separately identifiable treatment course is started on the same patient at a later date, 77470 may be billed if appropriate. For example, if a breast cancer patient undergoes radiation treatment, but later requires total body irradiation, 77470 can be used to describe the special therapy procedure provided in a second course of treatment that involves extra planning and effort. A separate, identifiable service alone is not an adequate reason for its use.

Situations When 77470 Should Not be Used

Code 77470 should not be used to describe modification of treatment. If there is a change in plan for any reason, the physician should use the appropriate code for simulation fieldsetting, 77280-77295, and dosimetry, 77300 and 77331, because these codes more accurately describe the services provided. Modification, while calling for the creation of a new treatment plan, does not necessarily require additional time and effort.

Keep these tips in mind when trying to determine if 77470 is appropriate:

It should not be used when chemotherapy follows radiation or radiation follows chemotherapy, unless a payer specifically allows it;

When the patient has another ongoing medical condition such as diabetes, hypertension or chronic obstructive pulmonary disease (COPD), it should not be used because the code is intended for use in radiation treatment and not to account for additional care as a result of other conditions;

It is a one-time-use code and should only be reported once per course of therapy, even if more than one reason qualifies.

Develop In-house Policy On 77470 Usage

Parman says practices should develop a policy on the use of 77470. It should include the situations when this is to be assigned, and the specific area of the chart where supporting documentation will be maintained. Documentation for assignment of 77470 can take many forms. In some cases, the radiation oncologist dictates the qualifier into the initial consultation report, such as when the patient is receiving concomitant chemotherapy. In other situations, the nature of the service performed, such as stereotactic radiosurgery, will drive its assignment.