Oncology & Hematology Coding Alert

But pay attention to two critical NCCI edits.

Good beginnings to radiation therapy programs are critical to successful patient outcomes. So, it’s important to correctly code that planning phase. That means going beyond just knowing which codes to use and applying them correctly to also knowing key terminology and CPT^® definitions.

Here, then, is your foolproof guide to coding the initial phases of radiation oncology — the period in time prior to the actual treatment itself — including all the critical vocabulary you need for precise radiation treatment planning code application.

Know What Planning Services Include

The first three codes you need to be familiar are the radiation treatment planning codes:

• 77261 (Therapeutic radiology treatment planning; simple)
• 77262 (… intermediate)
• 77263 (… complex)

To apply these codes correctly, you need to fully understand the CPT^® guidelines that accompany them. They tell you therapeutic radiology treatment planning services must include:

• 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
• Other procedures

Importantly, though these services include treatment volume, time, and dosage determinations, you’ll need other codes to describe these dosimetry services, such as:

• 77295 (3-dimensional radiotherapy plan, including dose-volume histograms),
• 77300 (Basic radiation dosimetry calculation …)
• 77306-77307 (Teletherapy isodose plan …)
• 77316-77318 (Brachytherapy isodose plan …).

Know the Difference Between Planning Services and Simulation

Generally speaking, once your oncologist has completed the clinical treatment planning, “which includes a written prescription or intent along with a note documenting the thought process and work, the patient proceeds to the next step in treatment preparation, which is simulation,” according to Stephanie A. Thebarge, CPC, CPCO, CPMA, CPPM, CPB, CEMC, CHONC, compliance manager at New England Cancer Specialists in Scarborough, Maine.

Three other codes describe this next phase in treatment planning (simulation):

• 77280 (Therapeutic radiology simulation-aided field setting; simple)
• 77285 (… intermediate)
• 77290 (… complex)

In these services, the radiation oncologist or other qualified healthcare provider (QHP) performs simulation-aided field setting “to identify normal and abnormal anatomy by acquiring images and/or data from the targeted treatment area. The simulation equipment helps define the optimal treatment position for the patient; design immobilization devices; employ localization lasers to align the patient; mark the skin with targeting markers/tattoo; visualize the ports/fields in reference to the landmarks; and document the parameters that are recorded during the sim. The codes describe the work and complexity involved,” Thebarge notes.

CPT^® describes simulation as the “process of defining relevant normal and abnormal target anatomy, and acquiring the images and data necessary to develop the optimal radiation treatment process for the patient.” Again, don’t confuse this with the tumor localization that is part of the 77261-77263 therapeutic radiology treatment planning services.

NCCI edit alert 1: National Correct Coding Initiative (NCCI) edits bundle therapeutic radiology treating planning and simulation services (77261-77263 and 77280-77290) into intensity modulated radiotherapy (IMRT) plan services coded to 77301. So, if your radiation oncologist decides to use IMRT to treat the patient, you won’t be able to separately report these codes.

Know What Simple, Intermediate, and Complex Mean

Confusingly, both treatment planning (77261-77263) and simulation (77280-77290) code descriptors employ similar terminology, differentiating between simple, intermediate, and complex levels of services.

As a rule of thumb, when either service involves one treatment area, you’ll designate that service as simple. Two treatment areas can be defined as intermediate, and three or more as complex.

However, CPT^® guidelines add some additional definitions for the services that you should consider as you assign a level, as the table below illustrates.

CPT^® also defines a treatment area as “a contiguous anatomic location,” meaning an area that is touching, or that shares a boundary with, another area. Therefore, you should regard areas that do not touch as separate for the purposes of determining treatment planning or simulation levels.

NCCI edit alert 2: Normally, once the patient’s radiation treatment has begun, you’ll report any changes to the treatment plan with 77336 (Continuing medical physics consultation, including assessment of treatment parameters, quality assurance of dose delivery, and review of patient treatment documentation in support of the radiation oncologist, reported per week of therapy). You can report this code once per week after a full week of treatment, which typically includes five sessions.

Because of this, NCCI has created edit pairs for 77336 when reported with 77261-77295, 77301-77318, and 77332-77334. However, “since radiation planning may occasionally be repeated during the course of treatment,” NCCI has assigned a modifier indicator of 1 to the pairs. This means you can unbundle the services with an NCCI-associated modifier “to capture radiation planning performed on the same date of service as the continuing medical physics consultation,” per AHA HCPCS Coding Clinic (Vol. 22, No. 1, 2022).