Oncology & Hematology Coding Alert

What's your payer's rule on 77301 and forward planning?

A lot of work goes into planning intensity modulated radiotherapy (IMRT) -- roughly $2,000 worth, according to Medicare. But if you don't know your payer's precise definition of IMRT planning and which codes bundle into the service, your claims are doomed. 

Here are the rules you need to know to send in clean claims every time.

Watch Out for Payer/AMA -IMRT- Discrepancies

The appropriate code for IMRT planning is 77301 (Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specifications).

Payers often have very specific medical-necessity requirements for 77301, such as adjacent important dose-limiting structures or failure of conventional techniques to reduce organ at risk margins.

Important: When you have documentation of IMRT planning, but the patient's diagnosis doesn't meet the payer's medical-necessity requirements, you absolutely should not -downcode- the service to a 3D plan (77295, Therapeutic radiology simulation-aided field setting; 3-dimensional) to receive reimbursement, says Cindy Parman, CPC, CPC-H, RCC, co-owner of Coding Strategies Inc. in Powder Springs, Ga., and president of the American Academy of Professional Coders National Advisory Board.

The Office of Inspector General requires you to report the services provided ( see -OIG Compliance Program for Individual and Small Group Physician Practices- at oig.hhs.gov/authorities/docs/physician.pdf).

Hidden trap: The AMA, which publishes CPT codes, and your payer may have different ideas about what constitutes IMRT planning.

-According to the AMA, IMRT planning includes forward planning, inverse planning, or a combination of the two. Insurance payers- policies tend to state that -a signed inverse treatment plan- is required when reporting code 77301,- Parman says.

Solution: Get your payers- rules on IMRT planning in writing and stick to them.

Checking payer policies is also important simply because IMRT is an emerging technology and payer and coding policies adjust to deal with problems that arise as practitioners use the codes, says Karen Beard, CPC, CHCC, Georgia Society of Clinical Oncology director and senior associate with Medical Management Associates.

Term: IMRT precisely delivers radiation to tumors and allows physicians to deliver high-dose radiation to some parts of a tumor while delivering lower-dose radiation to areas near sensitive tissues to keep them safe. You-ll most often see IMRT used for patients with prostate, breast, head and neck, central nervous system, lung, or liver cancer.

Include Multiple Services in 1 Unit of 77301

You should only report 77301 once per treatment course, Beard says.

Even when you treat a number of targets in the same anatomic site, you only have one planning task, so you should only report one unit of 77301, she says.
 
Watch for: The planning process takes place over a period of time with multiple steps, but you should not -bill components of the planning phase with different dates to try to obtain payment for those bundled components,- Beard says. (See -Take Action Against These Common 77301 Claim Killers- on page 19 to see many key 77301 bundles.)

Red flag: -Treatment devices bundle into the IMRT treatment plan for physician professional services and freestanding centers. According to CMS representatives, the allowance for devices under RBRVS has been incorporated into the daily treatment delivery for IMRT,- Parman says.

That means you should not report treatment device codes 77332-77334 with IMRT treatment plan (77301) for Medicare patients. The edit has a modifier indicator of -1,- meaning you technically can break the edit with a modifier, but remember that Medicare instructs you to only append 59 in very specific situations -- specifically when the two services occur at separate patient encounters or at separate anatomic sites.

Certain professional societies strongly disagree with this edit and argue that you should be able to report IMRT planning and devices together, but your payer has the final say on how you should report the service. Physicians have had to -reimburse Medicare contractors for professional/freestanding treatment device services,- Parman says.

Hospital note: CMS instructs hospitals to append modifier 59 (Distinct procedural service) to treatment devices because the hospital APC reimbursement system allows for separate reimbursement, Parman says.

Count Calculations for 77300 Units

One code you can report alongside 77301 is 77300 (Basic radiation dosimetry calculation, central axis depth dose calculation, TDF, NSD, gap calculation, off axis factor, tissue inhomogeneity factors, calculation of nonionizing radiation surface and depth dose, as required during course of treatment, only when prescribed by the treating physician).

Report one unit of 77300 for each gantry angle, says Parman. Example: Report seven calculations for seven gantry angles, she says.

Stay Consistent on IMRT Plan Dates

You shouldn't find it difficult to locate the IMRT plan in the documentation. -The actual IMRT plan will be about one-quarter inch of computer printouts that include the plan, organs at risk and tolerance, fluence maps and more,-  Parman says.

Key: Use either the date the physician signs the plan or the print date as the IMRT plan date, depending on your facility policy, she says. Crucial: Verify that the professional and technical charges have the same date, because the patient received the service one time, Parman says. The OIG focused on this issue in its 2003 Work Plan, so you know it's important.

You should be able to locate the physician's order for the IMRT treatment plan, too. The best practice is for the physician to include the order in the clinical treatment plan, which you generally report with 77263 (Therapeutic radiology treatment planning; complex) when IMRT is the treatment modality, Parman says.
 
The physician should also document the decision to use IMRT treatment as part of the assessment and plan in the initial patient visit, she adds.

Bottom line: The documentation for IMRT treatment planning (77301) should include -a permanent record (paper or electronic) of computer-generated inverse treatment plans, including 3D tumor and critical structure volumes, inverse planning dosimetric or biological objectives, DVHs and dose verification, with evidence of physician review and acceptance (signature and date, electronic or paper),- according to Coding Strategies- 2007 CSI Navigator for Radiation Oncology.

Next month: Read about coding IMRT delivery in the April issue of Oncology Coding Alert.