Oncology & Hematology Coding Alert

Know CMS' separate-session guidelines for correct coding

Your oncologist performed multiple radiation treatments at different sessions on the same day, so you can report 77401-77416 more than once, right? Not so fast. You first have to prove that the procedures merit a separate-session designation and determine the treatment "areas."

Know What Constitutes a Separate Session

To justify separate radiation sessions, your physician's documentation should show that the physician maintained a six-hour break between the radiation treatments.

Also, the medical record must clearly document the medical necessity of separate session scheduling (also referred to as "BID" or "hyperfractionation"), coding experts say.

For instance, Blue Cross Blue Shield of Alabama requires practices to prove that the treatment sessions contained a "distinct break in therapy services." In addition, sessions should resemble those "usually furnished on different days."

"You have to look at the nature of the radiation services," says Deborah I. Churchill, RTT, president of Churchill Consulting Inc., in Killingworth, Conn.

Suppose your physician treats a patient in the morning with two separate areas. "This constitutes only one treatment delivery code because you would normally address both of these areas during one session," she says.

Real-life scenario: The oncologist administers a lower-than-normal dose of radiation to a patient with larynx cancer (161.x, Malignant neoplasm of larynx) twice a day, allowing a minimum of six hours between sessions. The per-radiation dose is lower, but overall the patient receives a higher level of treatment, says Diane Corder, RTT, facility administrator at Gwinnett County Radiation Therapy Center in Lawrenceville, Ga.

What to do: Depending on complexity and documentation, you could report 77413 x 2 (Radiation treatment delivery, three or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, special particle beam [e.g., electron or neutrons]; 6-10 MeV), which represents a morning and afternoon treatment.

To prove separate sessions, be sure you clearly note that the radiation oncologist delivered one unit in the morning and one in the afternoon.

Payment: If you are billing Medicare, you could expect 77413 to bring in $100 for each session, for a total of $200, according to national averages.

Treatment 'Areas' Determine Codes
 
When you are trying to pinpoint the correct radiation treatment code (77401-77416), you must first know how many "areas" your oncologist treated.

"'Area' refers to the total volume within the body to which the radiation therapy is directed," Churchill says.

If your oncologist treats the breast with tangential and supraclav fields, you should consider that one treatment area.