Oncology & Hematology Coding Alert

Planning treatment for patients set to undergo radiation therapy is a complex task, but deciding how to properly bill clinical treatment planning often leaves the biller confused over which code to use. Often characteristics of planning resemble intermediate treatment planning when it could be correctly billed as complex treatment planning, and revenue gets lost.

Treatment plans themselves can be used to determine and document when a complex set of treatment considerations for radiation oncology has graduated to more complex handling, says Cindy Parman, CPC, CPC-H, and principal at CSI Coding Services, a Dallas, Ga.-based medical coding consulting firm that includes radiation oncology offices. Practices will still need to gauge the array of services planned to determine the complexity of treatment. But she says theres no reason to opt for a lower code to avoid overbilling with CPT 2000s careful discourse on the components to the clinical treatment planning process.

Parman first points to the new CPT 2000 manual, whose guidelines should be in place for most carriers by next spring. According to the manual, the clinical treatment planning process is defined as the interpretation of special testing, tumor localization, treatment volume determination, treatment time and dosage determination, treatment modality, the number and size of treatment ports, and selection of the appropriate treatment devices. Three CPT codes apply: 77261 (therapeutic radiology treatment planning; simple); 77262 (therapeutic radiology treatment planning; intermediate); and 77263 (therapeutic radiology treatment planning; complex).

Choosing Between Simple, Intermediate and Complex

While most practices can easily determine when the simple treatment planning code (77261) applies, differentiating between intermediate (77262) and complex (77263) tends to be trickier, she says. One of the biggest problems is [the absence of a] separate treatment planning record, she says.

This often leaves the biller with having to search through the entire medical record to determine which tests and procedures were ordered during the treatment planning process. The potential for missing items is increased without a central area in which the biller can go to gauge the level of clinical treatment planning complexity.

Parman recommends that practices keep a log to track clinical treatment planning where consultation notes, prescriptions, simulation notes, and block design can be easily found. Roberta Anne Strohl, RN, MN, AOCN, clinical specialist, radiation oncology at the University of Maryland in Baltimore, agrees. Anything that makes going through the patient record easier is good. Radiation oncologists at the University of Maryland routinely sit down with billing staff to review the record and the physician chooses the appropriate clinical treatment planning code, Strohl says.

Once a practice gets into the habit of listing clinical treatment characteristics on a centralized form they will garner a more accurate picture of what physicians planned for and administered. Still, there is the matter of interpreting whether these characteristics justify intermediate versus simple, or complex versus intermediate.

To help make the decision clearer, Parman uses the following list of treatment planning characteristics for each of the three categories. Both Parman and Strohl say that not all of the characteristics in each category need to be present to justify the code. Requirements will vary by payor. In some extreme circumstances a payor may require the presence of each of the items Parman lists below to correctly bill intermediate over simple and complex over intermediate.

Simple Treatment Planning

The CPT manual directs coders to use the 77261 code when treatment planning requires a single treatment area of interest encompassed in a single port or simple parallel opposed ports, with simple or no blocking. Parman also suggests the code be used when:

Treatment planning includes superficial, orthovoltage cobalt, linear accelerator (photon) treatments;

The treatment area is defined;

The planning requires no interpretation of special
tests for localization of the tumor volume;

The volume of interest can be encompassed with
simple portal arrangements, such as a single treatment area of interest encompassed in a single port or simple parallel opposed ports; and

There is minimal or no blocking.

Tip: Parman says this code may also be used to bill brachytherapy applications that are not time or effort intensive, such as strontium application to the eye.

Intermediate Treatment Planning

Planning that requires three or more converging ports, two separate areas, multiple blocks, or special time or dose constraints should bear the intermediate code (77262). Parman also recommends citing these planning characteristics in your documentation:

Treatment planning includes superficial, orthovoltage cobalt, linear accelerator (photon) treatments;

Theres a moderate level of difficulty in overall
planning or course treatment;

Two separate treatment areas are involved with
three or more converging ports;

Critical or sensitive organs need to be protected,
typically requiring multiple blocks;

There is the possibility of special time or dose restraints; and

The planning requires interpretation of special tests
for localization of the tumor volume.

Complex Treatment Planning

Complex treatment planning under CPT 2000 is supposed to require 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. Parman says radiology practices can safely code for complex treatment planning using the list below:

Treatment planning for superficial, orthovoltage,
cobalt, linear accelerator (photon), electron, neutron, proton, conventional brachytherapy, and remote after-loading, low- or high-dose brachytherapy is involved.

Interpretation of complex testing, such MRI or CT
scans, or special laboratory testing, is required;

Early or advanced disease is involved that is complex in its distribution;

Special planning and mapping is required to protect
more than two critical structures, such as the spinal
cord above T10, the eyeball, optic nerve, liver, kidney or heart;

Tangential ports, oblique fields, rotational or special beam considerations are involved, including any electron field, any neutron field, any proton any field, total body or hemibody irradiation, any intraoperative treatment and beam offsets;

Stereostatic radiosurgery is included;

Highly complex blocking is called for, such as TBI
hemibody, AP/PA mantle, inverted Y, and partial transmission;

Special wedges or compensators, custom shielding blocks, complex immobilization to protect critical structures, including an alphacradle, aquaplast and molds, are required;

Combine modalities, such as hyperthermia, chemotherapy, brachytherapy, surgery, electrons and photons and mixed beams, are at issue;

Three or more areas may require treatment or retreatment of previous ports, overlapping of current or previous fields, and abutting fields:

Repeated treatment of previously irradiated tissue
or surgically modified tissues is necessary; and

Theres a risk of long-term complications, thermal injury or skin graft.

Treatment planning generally is reported once during the course of radiation therapy because is it is directly tied to the site or sites in which the therapy is provided, Parman says. The course of radiation therapy is the only justification for treatment plan billing. If a new problem is discovered that requires a new course of treatment, an additional treatment planning code is allowed, says Parman. If treatment planning goes beyond the initial visit, specific documentation showing the need for additional sessions is required.

Tip: Parman says to be careful of single treatments that are incorrectly documented using multiple codes. This error can happen when a single treatment spans several days.

No modifiers are required for radiation treatment planning services because clinical treatment planning is a professional service with no facility component that would justify a modifier. Parman also notes that the services listed in all three categories do not include isodose/computer plan. If practices use this in their treatment planning, isodose/computer plan should be coded separately.