Oncology & Hematology Coding Alert

Practices that routinely bill for simple simulations (77280) may be undercoding, leading to lost revenue. Because of advances in technology, radiation oncologists are able to treat more than one area at a time using an array of devices, all of which characterize intermediate (77285) or complex (77290) simulation. 
 
"Today's reality dictates that there are very few simple simulations," says Margaret Hickey, MS, MSN, RN, OCN, CORLN, an independent coding consultant and the former clinical director for the Tulane Cancer Center in New Orleans.
 
Simulations now include a number of ports, more than one axis, and multiple and custom blocking, thus leading to a higher-level simulation code. The code for simple simulation should be reserved for block check simulations or those with non-custom blocking or no blocking at all.

A simulation is ordered by the radiation oncologist to determine the size and location of treatment ports, which are designed to direct radiation to the tumor areas and protect outlying areas. They may be performed on a dedicated simulator, a radiation therapy treatment unit, CT scanner, or diagnostic x-ray machine, all of which visualize and define the exact treatment area.
 
Like many radiation oncology procedures, simulations are made up of a technical and professional component. Append modifier -26 (professional component) to 77280-77290 if the physician group is not employed by the same company that owns the equipment and/or the physicians do not own or lease the equipment. You may bill for the technical and professional component if the practice owns the equipment by reporting the simulation code only.
 
According to Cindy Parman, CPC, CPC-H, principal and co-founder of Coding Strategies, a coding consulting firm in Dallas, Ga., each code has distinct characteristics:

Code 77280:

Superficial orthovoltage, cobalt linear accelerator treatments
 

A single treatment area with either a single port or parallel opposed ports
 

Simple or no blocking
 

Only one or two films are produced.

Code 77285: 

Superficial orthovoltage, cobalt linear accelerator treatments
 

Three or more converging ports on a single treatment area
 

Two separate treatment areas
 

The equivalent of multiple standard blocks
 

Two or more films of each area, with or without fluoroscopy
 

Tangential ports without devices or with a single pair of premanufactured wedges. (This is a payer-specific item. Some Medicare carriers state that simulation without use of devices or any premade devices is a simple simulation.)

Code 77290: 

Three or more treatment areas
 

Rotation or arc therapy
 

Highly complex blocking in cases such as total body or hemibody irradiation, special wedges or compensators, custom shielding blocks, complex immobilization and multi-leaf collimation 
 

Brachytherapy source verification
 

Hyperthermia probe verification
 

Use of any contrast material with or without fluoroscopy
 

Tangential ports, oblique fields, rotational or special beam considerations.

"Simulations may be performed on a number of occasions during a course of radiation therapy due to a change in the field size that is being treated. However, a simulation should only be reported once per setup procedure," Parman says. 
 
For instance, if a simulation involving three treatment areas and custom blocking is performed twice during a patient's radiation therapy once for initial setup and a second time to confirm previous results report 77290 once. Again, if the equipment does not belong to the practice, append modifier -26. For practices performing the simulation in the office, 77290 should be reported alone for the technical and professional services.
  
Port changes based on an unsatisfactory simulation may not be reported as an additional simulation. A simulation may be charged each time fields are added or changed during therapy. Minor changes in port size without changes in beam or without clinical justification do not qualify for an additional simulation or a higher level of complexity. 
 
The most common reason for a billable second simulation is that a new treatment area is identified, Hickey says. To bill for the second simulation, however, the practice must accurately document its necessity in the simulation note.
 
The note is an essential component. Documentation indicating changes in the treatment field or other reasons justifying the medical necessity should be included. Each simulation that a practice bills for must have a separate note. It should be completed and signed by the radiation oncologist to document physician participation. Make sure the note includes the following:

 

The date of the simulation
 

The reason for the simulation, such as initial simulation, block check or subsequent simulation 
 

A summary of the procedure including patient position, identification of field location and critical structures blocked or considered
 

A description of any immobilization designed and/or customized
 

A summary of fluoroscopy and contrast used.

According to the American College of Radiology, simulation services may be coded in addition to a three-dimensional treatment plan (77295). But Parman and Hickey agree that Medicare carriers' policies contradict this. Some local medical review policies (LMRPs) indicate that 77295 includes simulations and other procedures performed in preparation for use of coplanar beams. For this reason, it is important for practices to check their carriers' local medical review policies.