Oncology & Hematology Coding Alert

It is common for radiation oncologists to design multiple isodose plans (77305-77315) to plot lines for more than one treatment field and/or for a single area of interest all in one day. Confused by Medicare regulations, some oncology practices bill for only one of the isodose plans done that day, although each of the plans will be used for separate rounds of radiation treatment.
 
Medicare rules account for the fact that multiple plans developed on the same day may represent planning for radiation treatments that could be performed weeks apart, not just plans for a single dose of radiation therapy, says Cindy Parman, CPC, CPC-H, principal and co-founder of Coding Strategies, a coding consulting firm in Dallas, Ga.
 
"Date of service is often an issue where isodose plans are concerned because both the plan for the initial treatment and an off-cord or boost plan may be created at the initiation of treatment," Parman says. "The isodose plan does not become part of the patient's course of treatment until it is signed and accepted by the radiation oncologist."

 
The plans should either plot dosages for several areas of interest or be intended for separate treatment episodes to determine whether a radiation oncologist can rightfully bill for multiple ones. While only one may be reported for a given course of therapy, additional ones may be reported when field changes are required during the therapy.
 
For example, two isodose plans executed on the same day may be reported separately if the first one was plotted to determine dosage for the initial treatment of radiation therapy and the second was for a boost to be performed three weeks later.
 
In this case, the radiation oncologist should sign and date the first isodose plan and assign 77305-77315 on the initial date of service. The second should be signed and dated three weeks later when the radiation oncologist uses it to deliver boost therapy.
 
Seeking separate payment for same-day isodose plans, however, should be reserved for plans that are intended for distinct radiation treatments, Parman says. Each one that is accepted by the radiation oncologist should represent the one that is optimal for the patient's course of therapy on the date the therapy is delivered, she adds. If two isodose plans are printed to determine the optimal dosage of a single dose of radiation, the radiation oncologist may bill only for the one that was used to determine the dosage, and the second should be marked as "not used."

A Conservative Approach

 
The other option is more conservative. Rather than carry out several isodose plans for numerous episodes of radiation, oncology practices should create the isodose plan just before treatment, says Jim Hugh, MHA, senior vice president with AMAC, a reimbursement and billing firm based in Atlanta. "You should bill for one plan per day," he says.
 
Using this approach, you should still report 77305-77315 on separate days, and sign and date the plans on the same day as radiation treatment. The only difference is that the plans were designed on the day of each treatment, rather than both on the day of initial treatment.
 
Note: There is no advantage to choosing one method over the other. Both options are equally compliant.

 
Once you determine a method, you must choose the appropriate level: simple, intermediate or complex isodose plan.
 
Simple (77305) includes one or more of the following characteristics:
 

one or two parallel opposed unmodified ports, such as one that is not changed by any block or wedge compensator, directed to a single area of interest.
 

manual or computer calculations.
 

irregular field isodose calculations with off-axis irregular field dose calculation points.
 

dose volume histogram (DVH) when performed in conjunction with 3-D simulation is not separately coded and billed. In this scenario, only the 3-D simulation is coded because it includes the DVH.

 
Intermediate (77310) includes one or more of the following characteristics:
 

three or more treatment ports directed to a single area of interest.
 

manual or computer calculations.
 

standard blocking or the equivalent may be used to eliminate part of the beam from certain portions of the isodose plan.
 
 Complex (77315) includes one or more of the following characteristics:
 

mantle or inverted Y, the use of wedges, compensators and complex blocking.
 

rotational beam, or special beam considerations such as combined photon and electron fields.
 

tangential ports, oblique fields, rotation or arc beams and multi-planar.
 

manual or computer calculations.
 

five or more ports converging on a single area of interest or when complex blocking and/or wedges are used with any field arrangement.
 

three or four field whole central nervous system.
 

conformal plans multiple complex isodose plans may be reported for selected planes in a conformal treatment plan for stereotactic or conformal dose verification isodose plans. 
 
Parman warns that too many radiation oncologists overcode isodose plans, erroneously choosing 77315 when a lower level is more appropriate. With advances in technology, there is an assumption that all of these should be coded as 77315. Parman and Hugh agree that most plans are likely to be complex, but Parman warns against automatically assigning 77315.
 
Hugh says some practices routinely undercode as well. He cautions radiation oncology practices not to simply count the areas of interest or ports, but also to review other parameters of isodose planning, such as imaging equipment. For example, if sophisticated imaging such as CT scan or magnetic resonance is used, but only on a single area of interest with only a few blocks, this may be appropriately reported as 77315 rather than 77305.