Oncology & Hematology Coding Alert

Keeping track of all of the terminology used in brachytherapy isn't easy. You may feel a little befuddled by what "remote afterloading" refers to when coding high dose rate (HDR), or you may not be entirely sure what "high-intensity" means.

Not to worry, though. Just let our experts share their insights with you on how to identify all the necessary components of 77781-77784, and how you can apply them correctly every time based on the information you find in your documentation.

The are four CPT codes that specifically describe remote afterloading high-intensity brachytherapy:

- 77781 -- Remote afterloading high-intensity brachytherapy; 1-4 source positions or catheters

- 77782 -- ... 5-8 source positions or catheters

- 77783 -- ... 9-12 source positions or catheters

- 77784 -- ... over 12 source positions or catheters.

Heads up: CPT includes a note with 77781-77784 indicating that you shouldn't report these codes with 0182T (High dose rate electronic brachytherapy, per fraction), which you should use to report "provision of brachytherapy with electronically generated photons," according to the AMA's CPT Changes 2008.

Here's what our experts have to say regarding each component of the 77781-77784 descriptors. You can use these explanations to describe the services your physician should document for you to report these codes.

"Remote afterloading": For HDR brachytherapy, a single high-intensity radioactive material is supplied through one or more catheters by a special machine, says Cindy Parman, CPC, CPC-H, RCC, co-owner of Coding Strategies Inc. in Powder Springs, Ga.

In-depth explanation: Remote afterloading refers to the machine applying radioactive material after inserting the catheters.

"High-intensity brachytherapy": Brachytherapy involves the placement of encapsulated radioactive material, often cesium, iridium or cobalt, in or near tumor tissue. HDR material delivers radiation at a rate of 10 cGy to 100 cGy per minute, Parman says. Low dose (LDR) delivers the same dose per hour.

More info: HDR requires less patient treatment time and can be performed as an outpatient service, making it increasingly more popular with patients than LDR, according to Parman.

Note: HDR treatments involve radiation sources that are used again and again for multiple patients. Payers include the cost of this sort of source in the HDR treatment codes, meaning that even if your freestanding center supplies the material, you shouldn't charge separately for it, according to the Nov. 1, 2002, Federal Register.

Note: Hospitals may report C1717 (Brachytherapy source, nonstranded, high dose rate iridium-192, per source) under Outpatient PPS.

"Source positions or catheters": The final element of codes 77781-77784 is based on the number of source positions -- also known as dwell positions -- or catheters the oncologist uses, Parman says:

- 77781-- ... 1-4 source positions or catheters

- 77782 -- ... 5-8 source positions or catheters

- 77783 -- ... 9-12 source positions or catheters

- 77784 -- ... over 12 source positions or catheters.

For HDR brachytherapy, a physician places small catheters in and around the tumor area. During treatment, the catheters connect to the HDR machine, which inserts the radioactive source.

Experts note: While another physician may insert the catheters, the oncologist is the one in charge of the radioactive sources.

Why? In most states, the radiation oncologist is specially trained to handle radioactive material, says Michael A. Ferragamo, MD, FACS, assistant clinical professor at the State University of New York, Stony Brook School of Medicine. The radiation oncologist generally has a Nuclear Regulatory Commission (NRC) license, as well.

Here is an example of how you will apply the HDR codes to a MammoSite procedure.

Example: A breast cancer patient returns to your practice for HDR treatment by your oncologist. A tumor excision was followed by the insertion of a single balloon catheter. The oncologist treats the patient with HDR brachytherapy twice daily over a five-day period. For the first day, report the following for the HDR treatment, Parman says:

- Treatment 1: 77781

- Treatment 2: 77781-76 (Repeat procedure or service by same physician).

For days two through five, report the following:

- Treatment 1: 77781

- Treatment 2: 77781-76.

Rationale: The patient has only one catheter and one dwell position, making 77781 your appropriate HDR coding choice.

You may report HDR for each treatment. Appending modifier 76 to the second service performed on a single service date defines the separate nature of each treatment.

Some payers may prefer that you report two units of 77781 each day instead, so be sure to track your payers- specific preferences.

Note: While you may report a number of other radiation codes separately with HDR (such as 77263, Therapeutic radiology treatment planning; complex and 77290, Therapeutic radiology simulation-aided field setting; complex), you should not report 77427 (Radiation treatment management, five treatments) with the brachytherapy.

Remember: ACR and ASTRO maintain that 77427 is appropriate only for external beam therapy radiation management, Parman says. As always, she notes that individual payer guidelines take precedence, so follow your local policies.