Oncology & Hematology Coding Alert

Master the math required for accurate 'weekly' reporting.

CPT and CMS offer helpful rules for reporting 77427,but applying these rules in real world situations is a wholeother matter. Let the answers to these three FAQs shed light on this confusing code.

1. What Does 'Weekly' Mean?

Providers often refer to 77427 (Radiation treatment management, five treatments) services as "weekly clinical management," but you shouldn't report 77427 automatically each calendar week. Instead, "weekly" clinical management is based on delivery of five fractions and documentation of a patient evaluation, says Deborah

I. Churchill, president of Killingworth, Conn.-based Churchill Consulting Inc., which provides radiation oncology consulting. Those five fractions add up to whatproviders call a "week," "regardless of the time interval separating the delivery of treatments," Churchill says.

Example: A patient has three treatment fractionsduring a calendar week, has a three-day break from therapy, and then resumes treatment the next calendar week, receiving a visit with the radiation oncologist and two additional fractions. You should report 77427 once following the fifth fraction.

Support: CPT's "Radiation Treatment Management" guidelines express the five-fraction rule this way: "Radiation treatment management is reported in units of five fractions or treatment sessions, regardless of the actual time period in which the services are furnished." And "services need not be furnished on consecutive days.

Similarly, Medicare Claims Processing Manual (MCPM),Chapter 13, Section 70.1, states, "A weekly unit of treatment management is equal to five fractions or treatment sessions. A week for the purpose of making payments under these codes is comprised of five fractions regardless of the actual time period in which the services are furnished."

2. How Do You Handle BID Therapy?

Because five fractions (not days) are the key to proper 77427 use, reporting "weekly" management more than once a calendar week may be appropriate when patients receive treatment more than once a day. For instance, you may see oncologists order treatment twice daily (BID) for patients with head and neck cancers, for those undergoing accelerated partial breast irradiation (APBI), or in any case the oncologist deems the treatment necessary, says Scott Plemmons, RT(R)(T), senior consultant with Revenue Cycle Inc. in Austin, Texas.

Example: A patient has twice daily (BID) treatment Monday through Friday for a total of 10 fractions, and the physician documents seeing the patient on Tuesday and Thursday. In this case, two 77427 charges are appropriate,says Plemmons. "The important thing to keep in mind is that this charge is fraction based and not calendar based."

Guidelines: CPT and the MCPM word their rules on this issue almost exactly the same way: "Multiple fractions representing two or more treatment sessions furnished on the same day may be counted [note: CPT adds "separately" here] as long as there has been a distinct break in therapy sessions, and the fractions are of the character usuallyfurnished on different days."

3. Is 77427 OK for < 5 Fractions?

Patients won't always have treatment sessions in multiples of five (10 fractions, 15 fractions, etc.). The number of additional fractions will make a difference in your 77427 reporting.

The rule: The MCPM and CPT both state that at the final billing, contractors should pay 77427 for three or four fractions beyond a multiple of five. (Remember that you'll need an additional patient visit for the additional 77427 charge). Both also agree that you should not report 77427 if the patient has only one to two additional fractions beyond a multiple of five. "Payment for these services is considered as having been made through prior payments," the MCPM states.

Example: The MCPM provides the followingexamples:

Unit 1 5 Fractions

Unit 2 5 Fractions

Unit 3 5 Fractions

Unit 4 3 Fractions

Total = 4 Units Total = 18 Fractions

In contrast, you report only 1 unit for 6 fractions because 6 fractions divided by 77427's required 5 fractions equals 1 unit and a remainder of 1 fraction. You should not report an additional unit for 1 additional fraction.

Unit 1Total = 1 Unit

Tip: The MCPM instructs that you "must indicate on each claim the number of fractions for which payment is sought."

Stay tuned: In Part II, take your 77427 skills up another notch by learning which services weekly treatment management includes. And as a special bonus, you'll find Churchill's helpful 5-fraction grid to simplify tracking your "weeks."