Oncology & Hematology Coding Alert

Understanding 77427 is a key element of keeping your radiation coding on track. Frequently Asked Questions digging into the truth behind the term "weekly" management, the effect of twice daily treatment on your coding, and how to report three to four additional fractions all got answered in last issue's "Part 1: 3 FAQs Clear Up the 77427 5-Fraction Mystery."

Now, FAQs 4, 5, and 6 help you steer clear of tempting coding mistakes and make sure you have your documentation ducks in a row.

You may report 77427 (Radiation treatment management, five treatments) once for every five treatment fractions. If the patient completes treatment and has three or four final treatments beyond a multiple of five, you may report one unit of 77427 for those final three or four fractions. You should not report 77427 for one or two final fractions, however.

You also should never report 77431 (Radiation therapy management with complete course of therapy consisting of one or two fractions only) for the last one or two fractions in a long course of therapy, says Deborah I. Churchill, president of Killingworth, Conn.-based Churchill Consulting Inc.

Only report 77431 if the entire course of treatment consists of one or two fractions, and you are not reporting a stereotactic case, says Scott Plemmons, RT(R)(T), senior consultant with Revenue Cycle Inc. in Austin, Texas.

Support: A CPT note with 77431 states "77431 is not to be used to fill in the last week of a long course of therapy." And for stereotactic treatment management, CPT offers more specific codes: 77432 (Stereotactic radiation treatment management of cranial lesion[s] [complete course of treatment consisting of 1 session]) and 77435 (Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions).

Caution: If you've sent in claims indicating the treatment course has ended but treatments resume, CMS instructs contractors to pay for additional services as if the break had not occurred. That means that if a patient resumes treatment and has one or two additional fractions, you again should not report 77431.

Example: You reported 77427 twice for eight fractions, which the oncologist expected to complete the course of therapy. But then the same physician decides to furnish two additional fractions. Contractors should not pay separately for the two additional fractions, states Medicare Claims Processing Manual (MCPM), Chapter 13, Section 70.1.

There are four elements to 77427, according to the American Society for Radiation Oncology (ASTRO), the American College of Radiation Oncology (ACRO), and the American Medical Association (AMA), says Plemmons:

1. Review of port films

2. Review of dosimetry and chart prescription (dose delivery and treatment parameters)

3. Review of the patient's treatment set-up

4. Examination of the patient for medical evaluation and case management.

CPT specifies that the examination includes assessing the patient response to treatment, coordinating care and treatment, and reviewing imaging or lab results.

"This code also requires a documented face-to-face encounter with the patient," says Plemmons. For more on this requirement, see the next section.

The radiation therapist doesn't have to examine the patient during each fraction for you to receive 77427 reimbursement, says the MCPM. But you do need a progress note in the record for the five-fraction date span (treatment "week"), says Plemmons.

"When the radiation oncologist sees a patient, it is the radiation oncologist's responsibility to document that encounter via a progress note, which will become part of the patient's medical record," Churchill says. "The weekly progress note, commonly referred to as the OTV (on treatment visit note) should include the date of the visit, the current dose, exam, symptoms, orders, etc.," she says. The oncologist should also document a recommendation,such as "continue as planned," says Churchill.

Because you can report 77427 only if you have a documented physician progress note within the "week" (five-fraction period), a five-fraction grid is a "greattool to assist the coder in determining when a 'week' is reportable," says Churchill. Remember that to report 77427 you need three or more "days" in the final week, with a progress note available, she adds.

Here is a sample chart, provided by Churchill:

In the "Date From" column, put the date the patient had the first treatment in the five-fraction week, and in the "Date To" column, note the date of the last fraction in the "week." For example, if the patient received treatment on a Wednesday, Thursday, Friday, Monday, and Tuesday,you would enter the Wednesday date in the "Date From" column and the Tuesday date in the "Date To" column. Then you can quickly assess whether the dates of the visit ("Date Seen") and the "Progress Note" date fall within the five-fraction week.