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Oncology & Hematology Coding Alert

Part I:

Prostate Brachytherapy Coding to Tumor Mapping

Published on Wed Feb 02, 2005

Use ICD-9 code 185 for prostate cancer patients

When your oncologist evaluates a patient for possible prostate brachytherapy, determine whether the encounter was a consult or an office visit and report the treatment planning with 77263 - if the planning service shows a high level of complexity.

Prostate brachytherapy does not have its own unique CPT code, which leaves coders with questions about how to report each procedure ethically and gain maximum reimbursement for the office.

Read on for expert advice on reporting the patient's initial encounter with the oncologist and treatment planning. See next month's edition of Oncology Coding Alert for advice on coding for implant procedures, post-treatment planning, and consultations with physicists.

Brachytherapy Patient Evaluations Get Level 4 or 5

Oncology offices usually encounter prostate brachytherapy patients in two ways: in the course of an evaluation and management service or during a consultation, typically at the request of a urologist, says Sandy McMaster, outpatient oncology financial specialist at Edward Cancer & Radiation Centers in Lisle, Ill.

During these initial visits, the oncologist generally documents and reports a level- four or level-five service. The first encounter with a brachytherapy candidate is very involved because the physician must be careful to rule out other treatment modalities (such as external beam treatments) before settling on brachytherapy, McMaster says.

Example: The oncologist sees Patient X, who has prostate cancer and may benefit from prostate brachytherapy. The oncologist spends 35 minutes taking a history, performing a physical examination, and considering various treatment options - then calls Patient X's family into the room and counsels them for 20 more minutes. Documentation qualifies this encounter as a level-five service.

On this claim, you should report:

  • 99205 - Office or other outpatient visit for the evaluation and management of a  new patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision-making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 60 minutes face-to-face with the patient and/or family, when the encounter is a new patient office visit.
  • 99215 - Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a comprehensive history; a comprehensive examination; and medical decision-making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family, when the encounter is an established patient office visit.
  • 99245 - Office consultation for a new or established patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision-making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 80 minutes face-to-face with the patient and/or family, if the service was a consultation.

    For consults, you would report 99245 whether the patient was new or established.

    No matter what: You should include proof of medical necessity for this high level of service. Whether you report 99205, 99215 or 99245 in the above example, you should attach ICD-9 code 185 (Malignant neoplasm of prostate) as the primary diagnosis for the patient visit.

    Complex Planning Is Usually in Order

    Once your physician identifies the patient as a prostate brachytherapy candidate, the office can begin treatment planning. Planning a prostate brachytherapy course of treatment can include interpreting special tests and prostate localization. This service is a professional service only, and there is only one unit of this service allowed per course of therapy.

    CPT commits a trio of codes to brachytherapy treatment planning:
     

  • 77261 - Therapeutic radiology treatment planning;simple
     
  • 77262 - ... intermediate
     
  • 77263 - ... complex.

    In most instances, you report the oncologist's brachytherapy planning with 77263, provided that the medical record reflects the high level of complexity the service required.

    Remember: If the patient had a course of external beam treatment or other radiation modality, prior to the brachytherapy, report only one clinical treatment planning service per course of therapy, says Cindy Parman, CPC, CPC-H, RCC, president elect of the AAPC National Advisory Board and co-founder of Coding Strategies Inc., in Dallas, Ga.
     
    "Therefore, if the physician's treatment planning was reported for the initial service, it would not be reported again for the brachytherapy boost," Parman says.

    Don't Forget to Report Mapping

    For most patients, the oncologist may need to perform ultrasound volume and tumor mapping services before inserting the catheter and prostate seeds, McMaster says. Suppose your oncologist performs a prostate volume study during prostate brachytherapy planning for Patient X.

    On the claim, you should report 76873 (Ultrasound, transrectal; prostate volume study for brachytherapy treatment planning [separate procedure]) for the procedure and attach ICD-9 code 185 to 76873.

    Heads-up: "For some practices, both the urologist and radiation oncologist participate in this ultrasound volume study. Only one physician can bill for the professional service associated with code 76873," Parman says.

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