Oncology & Hematology Coding Alert

And pay attention to these valuable documentation tips.

Even though radiation oncology has just a small number of codes in the CPT^® 77000 radiology series, “one of the difficulties with radiation oncology coding is that it’s used multiple times, in multiple ways. That’s where it gets confusing.” So began Teri Bedard, BA, RT(R)(T), CPC, executive director, client & corporate resources at Revenue Cycle Coding Strategies, Des Moines, Iowa in her HEALTHCON 2023 presentation “Radiation Oncology Coding.”

To keep everything straight, Bedard provided a systematic breakdown of the process of care typically used in radiation oncology. Here is her step-by-step process for coding the services, along with some coding tips to help you code them correctly every time.

Step 1: Document Clinical Treatment Planning

Codes involved: 77261/77262/77263 (Therapeutic radiology treatment planning; simple/intermediate/complex).

“The numerical sequence of the CPT^® codes tells you the process of care for the patient,” Bedard began. So, 77261-77263 represent the first step in the process and reflect the physician’s cognitive thought process. The codes explain “what’s the diagnosis? What area or areas are we going to treat? What is their plan of care? What services are needed in order to treat this patient? Is the treatment curative or palliative?” Bedard noted. Though these things can change during the plan of care, these codes show the oncologist’s ongoing orders for patient treatment.

Coding tip 1: Some patients will require extra work, and with that comes extra time and effort on the oncologist’s part. This can be billed with 77470 (Special treatment procedure (eg, total body irradiation, hemibody radiation, per oral or endocavitary irradiation), which you should also bill only once for the course of therapy.

Step 2: Document Setup or Initial Simulation

Codes involved: 77280/77285/77290 (Therapeutic radiology simulation-aided field setting; simple/intermediate/complex). Also, 77332/77333/77334 (Treatment devices, design and construction; simple …/intermediate …/complex …).

These codes document the process of positioning the patient in a “reproducible and tolerable (though not necessarily comfortable) position, because the key to radiation is not treating areas that don’t need radiation,” Bedard explained. They involve the oncologist participating in creating imaging, marking the patient’s skin, and developing devices that immobilize the patient into a specific body position so that clinical staff can then set the patient up in exactly the same position every time the patient receives treatment.

Coding tip 2: The National Correct Coding Initiative (NCCI) edits bundle computed tomography (CT) simulation into 77280-77290, which means you cannot separately bill for 77014 (Computed tomography guidance for placement of radiation therapy fields). Also, 77301 (Intensity modulated radiotherapy plan …) bundles into 77280-77290. So, you should “hold off on putting 77301 through until you know if the oncologist plans on using IMRT,” Bedard advised.

Step 3: Document Dosimetry Calculations

Codes involved: 77306/77307 (Teletherapy isodose plan; simple/ complex …) and 77321 (Special teletherapy port plan, particles, hemibody, total body) for isodose plans; 77295 (3-dimensional radiotherapy plan, including dose-volume histograms) for 3-D conformal plans; and 77301 for IMRT plans.

Additional codes:

• 77332/77333/77334 (Treatment devices, design and construction; simple/intermediate/complex …) for beam modifier devices with 77306/77307 and 77295
• 77338 (Multi-leaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT)) for beam modifier devices with 77301
• 77300 (Basic radiation dosimetry calculation …) with 77295 and 77301 (for secondary calculations)
• 77293 (Respiratory motion management simulation …) with 77295 and 77301 (if applicable to either service)

“Regardless of patient diagnosis, there are really only three routes of dosimetry planning, each one increasing in complexity,” Bedard explained. They are isodose plans, 3-D conformal plans, and IMRT plans. Documentation for these plans is visual rather than narrative, using CT scans for 77306/77307/77321 and graphs representing tumor volume (TV) and anatomical structure for 77295. For IMRT, there also needs to be a statement of medical necessity explaining why the oncologist chose this form of treatment over others.

Coding tip 3: Because IMRT is so complex, and payers reimburse it at a much higher rate than the other dosimetry codes, 77301 is subject to multiple bundling restrictions, which you can view in chapter 4 of the Medicare Claims Processing Manual (www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c04.pdf) and private payer documentation.

Step 4: Document Verification Simulation or IGRT

Codes involved: 77280/77285/77290 (Therapeutic radiology simulation-aided field setting; simple/intermediate/ complex) for verification simulation and G6001 (Ultrasonic guidance for placement of radiation therapy fields), G6002 (Stereoscopic X-ray guidance for localization of target volume for the delivery of radiation therapy), G6017 (Intra-fraction localization and tracking of target or patient motion during delivery of radiation therapy …), or 77014 (Computed tomography guidance for placement of radiation therapy fields) for image guided radiation therapy (IGRT).

This part of the treatment plan involves verifying the accuracy of custom blocks and treatment parameters with the patient present, Bedard explained. The code you use will correspond to the type of imaging used.

Coding tip 4: Documentation for this service needs to include images and a written narrative describing the procedure, along with evidence that the oncologist has reviewed the images prior to the treatment session, according to Kristen Taylor, CPC, CHC, CHIAP, associate partner for Pinnacle Enterprise Risk Consulting Services, LLC in Columbia, SC.

Step 5: Document Treatment Delivery

Codes involved: 77401 (Radiation treatment delivery, superficial and/or ortho voltage, per day) for skin cancers. Linear accelerator and beam shaping codes are based on number of treatment areas and intensity: G6003-G6005 (Radiation treatment delivery, single treatment area …) and G6007-G6009 (Radiation treatment delivery, 2 separate treatment areas …).

Stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SRS or SBRT): Treatment is now moving toward stereotactic delivery, which features a shorter course of delivery, according to Bedard. Codes involved in SRS, for cranial lesions, and SBRT, for treatment to the body, are:

• 77371 (Radiation treatment delivery … (SRS) ... multi-source Cobalt-60 based)
• 77372 (Radiation treatment delivery … (SRS) ... linear accelerator based)
• 77373 (Stereotactic body radiation therapy …)

Coding tip 5: Code 77373 has a threshold of five fractions, and the physician must create a procedure note for each fraction.

Step 6: Document Physician Treatment Management

Codes involved: 77427 (Radiation treatment management, 5 treatments), 77431 (Radiation therapy management with complete course of therapy …), 77432 (Stereotactic radiation treatment management of cranial lesions …), 77435 (SBRT, treatment management, per treatment course …).

Coding tip 6: “Payers may have specific instructions for reporting these codes and for the date of service. For example, 77427 is usually only billable after your oncologist delivers the fifth fraction, with three or more fractions required to bill the final week,” Bedard reminded her audience.