Oncology & Hematology Coding Alert

Let this guide lead you to the correct guidance codes.

To code intensity modulated radiation therapy (IMRT) services, you only need two codes. But there is a lot packed into the services described by 77385 (Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; simple) and 77386 (… complex).

For one thing, separating out the codes’ professional and technical components, especially the correct way to code the professional component for IMRT guidance, isn’t obvious. And, as with all radiation oncology procedures, there are plenty of services bundled into the codes.

Here, then, are all the dos and don’ts you should bear in mind the next time you bill for IMRT.

Do Understand IMRT

Like all external beam radiation therapies, IMRT targets cancer cells with high-energy X-rays. However, IMRT directs the X-rays with more precision than the other therapies, so it delivers “higher, more effective doses of radiation while limiting damage to the healthy tissues and organs around it,” according to the Memorial Sloan Kettering Cancer Center (https://www.mskcc.org/cancer-care/diagnosis-treatment/cancer-treatments/radiation-therapy/ what-imrt). This makes it an effective way to treat such cancers as “prostate cancer, head and neck cancers, lung cancer, brain cancer, gastrointestinal cancers, and breast cancer, in part because these tumors tend to be located close to critical organs and tissues in the body.”

Do Understand Simple and Complex

The good news about coding for IMRT is that the criteria for choosing between 77385 and 77386 are the same criteria you already use for all the radiation treatment delivery codes, with one important difference, as you’ll see later.

Simple IMRT, coded to 77385, must consist of a “single treatment area, one or two ports, and two or fewer simple blocks,” and “none of the complex or intermediate criteria are met” according to CPT^®’s current radiation treatment delivery guidelines. Complex IMRT, on the other hand, must meet any of three criteria, including “3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, field-in-field or other tissue compensation that does not meet IMRT guidelines, or electron beam,” the CPT^® guidelines continue.

Don’t Overlook IMRT-Specific Guidelines

Additionally, two important CPT^® instructions differentiate IMRT from the other radiation treatment delivery services. The guidelines tell you that if the radiation oncologist uses a compensator — a high-density metal block that controls the amount of radiation directed to the cancer source, such as the prostate or breast — you will use 77385.

For “all other sites if not using physical compensator based IMRT,” you’ll use the complex procedure code: 77386.

The guideline also tells you that both simple and complex IMRT procedures include the technical services for guidance.

Do Understand Components for 77385/77386

For the professional component of IMRT guidance and tracking, CPT^® instructions that accompany 77385/77386 tell you to use 77387 (Guidance for localization of target volume for delivery of radiation treatment, includes intrafraction tracking, when performed) and append modifier 26 (Professional component) to the guidance code. However, “For Medicare patients IMRT treatment delivery is not billed with 77385/77386 [according to the Medicare Physician Fee Schedule (MPFS)]. Instead, you report the professional component of IMRT treatment delivery with HCPCS Level II code G6015 [Intensity modulated treatment delivery, single or multiple fields/ arcs, via narrow spatially and temporally modulated beams, binary, dynamic MLC, per treatment session],” explains Kristen Taylor, CPC, CHC, CHIAP, Associate Partner for Pinnacle Enterprise Risk Consulting Services, LLC in Columbia, SC.

“Then, for the 77387, you will use one of the following HCPCS Level II codes: 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], or G6017 [Intra-fraction localization and tracking of target or patient motion during delivery of radiation therapy (eg, 3D positional tracking, gating, 3D surface tracking), each fraction of treatment],” Taylor adds.

Why? “Because code 77387 was not assigned a value under the M[P]FS, the professional component of image guidance is typically reported with a HCPCS G-code (… depending on the modality used to perform the IGRT services),” according to CPT^® Assistant, Volume 26, Issue 2, February 2016.

Depending on circumstances and payer preference, you may also report 77014 (Computed tomography guidance for placement of radiation therapy fields). But you’ll append modifier 26 to G6001, G6002, G6017, and/or 77014 whenever you separately report the professional component of IMRT guidance and tracking.

For the technical component “CPT^® codes 77385 and 77386 include the TC of guidance or tracking, if performed. Therefore, the TC of code 77387 should not be separately reported with IMRT treatment delivery code 77385 or 77386,” according to the same CPT^® Assistant article.

Don’t Code These Services Separately with 77385/77386

Last, remember to follow CPT^® guidelines established for all radiation oncology services before you code other services separately from the IMRT procedures. Do not bill these services separately:

• The initial consultation
• Clinical treatment planning
• Simulation
• Medical radiation physics
• Dosimetry
• Treatment devices
• Special services and
• Clinical treatment management procedures.

IMRT also includes “normal follow-up care during course of treatment and for three months following its completion” per CPT^®.

For another breakdown of each IMRT service, which may help reinforce this information, Noridian provides additional guidance at https://med.noridianmedicare.com/web/jfa/topics/ radiology-radiation-oncology/intensity-modulated-radiation-therapy-imrt-billing.