Oncology & Hematology Coding Alert

Last issue, we discussed coding for prostate brachytherapy beginning with an initial E/M service, through treatment planning and possible volume studies and special treatment procedures. To report the full course of treatment accurately, you-ll need to continue a step-by-step coding approach. Read on for more expert tips to help you succeed.

Following treatment planning (77261-77263) for prostate brachytherapy, the oncologist may obtain images (x-ray film) of the targeted treatment area -- to define and adjust dose calculations -- and of the eventual position of the brachytherapy seeds. For this service, you should select an appropriate simulation code (77280-77290).

"The initial simulation may be reported as a complex simulation (77290, Therapeutic radiology simulation-aided field setting; complex) when it requires AP and lateral orthogonal films and contrast," Empire Medicare, Part B Carrier for New York and New Jersey, states in its local coverage determination for prostate brachytherapy.

In contrast, you would report three-dimensional MRI or CT-based simulations with dose volume histograms and dose cloud preparation using 77295 (-3-dimensional).

Note: You would not report 72290 and 77295 together. "Real-time" 3D planning (72295), which occurs at the same time as placement of the brachytherapy seeds, bundles 77290 on the same date.

Additionally, you may report 77280 (-simple) for verification simulations during treatment, says Janae Ballard, CPC, CPC-H, CPC-E/M, PCS, FCS, ACS-EM, revenue coding analyst at Virginia Mason Medical Center in Seattle.

You may need modifier 26: If your oncologist performs any type of simulation in a facility setting, you must append modifier 26 to the simulation code to show that he provided the "professional" portion of the service only.

Next, the physician will order an isodose plan, which determines the dose at each implanted source and throughout the treatment volume, as well as the doses to surrounding normal tissue. Depending on the number of sources the physician specifies, you will select:

- 77326 -- Brachytherapy isodose plan; simple [calculation made from single plane, one to four sources/ribbon application, remote afterloading brachytherapy, 1 to 8 sources])
(for eight sources or fewer)

- 77327 -- ... intermediate [multiplane dosage calculations, application involving 5 to 10 sources/ribbons, remote afterloading brachytherapy, 9 to 12 sources) (for 9-12 sources)

- 77328 -- ...complex [multiplane isodose plan, volume implant calculations, over 10 sources/ribbons used, special spatial reconstruction, remote afterloading brachytherapy, over 12 sources]) (for more than 12 sources).

Tip: A typical course of brachytherapy should require no more than three isodose plans. Documentation should reflect medical necessity for additional units of service. For instance, the physician may need additional calculations to determine decay or point dose calculations.

Brachytherapy requires dosimetry calculations prior to (and during) the course of therapy, and you may report these services separately in limited cases, Ballard confirms.

To report dosimetry calculation to determine dwell times, other than those times estimated in the isodose plan, use 77300 (Basic radiation dosimetry calculation, central axis depth dose calculation, TDF, NSD, gap calculation, off axis factor, tissue inhomogeneity factors, calculation of non-ionizing radiation surface and depth dose, as required during course of treatment, only when prescribed by the treating physician).

Proceed carefully: To report dosimetry calculations separately during brachytherapy, the dosimetrist or physicist must determine (and the oncologist must approve) dwell times other than those estimated in the isodose plan. The isodose plan generally includes multiple calculation points, and you would not separately report calculations made solely for quality assurance (that is, to confirm dose delivery).

Bottom line: You will report basic radiation dosimetry calculation separately with brachytherapy only in rare circumstances (for instance, if tumor volume changes).

You will report the actual brachytherapy treatment based on the type of radioactive source and its delivery method.

To describe the placement of seeds, needles, ribbons or wires containing radioactive materials into body tissues, you should report 77776-77778 (Interstitial radiation source application ...), as determined by the number of sources (prostate seed implants are usually "complex"):

1-4 sources: 77776 (-simple)

5-10 sources: 77777 (-intermediate)

10 or more sources: 77778 (-complex).

Watch for included services: Note that CPT includes hospital services (admission, daily visits, discharge) in the clinical brachytherapy codes. You should not report hospital services separately with 77776-77778.

Imaging note: In some cases, the radiation oncologist may provide the ultrasonic guidance (76965, Ultrasonic guidance for interstitial radioelement application) for placing the seeds. Typically, however, a urologist will provide this service. You should report 76965 only if your oncologist performs and documents the guidance.

If the brachytherapy requires manual loading of an isotope (LDR), you might report 77790 (Supervision, handling, loading of radiation source).

"The service includes receipt, accounting, handling and storage of the material," Ballard says.

Note that physicians will rarely perform 77790. Instead, this usually is a technical service that the physicist will provide.

Watch for Needle or Catheter Placement

If your oncologist performs and documents placement of the needles or catheters used to implant the brachytherapy seeds, you may report 55875 (Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without cystoscopy), says Teresa A. Dailey, CPC, coding specialist for Urology Center of Spartanburg in South Carolina.

Be aware, however, that a radiation oncologist often will work with a urologist to treat a prostate brachytherapy patient, and traditionally the urologist has been responsible for placing the needles or catheters. Only the physician who actually places the needles or catheters should report 55875, Dailey says.

Note that 55875 includes cystoscopy, which allows the physician to determine the seeds- location and whether any have been misplaced.

"Generally, the surgeon will use a simple treatment device with prostate brachytherapy," Ballard says.

You may report 77332 (Treatment devices, design and construction; simple [simple block, simple bolus]) separately for this service.

"The device is an interstitial brachytherapy prostate seed template," Ballard continues. "You may report 77332 if documentation from the radiation oncologist states involvement in selection and placement of the device."

Finally, as we discussed last month, you might be able to report 77470 (Special treatment procedure [e.g., total body irradiation, hemibody radiation, per oral, endocavitary or intraoperative cone irradiation]) if the physician does extra work or uses facility resources.

"Documentation must clearly state why the case was more complex to bill for 77470," Ballard stresses.

After the initial brachytherapy treatment, you might be able to report several post-treatment services. For example, the oncologist may want to verify the source of radiation by repeating isodose planning, or by performing another complex simulation.

When your oncologist performs simulation and reviews isodose plans post-brachytherapy, you should report them the same way you would have pre-brachytherapy.

For instance, a patient arrives for a complex, post-brachytherapy isodose plan in an office setting. On the claim, you should report 77328 (Brachytherapy isodose plant; complex [multiplane isodose plan, volume implant calculations, over 10 sources/ribbons used, special spatial reconstruction, remote afterloading brachytherapy, over 12 sources]).