Oncology & Hematology Coding Alert

Keep your hands off 77402-77416 if you bill professional only.

If you don't understand the importance of energy levels or same-day sessions, your independent facility's radiation treatment delivery claims could be headed for trouble. But if you follow these three steps, you'll be on your way to coding 77402-77416 with confidence.

Step 1: Sort 77401-77416 by Complexity

CPT breaks "Radiation Treatment Delivery" codes 77402-77416 into different families based on complexity. (Note that the CPT manual does not refer to the codes as simple, intermediate, and complex.)

Simple: 77402-77406 -- Radiation treatment delivery,single treatment area, single port or parallel opposed ports, simple blocks or no blocks ...

Intermediate: 77407-77411 -- Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks ...

Complex: 77412-77416 -- Radiation treatment delivery,3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam ...

Assuming the documentation supports medical necessity, you should need to meet only one of the requirements listed in a definition to choose that level of complexity. In other words, if the patient has custom blocking (complex) and three ports on a single treatment area (intermediate), you may report a complex code (77412-77416).

Crucial: All of these codes are technical component codes. That means "only the facility will report these codes; there is no physician component for them," explains Clair Callaway, CPC, operations manager for RadMax Ltd., a radiation oncology billing and consulting firm in Tyler, Texas. The physician instead reports 77427 (Radiation treatment management, 5 treatments) once per five fractions, Callaway says. The physician's code includes services such as image review and evaluation of treatment set up, she says.

Step 2: Check Energy Level Impact

Once you've determined the complexity level, you can make your code selection based on energy level: For external beam treatment, excluding intensity modulated radiation therapy (IMRT) and image guided radiation therapy (IGRT), you may see 77413 (complex, 6-10 MeV) and 77414 (complex, 11-19 MeV) most often, says Callaway. In many practices, the radiation therapist assigns the treatment code by putting it in the system, such as IMPAC or ARIA, and the coder confirms the code is accurate, she adds.

Whether you're assigning the code or verifying it, remember that if the patient has multiple treatment areas at the same session, you should not add the energy levels together to choose your code.

Example: If the patient has two treatment areas each treated with 10 MeV, you should choose a 10 MeV code (such as 77408). You should not add 10 MeV (treatment area 1) and 10 MeV (treatment area 2) to choose a 20 MeV code. You also should not report 77408 twice for the two areas treated at the same session. The code's definition takes "2 separate treatment areas" into account.

Step 3: Comply With 'Different Session' Rule

Although you should not report multiple codes for multiple treatment areas at a single session, certain types of cancer may require two or more radiation treatments a day. You may report 77402-77416 more than once per date of service only when the patient receives radiation treatment "during completely different sessions," according to Medicare Claims Processing Manual, chapter 13, section 70.3 (manuals available at www.ms.gov/Manuals/IOM/list.asp).

To qualify as different sessions, payers often want documentation of a six-hour break between the two sameday treatments, says Erin Goodwin, CPC, CMC, director of radiation reimbursement for South Carolina Oncology Associates in Columbia. Some payers may OK a minimum four-hour break.

Documentation should support the multiple sessions, such as describing medical necessity for twice-daily treatment and including a twice-daily prescription order.

Payer preference: Verify your payers' reporting preference for these services. For example, if the same code applies to both sessions, a payer may ask you to report a single line-item with multiple units or to report two line-items with modifier 76 (Repeat procedure or service by same physician) appended to the second, Goodwin says. Alternatively, for two same-day services, South Carolina Medicare carrier Palmetto GBA asks facilities to report the appropriate treatment codes -- without modifiers -- and include a note in box 19 that indicates there were A.M. and P.M. treatments, Goodwin says.