Oncology & Hematology Coding Alert

Don't forget to hit the Category III section for your most recently added option.

Imaging technology is making it easier to target treatment fields precisely. So be sure your claims hit the mark by mastering the guidance and tracking codes you need to know for image guided radiation therapy.

Spotlight the 'I' in IGRT Image guided radiation therapy (IGRT) refers to using imaging "to account for changes in the position of the intended target before or during treatment delivery," according to Part B J12 MAC Highmark's local coverage determination (LCD) L27515.

The imaging takes place in the treatment room when the patient presents for therapy.

Oncologists may choose IGRT for patients with tumors near or in critical structures or if the tumor is "in tissue with inherent setup variation," Highmark notes. In other words, tumors and normal tissues can change position between fractions or even during a treatment session.

For instance: Consider how tumor size can change or how gastric motility could alter tumor position. IGRT tracks the changes to ensure the radiation targets the tumor as accurately as possible. To locate the target, the clinicians may use fiducial markers, external markers, or an organ or other anatomic structure.

Proper Code Depends on Modality

IGRT is a distinct service that you may bill along with traditional treatment delivery codes. You may see IGRT services paired in particular with intensity modulated radiation therapy (IMRT) delivery (77418, Intensity modulated treatment delivery ...), which "imposes a more stringent requirement than conventional radiation therapy in terms of accounting for patient position and organ motion," according to Part B MAC WPSIC, in LCD L30316.

The IGRT code you report will depend on the imaging modality used. For radiographic imaging guidance, you'll see the following most often, says Beth Potratz, CPC, certified coder with the Cancer Treatment Center in Swansea, Ill.:

• 76950 -- Ultrasonic guidance for placement of radiation therapy fields
• 77014 -- Computed tomography guidance for placement of radiation fields
• 77421 -- Stereoscopic x-ray guidance for localization of target volume for the delivery of radiation therapy.

(Note: Remember that only facilities, including freestanding centers, may report treatment delivery codes because the codes do not have a professional component. Each of the IGRT codes listed has both a professional and technical component.)

Single Out 77421 for Success

Ultrasonic and CT guidance may be easy to spot in your documentation, but if you need a little more help with stereoscopic X-ray guidance, CPT Changes 2006: An Insider's View offers some helpful hints.

For 77421, the "technology detects any 3D deviations between actual and planned target position." The clinical example in CPT Changes 2006 includes placement of infrared markers either on the patient or treatment couch to monitor position, kV or mV stereoscopic X-ray imaging of internal anatomy or implanted markers just before treatment, comparison of those images with digital reconstructed radiographs (DRRs) from treatment planning to identify discrepancies, and addressing any deviations by adjusting patient position. In addition, the radiation oncologist reviews the images daily, compares them with previous shifts, and offers feedback to the radiation therapist, according to CPT Changes 2006.

Potratz notes her practice uses 77421 for most prostate cases requiring IGRT, as well as for head and neck cancer cases and some breast patients. The patients with prostate cancer "have fiducial markers placed. For the other ones we use the bony anatomy to find the tumor/target volume," she says.

And don't forget that in 2009 Medicare changed 77421's technical component supervision requirement to direct supervision (02), says Potratz. Direct supervision means the oncologist doesn't have to be in the room, she just needs to be in the same office suite, readily available to offer assistance if necessary.

Capture Cat. III Code for Live Tracking

The codes above -- 76950, 77014, and 77421 -- describe radiographic imaging guidance to identify the organ or target position before radiation delivery, according to CPT Changes 2010: An Insider's View. But because target position can change during treatment due to breathing motion or muscle contraction in the gastrointestinal tract, radiation may miss the target. So CPT established 0197T (Intra-fraction localization and tracking of target or patient motion during delivery of radiation therapy [e.g., 3D positional tracking, gating, 3D surface tracking], each fraction of treatment) for localization and tracking performed during treatment delivery. You may report the code for each treatment fraction.

The clinical example in CPT Changes 2010 includes placing tracking devices, documenting baseline position stability or cyclical motion, monitoring from the device console, interrupting treatment "according to tracking rules" and changing delivery as needed, and then preparing the tracking record for physician review.

Payer check: Many payers consider 0197T services investigational and noncovered. Others require precertification and some others consider it covered for certain conditions only, such as prostate cancer.

CPT requires providers to report the code that accurately describes the services provided, so "you must pick the  ategory III code for a particular service before using an unlisted Category I CPT code," says Lisa Center, CPC, a billing professional with Mt. Carmel Regional Medical Center in Pittsburg, Kan. CPT creates Category III codes for emerging technology, services, or procedures that might not be widely performed. If a technology (and therefore a code) becomes more widely used, it has the potential to become a Category I code, says Center.

Examples of technology that merits 0197T includes Calypso 4D Localization System, C-RAD Sentinel system, or RayPilot System.