Oncology & Hematology Coding Alert

Question: Can I charge for 76370 if the CT scan is ultimately used for a 3-D simulation (77295)? If so, what documentation is required, and are there any restrictions?

Wisconsin Subscriber

Answer: If the CT was used only for planning, 76370 (Computerized axial tomographic guidance for placement of radiation therapy fields) may be billed. However, the professional component of a CT scan used for three-dimensional (3-D) simulation should not be separately reported by the radiation oncologist. Some facilities require that a radiologist perform an interpretation and generate a written report to document accurately the CT slices obtained for technical component billing. To bill insurance companies for this professional service, you must document the medical necessity. Many payers will not reimburse the professional component of this service because they believe that the patients condition is established, the location and extent of the cancer is known, and there is no diagnostic reason to interpret the CT slices obtained for treatment planning. Other facilities manually enter the CT information in the patient medical record (date, number of slices, technologist name, etc.) and eliminate the need for radiologist dictation.

3-D simulation (77295, Therapeutic radiology simulation-aided field setting; three-dimensional), a computer-generated three-dimensional reconstruction of tumor volume and surrounding critical normal tissue structures, is derived from direct CT scans and/or MRI data in preparation for non-coplanar or coplanar therapy. The CT and/or MRI slices are used to target tumor volume that is difficult to visualize using other imaging equipment. If the CT scan is used to obtain the treatment planning images, 76370 cannot be billed with 77295 because services integral to treatment planning are included in the computerized simulation. This coding practice is supported by the American College of Radiology, and the acquisition of CT slices (76370) is bundled into the 3-D simulation (77295) by Medicare and other third-party payers.

Important note: If practices are using 3-D simulations on all of their patients, this should be coded and billed according to medical-necessity guidelines. In other words, just because a 3-D simulation was performed doesnt mean the procedure was medically necessary, and it may be more appropriate to report 77290 (Therapeutic radiology simulation-aided field setting; complex) or another simulation code.

Reader Questions and You Be the Coder were answered by Elaine Towle, CMPE, practice administrator for New Hampshire Oncology and Hematology in Hooksett, N.H.; Margaret Hickey, MS, MSN, RN, OCN, CORLN, independent coding consultant in New Orleans; and Lillie McAlister, CPC, president of Double Diamond Enterprises in Conroe, Texas. q