Oncology & Hematology Coding Alert

Question: Which codes are billed with remote afterloading high-intensity brachytherapy? How are they billed if the patient also receives regular beam treatment?

Texas Subscriber

Answer: The answer depends on the services performed and documented in the patient medical record. If the high-dose rate (HDR) brachytherapy is combined with external beam therapy, then the possibilities for code assignment include nearly all of the services listed in the radiation oncology section of CPT 77261-77799.

In general, there is an initial patient E/M service consultation (99251-99255) or patient exam (99201-99205) typically coded once per patient regardless of any combination of therapy services provided. There will generally be a treatment plan (77261-77263, Clinical treatment planning [external and internal sources]) and one or more brachytherapy isodose plans (77326, Brachytherapy isodose calculation; simple [calculation made from single plane, one to four sources/ribbon application, remote afterloading brachytherapy, 1 to 8 sources]; or 77328, ... complex [multiplane isodose plan, volume implant calculations, over 10 sources/ribbons used, special spatial reconstruction, remote afterloading brachytherapy, over 12 sources]) for the HDR services, and potentially surgical services for implantation of devices such as colpostats.

The radiation oncologist would bill only for the services rendered. So, if surgery is performed by another specialist, such as a gynecologist or urologist, the radiation oncologist would not bill for the surgery. Also, the treatment plan is coded once per course of treatment and would typically be complex (77263) when combined modalities are applied to the tumor volume. Code 77470 (Special treatment procedure [e.g., total body irradiation, hemibody radiation, per oral, endocavitary or intraop-erative cone irradiation]) would be assigned to indicate that a special service exists if combined modalities are performed. The physician may also perform special dosimetry (77331, Special dosimetry [e.g., TLD, microdosimetry][specify], only when prescribed by the treating physician) and special teletherapy (77321, Special teletherapy port plan, particles, hemibody, total body). Code 77790 (Supervision, handling, loading of radiation source) would not be coded because Medicare and most third-party payers bundle it into the HDR codes.

Depending on the type and length of the therapy, you may also assign codes for simulation (77280-77295), isodose plan (77305-77315) and weekly treatment management (77427) for a fractionated course of treatment. The weekly treatment management code is billed only once per five fractions, regardless of whether there is only external beam or HDR combined with external beam.

If you are billing for physician services only, some of the codes listed are professional only, such as treatment planning and management, but others require modifier -26 (Professional component) to indicate that you are billing for the professional services portion of the procedure. The facility where it was performed will bill for the technical component.