Oncology & Hematology Coding Alert

Question: A patient who was in treatment with our oncologist is now diagnosed with bone metastasis, 198.5 (Secondary malignant neoplasm of bone and bone marrow). The patient earlier had brain metastasis, 198.3 (Secondary malignant neoplasm of brain and spinal cord). Can we charge a separate 77295 (Therapeutic radiology simulation-aided field setting; 3-dimensional) for the bone metastasis? Can we use the same CT planning for this patient who will be receiving radiation treatments on both sites?

New Mexico Subscriber

Answer: You will need a second set of CT data to support your coding for a separate 77295 again. Your oncologist would need to order 2 separate 3D plans and each will need a separate set of CT slices. In the case described, the patient seems to have metastasis in two body areas that need 3D planning. Your oncologist will need to indicate medical necessity for each 3-D planning, which may be based on the structures the oncologist wants to protect in addition to the tumor volume to be treated. Your oncologist should also sign and date the documentation produced by the 3D software and retain a copy in the patient’s chart.

Single unit of 77295: In most circumstances, you report a single unit of 77295. This is because the anatomy and the tumor volume do not typically change for the highest dose regions throughout the course of treatment.

You report CPT® Code 77295 only ONCE per course of therapy even if there is a planned ‘cone-down’ treatment feature or change in field size. You report a single unit of 77295 when your oncologist uses the same CT data-sets to plan the two sets of treatments. For example, when your oncologist uses more than one set of beams utilizing different beam and gantry angles to treat a larger "nodal" volume and a smaller "cone-down" volume, two sets of beam’s eye view can be generated. However, your oncologist may only document a single cumulative dose distribution from the dose-volume histograms of the two plans. Thus, it would be most appropriate for you to report a single unit of 77295.

When to report multiple units of 77295? You may report a second unit of 7795 in the uncommon circumstance when there is a substantial change in either patient anatomy or tumor conformation which necessitates a second CT dataset to produce an accurate and efficacious "cone-down" plan. Your physician, in this case, will need to document the need medical necessity for the second plan.

In summary: You cannot bill for CPT® code 77295 during the same course of treatment unless required by a change in patient anatomy during treatment require repeat CT scanning.