Oncology & Hematology Coding Alert

Question:

New Jersey Subscriber

No. If you check CPT's "Clinical Treatment Planning (External and Internal Sources)" guidelines, the definition of complex planning includes "combination of therapeutic modalities."

Your New Jersey Medicare Part B contractor, Highmark, specifies that "Treatment planning is a one-time charge per course of therapy. Billing for multiple treatment plans for a single course of treatment is not allowed." This information is in Highmark's "Radiation Therapy Services" local coverage determination (L27515).

The policy explains that 77263 (Therapeutic radiology treatment planning; complex) is appropriate "when complex treatment planning is involved. Three or more volumes of interest may require treatment. Planning includes interpreting complex tests such as MR and/or CT localization of tumor(s). The cancer is generally complex in its distribution regardless of whether the patient is in early or advanced stages of cancer. Multiple critical areas generally require planning of special protection. Combined therapy may be required for optimum benefit such as brachytherapy, surgery, and chemotherapy." (Search for the policy at www.cms.gov/mcd/search.asp.)

Room for improvement: Treatment planning documentation is often not as complete as it should be. Thorough documentation should record reviews of imaging studies and biopsies, medical necessity for the treatment modality (or modalities) selected, and anything distinctive about the patient (such as body size or prior radiation) that affects planning.