Oncology & Hematology Coding Alert

Question: I am working a denial with 77427 per the Humana policy. I know that Humana plans require providers to submit a “from” date, representing the date of the first session of the charge, and a “to” date, representing the date of the last session of the charge. What other supporting documentation do I need to overturn the denial?

AAPC Forum Participant

Answer: You are correct in saying Humana requires you to document 77427 (Radiation treatment management, 5 treatments) “with a ‘from’ date representing the date of the first session of the charge and a ‘to’ date representing the date of the last session of the charge.”

However, one possible reason for a denial in this part of the documentation may be a failure to “include comments when there are five or fewer days between the ‘from’ date for one covered charge and the ‘from’ date of the charge in question,” per their document Radiation Therapy Management (Revised), which can be found at www.humana.com/provider/medical-resources/ claims-payments/claims-payment-policies. The Humana document also outlines two other possible reasons for denial:

• “Humana plans deny, as inappropriately billed, charges at the end of a course of treatment for fewer than three sessions,” and only allow 77427 to be “submitted for five sessions.” For three- and four-sessions units, “the billing provider must submit a single-unit charge distinct from all other units.”
• For Medicare Advantage (MA) members, Humana requires you to submit comments “when there are five or fewer days between the ‘from’ date for one covered charge and the ‘from’ date of the charge in question … if Original Medicare (OM) would do so.” Additionally, such comments for MA members must “conform to the syntax that OM would require for them.”

Last, per the article “Coding Tips from the NCCI Policy Manual Chapter IX” in AHA Coding Clinic Vol. 22, No.(2022), 77427 may be subject to bundling with the clinical brachytherapy codes (77750-77790). So, you should check with your Humana rep to see if this, or any of the above reasons, are responsible for your denial.