Oncology & Hematology Coding Alert

Question: When can we code a 3-D simulation on the right breast if we use multiple field tangents? We code 3-D for the left breast because of the dosimetry to keep the heart out of the field.

Florida Subscriber

Answer: The area you're protecting, not the area you're treating, usually dictates medical necessity for 77295 (Therapeutic radiology simulation-aided field setting; three-dimensional), so unless you are protecting critical normal tissue structures, don't report 3-D treatment planning.
 
Translation: In your example, don't code 77295 for the right breast without more specific documentation. Never, never, never perform a 3-D plan and code it as something else just for the sake of reimbursement. (The Office of Inspector General agrees in its Physician Compliance Program, on-line at http://oig.hhs.gov/authorities/docs/physician.pdf.)
 
Code 77295 requires documentation of 3-D imaging to reconstruct tumor volume and surrounding critical normal tissue from CT or MRI data to prepare for therapy. Payers typically reimburse you for this code only once per course of treatment. They may pay again if tumor volume or patient body size changes significantly.
 
Note: To report 77295, your system must be able to perform 3-D modeling of the tumor and the surrounding critical structures, design shielding blocks, present a beam's-eye view, produce a 3-D isodose plan, and evaluate treatment plans. The radiation oncologist should indicate medical necessity for 3-D planning, and sign and date the documentation produced by the 3-D software, and you should keep a copy in the patient's chart.