Oncology & Hematology Coding Alert

The key to getting paid for simulations in radiation oncology no matter how many are performed is documenting all changes in the treatment field. Otherwise, payers will have a difficult time determining the medical necessity of multiple simulations, says Jim Hugh, MHA, senior vice president with AMAC, a reimbursement and billing firm based in Atlanta.

In addition, a high reimbursement rate is associated with three-dimensional simulations (77295) and its tempting for physicians to perform these. However, radiation oncologists must be sure the procedure falls into the narrow guidelines payers have set, says Margaret Hickey MS, MSN, RN, OCN, CORLN, an independent coding consultant and former clinic director at Tulane Cancer Center in New Orleans.

There is no question that a simulation, 77280-77290, is an integral part of radiation treatment planning. It is used prior to radiation treatment to determine the size and location of initial treatment ports that are used to direct the radiation at tumors without destroying surrounding tissues and organs.

A simulation note (a specific document) should be included for each one performed and include the following:

The date;

The reason (this may include initial simulation, block check and subsequent simulations as a result of changes in field setting);

A summary of the procedure including patient position, identification of field location and critical structures blocked;

A description of any customized immobilization equipment; and

A summary of fluoroscopy and contrast used.

While documenting changes in the treatment field is important to reimbursement, revisions such as portal changes that are the result of poor or unsatisfactory initial simulations should not be documented or billed, because payers do not expect to pay for mistakes or poor services. In addition, you should not bill for additional simulations if only minor changes are made to the port size without changes in beam (radiation) such as amount or placement.

Each level has its own set of rules and conditions as follows:

Simple:

Code 77280 is used to describe the most straightforward use of a simulator, including superficial simulation, orthovoltage, cobalt, and linear accelerator treatments. It should also be used when radiation treatment is limited to a single area with either one port or parallel, opposed ports.

Blocking under this code is either simple or non-existent. However, the code can be used for block checking and is then billed separate of the first simulation. This procedure is usually performed afterwards to verify the accuracy of custom blocks before treatment begins.

It is important to remember that not every setup requires a block check simulation and that this procedure is usually limited to the complicated treatment fields where there are multiple blocks or if a specific problem with the current blocking is noticed. Whatever the case, it is important that the simulation note include the reason for it.

A simple simulation should require no more than two films. Radiation oncologists will rarely assign 77280, because most simulations require the use of more complex equipment and treatment involves more than one port, says Hickey.

Examples of simple simulation involve radiation treatment of the spine where no blocks are used, or radiation of the whole brain where standard eye blocks are used.

Intermediate:

Code 77285 is used to describe many of the same types of simulations described in 77280. An intermediate simulation may involve the treatment of two areas that, if treated separately represent simple ones. The difference between intermediate and simple lies in the number of ports and treatment areas. In order to use 77285, there must be at least three converging ports focused on one or two areas. Another characteristic of an intermediate simulation is the use of multiple standard blocks (they do not require customization to protect vital structures).

Usually, two or more films of each area are taken with or without fluoroscopy for simulations associated with 77285.

Complex:

Code 77290 is reserved for patients with three or more treatment areas who need rotation or arc therapy; or who need highly complex blocking. According to Hugh, the following characteristics apply to 77290:

Use of multiple custom blocks;

Special wedges;

Complex immobilization;

Brachytherapy;

Tangential ports;

Oblique fields;

Rotational or special beam considerations; and

Highly complex blocking used in treatments such as total body irradiation and hemibody irradiation.

Also, complex simulation can be reported when verification of a brachytherapy source or a hyperthermia probe is performed. However, it is most commonly assigned for prostate seed implants.

Radiation oncology practices commonly bill simple and intermediate simulations when they should have billed complex, which lessens their reimbursement. One example, says Hugh, is a simulation involving brachy-therapy where only one film is taken. Although only one is taken, the presence of brachytherapy allows for using 77290.

You can also erroneously bill higher than appropriate. For example, use of contrast material sometimes prompts a complex code when it might be better to bill a lower one. Hugh says the presence of contrast material alone is not enough to code 77290. However, if it is used to view organs that may be affected by three or more treatment areas, then a reason has been established.

Prove Medical Necessity for 3-D Simulation

Some commercial payers may require radiation oncologists to establish medical necessity prior to the performance of a three-dimensional simulation. Among the factors payers are looking for in documentation is evidence that the tumor cannot be seen clearly using the other levels of simulation.

For instance, a patient whose tumor is close to an organ that must be protected from radiation may qualify for three-dimensional simulation. To further prove medical necessity, the documentation should show irregular tumor volume and that use of conventional fluoroscopy or CT scan will not provide a clear view.

Codes 77280-77290 may be billed in addition to a three-dimensional simulation, in some cases, because the plan is more similar to a comprehensive treatment than to a simulation. However, this varies from one payer to the next, so specific guidelines should be requested.

Finally, Hickey says that a treatment planning code cannot be used with 77295. Although a three-dimensional simulation provides the highest reimbursement, it eliminates payment for treatment planning, because the data gathered by the three-dimensional simulation is placed into a computer, which generates the treatment plan. In short, payers bundle the three-dimensional simulation and treatment planning because the latter does not represent the same amount of work usually provided in radiation treatment planning.