Oncology & Hematology Coding Alert

Radiation oncologists meet with candidates for brachytherapy, Parman says. "This is an intense and time-consuming encounter," she says. "The physician performs all the key components of an E/M service, taking a history, performing a physical examination and considering treatment options."

Assign an office visit code for this appointment. "In most cases, it will be a level-five E/M service (i.e., 99205, New patient, office or other outpatient visit; 99215, Established patient, office or other outpatient visit; or 99245, Office consultation, new or established patient), because of the intensity of the history and examination elements, and the complexity of the medical decision-making," she says.

If the oncologist determines the patient will benefit from brachytherapy, detailed treatment planning comes next, Parman says: "This includes interpretation of earlier testing, localization of the treatment area, and other procedures." CPT provides three codes to describe the professional treatment planning for clinical brachytherapy: 77261 (Therapeutic radiology treatment planning; simple), 77262 ( intermediate) and 77263 ( complex). In most cases, Parman says, coders should assign 77263 because of the complicated nature of brachytherapy planning.

Coders might be able to report CPT 76873 (Echography, transrectal; prostate volume study for brachytherapy treatment planning [separate procedure]) in addition to treatment planning when they code interstitial brachytherapy with prostate cancer patients. The study allows the oncologist to visualize the prostate and determine its position so he can optimize subsequent radioactive seed placement. A coder should report only the professional component of this service with a -26 modifier (Professional component) when this service is performed in the hospital.

Note: In some facilities, the urologist performs this service and should report it.

"[Treatment simulation] is an important step because the physician must assure that the therapy is delivered only to the diseased tissue and does not damage tissue unaffected by the cancer," Parman says.

Simulation coding is determined by the complexity of the service. Four codes are available, each representing a higher level of simulation. 77280 (Therapeutic radiology simulation-aided field setting; simple) is assigned for a single treatment area, with either a single port or parallel opposed ports, while 77285 (... intermediate) describes two separate treatment areas with three or more converging ports. Likewise, 77290 (... complex) represents involved simulation of three or more treatment areas with tangential portals. The 2002 CPT manual notes that the complex code is assigned when the following elements are present:

Parman says clinical brachytherapy generally requires complex simulation. "In other instances, oncologists may use 3-D simulation (77295, ... three-dimensional) instead of the more traditional methods." 3-D simulation is controversial, however, because some oncologists believe it is valuable only with external beam radiation. Others say they would never consider doing brachytherapy without a 3-D simulation. "Payers also have widely varying policies on this issue," she says. "Coders need to be aware of both carrier and physician preferences."

Before assigning a simulation code, Parman advises, coders should ensure that the oncologist personally participated in the process. "The physician should document his or her presence in the patient record and summarize what occurred in a simulation note."

Modifier -26 is required with the simulation codes to describe it as a physician service. When simulation is performed in a hospital setting, the facility should report the simulation code with the appropriate revenue code to indicate the technical component of the service.

After the simulation, the physics team joins the oncologist to calculate the proper amount of radiation to be delivered. "An isodose plan is necessary for the physician to determine the exact distribution of radiation around the brachytherapy radiation sources," Parman says.

The time and effort invested in this stage of treatment are reflected in codes 77326 (Brachytherapy isodose calculation; simple [calculation made from single plane, one to four sources/ribbon application, remote afterloading brachytherapy, 1 to 8 sources]), 77327 ( intermediate [multiplane dosage calculations, application involving 5 to 10 sources/ribbons, remote afterloading brachytherapy, 9 to 12 sources) and 77328 ( complex [multiplane isodose plan, volume implant calculations, over 10 sources/ribbons used, special spatial reconstruction, remote afterloading brachytherapy, over 12 sources]).

Coders should choose the actual treatment code (77750-77799) based on the type of radioactive source and the delivery method used. "Treatment using liquid radioactive sources is reported with 77750 (Infusion or instillation of radioelement solution)," Parman says. "This technique is most commonly used to prevent malignant effusions in the pleural or peritoneal cavities."

Codes 77761-77763 describe simple, intermediate and complex intracavitary radiation source application. "This treatment consists of placing the radioactive sources within a body cavity such as the vagina, uterus, lung, esophagus, biliary system or other cavity that can be entered without major invasive surgical procedures," she says. Interstitial radiation source application, in which seeds, needles, ribbons or wires containing radioactive materials are inserted directly into body tissues, is reported with 77776-77778. Modifier -26 is appended to designate the physician service when the brachytherapy is performed in the hospital.

In some cases, ultrasound guidance is used to ensure proper placement of interstitial sources. This is coded with 76965 (Ultrasonic guidance for interstitial radioelement application) and modifier -26. Code 76950 (Ultrasonic guidance for placement of radiation therapy fields) is also available for ultrasound placement of radiation therapy fields and is used for applications other than interstitial.

"The intracavitary applications are left in place over a period of minutes, hours or days while they deliver relatively low-intensity radiation directly into the tumor. Often, they're used in conjunction with radiation beam therapy to bring the total dose up to a desired level," Parman says. When both brachytherapy and external beam therapy (77401-77418) are used, report both treatment modalities separately. However, only one physician treatment planning code should be reported since the overall plan encompasses both therapies.

Coders may also report 77470 (Special treatment procedure [e.g., total body irradiation, hemibody radiation, per oral, endocavitary or intraoperative cone irradiation]). This code covers the additional physician effort and work required for special procedures like:

Documentation to support the use of this special code includes a statement by the physician explaining the reason for the extra time and effort spent planning the patient's course of radiation therapy.

Freestanding centers assign 79900 (Provision of therapeutic radiopharmaceutical[s]) when they supply the agents. To describe the radiation oncologist's work in handling the radioactive isotope material, you should also assign CPT 77790-26 (Supervision, handling, loading of radiation source). This code is not valid with high dose rate (HDR) brachytherapy services (77781-77784).

When treating certain cancers, oncologists may surgically implant devices like vaginal cones, oral catheters or tubes. If the oncologist performs these procedures personally, they can be billed separately. "When there are no CPT codes that precisely describe some of these implantations, coders should use unlisted-procedure codes," Parman says.

Similarly, oncologists may work with other specialists (e.g., urologists, gynecologists or surgeons) to implant devices or deliver the radiation therapy. When the procedure requires the services of a second physician, each physician bills the portion of the service personally performed. Alternatively, if the service is identified by one CPT code and jointly performed, it may be appropriate to assign modifier -62 (Two surgeons).

After initial treatment, the oncologist may repeat isodose planning and complex simulation for source verification. "It's not uncommon to conduct a post-treatment isodose calculation," Parman says. "This is done to measure the dose actually delivered to the tumor, compared to what had been indicated in the pretreatment plan." It is appropriate to code and bill for this service when the medical record supports the necessity of the posttreatment isodose plan. Modifier -26 should again be appended if only the professional component is billed.

Coders should also note that the treatment codes (77750-77799) include many hospital services, e.g., admission, daily visits and discharge services. None of these services is typically reported in addition to brachytherapy codes.