Oncology & Hematology Coding Alert

Find out when you can report complex planning more than once per course

If you report radiation oncology, chances are you wrangle with 77263. Here's the skinny on the proper use of this complex clinical treatment planning code.

Reality: -In today's world of 3D, IMRT, and MLCs, complex blocking and normal tissue protection have become a mainstream majority,- says Ron DiGiaimo, MBA, president and CEO of Revenue Cycle Inc. in Austin, Texas.

This high-tech standard means you often use complex planning code 77263 (Therapeutic radiology treatment planning; complex).

You-re unlikely to see cases that fit the exact descriptor for 77262 (- intermediate), DiGiaimo says. -One example would be two fields with simple or intermediate blocking such as an open spine and simple blocked hip,- he says.

Include These Services in 77263

Code 77263 represents the cognitive component radiation oncologists use -in determining the amount of treatment a patient will need and how it will be delivered,-  DiGiaimo says.

Radiation oncologists decide, based on stage as well as curative or palliative intent, whether the patient needs -2D external beam, 3D planning, IMRT, brachytherapy, or some combination of radiation therapy delivery variables,- DiGiaimo says.

The oncologist prescribes the total radiation dose and daily fractionation schemes, recording them as a prescription and -- ideally -- in a treatment planning note, he says. This is good documentation for compliance and billing purposes, he says.

Watch out: You need more than a prescription to report 77263, says Cindy Parman, CPC, CPC-H, RCC, co-owner of Coding Strategies Inc. in Powder Springs, Ga., and president of the American Academy of Professional Coders National Advisory Board.

The American Medical Association, which publishes the CPT codes, considers prescription writing part of post-E/M work, meaning you won't be separately paid,
she says.

Documentation: You need separate documentation of clinical treatment planning to report this code, Parman says. And because the code represents the physician's -cognitive effort documented in the chart,- you shouldn't use the code for computer planning, she adds.
 
Tip: You-ll usually see the physician document orders for -special- services, such as special physics and special dosimetry, Parman says.

Let the physician know that this is a great place to document -extra cognitive planning time and effort for the special treatment procedure,- Parman says.

Bottom line: You can't automatically report a clinical treatment planning code because the patient has IMRT or brachytherapy, Parman says. The physician needs to document his cognitive services.

The planning note offers a record of the physician's thought process, DiGiaimo agrees. The note gives you medical-necessity justification of items such as choosing IMRT over 3D or choosing a brachytherapy boost or monotherapy, he adds.

Tip: Use the prescription date or planning note date as the day of service, DiGiaimo says.

Spot Exceptions to the Once-per-Course Rule

You typically only report one planning code per treatment course, but there are a few exceptions, DiGiaimo says:

1. You may be able to report a separate treatment planning code if the physician discovers a new primary malignancy or metastasis with a different ICD-9 code during the course of treatment for a separate primary malignancy, DiGiaimo says.
 
Caution: To report a second planning code, the new malignancy or metastasis must require treatment and the physician must not have known about the second problem at the onset of the initial treatment course, DiGiaimo adds.

2. Payers may cover a second planning code for a patient if physician A refers the patient to physician B (who has an outside tax identification) for treatment physician A doesn't offer, such as a brachytherapy boost, DiGiaimo says.

Brachytherapy tip: When appropriate, you may report 77263 for brachytherapy planning, says Indianapolis compliance officer Morgan Hause, CCS, CCS-P.

But if the patient received external beam treatment and the physician included brachytherapy in the overall treatment plan, and you have already reported a treatment code, you shouldn't charge an additional plan for the brachytherapy planning.

Check Out These Authoritative Sources

You should research your payer's local coverage determination for 77263, DiGiaimo says. You can also turn to ASTRO (American Society for Therapeutic Radiology and Oncology) and ACRO (American College of Radiation Oncology) for advice on reporting complex treatment planning.

You should also double-check the National Correct Coding Initiative edits.

Example: Don't report 77263 on the same date as IMRT planning code 77301 (Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance verifications), DiGiaimo says.

NCCI bundles 77263 into 77301. The edit has a modifier indicator of -0,- meaning you can't break the bundle with a modifier. (Note: You can learn more about NCCI edits on the Web at www.cms.hhs.gov/NationalCorrectCodiNitEd/01_overview.asp. The site includes the NCCI policy manual.)