Oncology & Hematology Coding Alert

If you forget to append modifier 26 on your claim when your radiation oncologist renders a service in a facility setting, the payer may think you-re double-billing.

Here's why: Several radiation therapy codes may be split into professional and technical components. If your oncologist and another facility both submit bills for the same code and one or both fail to specify which component was provided, payers will reject the claim -- and may accuse you of fraud.

The basics: Usually, you split a procedure when an oncologist provides professional services (such as diagnosis and planning) and another facility with specialized equipment provides imaging or radiation therapy. If that facility bills separately, you may find yourself appending modifier 26 (Professional component). Here's what you need to know.

Example: Let's say your oncologist is planning a complex "seed therapy" for a prostate cancer patient. Following treatment planning (77261-77263), the oncologist may obtain images (x-ray film or electronic images) of the targeted treatment area -- to define and adjust dose calculations -- and of the eventual position of the brachytherapy seeds. For this service, you should select an appropriate simulation code (77280-77290).

If your oncologist performs any type of simulation in a facility setting, you must append modifier 26 to the simulation code to show that he provided the "professional" portion of the service only. Remember the place of service indicators for the CMS 1500 claim form:

- 11 -- Office

- 22 -- Outpatient hospital

- 49 -- Independent clinic.

After the simulation imaging, if your oncologist provides the complex brachytherapy plan 77328 (Brachytherapy isodose plan; complex [multiplane isodose plan, volume implant calculations, over 10 sources/ribbons used, special spatial reconstruction, remote afterloading brachytherapy, over 12 sources]) in-house, you wouldn't append a modifier to reflect a professional-technical split. If he used another facility's equipment, you-d append modifier 26; the facility would bill separately using modifier TC.

Keep track: "As long as both parties understand the service they are providing and bill accordingly, there should not be a problem," says Lisa Martin, CPC, CPC-IM. Martin's employer, Illinois CancerCare of Peoria, Ill., provides CT and PET scans on-site and only bills for the technical component, she says; the professional component is provided by another group off-site. 

"A complete understanding of who is providing what is essential," Martin says, "in addition to understanding the appropriate modifier usage."

To add to the confusion, CPT already splits some procedures, such as stereotactic body radiation therapy (SBRT), in a sense.

Example: SBRT precisely maps a tumor and uses a frame to keep a patient nearly immobile so doctors can aim radiation precisely.

That's some pretty specialized equipment, so it may be that an oncologist would contract with a facility for therapy delivery (77373, Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions) while he manages the therapy (77435, Stereotactic body radiation therapy, treatment management, per treatment course, to one or more lesions, including image guidance, entire course not to exceed 5 fractions).

If that were the case, you-d only submit code 77435. If your facility owns the equipment, you-d code both 77373 and 77435. You-d never append modifiers 26 or TC to 77373 or 77435 because you-re using separate codes for both the professional and technical components.