Oncology & Hematology Coding Alert

Reporting IMRT as conformal treatment for coverage will land you in hot water

Tracking payer requirements for intensity modulated radiotherapy (IMRT) is no picnic, but putting these tips to work will keep your IMRT claims clean every time.

Common problem: Payers have very strict rules about when they will pay for IMRT. People often ask, if the insurance company pays for conformal treatment for this diagnosis, can we bill the conformal and get paid for that -- even though we are doing IMRT? -The answer is no,- says Erin Goodwin, CPC, CMC, with South Carolina Oncology Associates.

Bill the service provided, she says. Exception: The only time you should deviate from CPT guidelines is when your insurance company instructs you in writing to do so, Goodwin says.

Remember: For IMRT daily treatment delivery, you should look to 77418 (Intensity modulated treatment delivery, single or multiple fields/arcs, via narrow spatially and temporally modulated beams, binary, dynamic MLC, per treatment session).

Head Off Denials With Supplemental Documentation

Knowing an individual payer's coverage rules can help you send in an accurate claim that meets the payer's requirements. You can learn coverage rules a number of ways:


1. Check your local policy. When an Illinois practice started getting denials for IMRT prostate for BCBS patients not receiving more than 75 Gy, coders were perplexed. But a quick look at the BCBS Web site informed them that the policy was updated in March 2006 to say that the payer considers IMRT medically necessary for the following indications:

- Non-metastatic prostate cancer for escalation >75 G

- Head and neck cancer, specifically patients with nasopharyngeal carcinoma, and disease located at the unilateral base of the tongue/tonsils with limited neck lesions

- Central nervous system (CNS) lesions with close proximity to the optic nerve or brain stem.


As the first bullet point explains, Illinois BCBS only considers IMRT medically necessary for -Non-metastatic prostate cancer for escalation >75 Gy.-

Don't forget: If the physician documents IMRT, you must report IMRT, regardless of whether the payer will cover it for the patient's condition.


2. Verify benefits early.  Every plan may be different, so some coders recommend verifying benefits before treatment and holding on to that information if you need
to appeal.


3. Work through appeals. Goodwin has determined that BCBS in her state often requires proof of some kind of preexisting heart problem to cover IMRT for the left breast. Denials sometimes offer enough information to explain payer requirements for preexisting conditions, but working through the appeals usually offers more information, Goodwin says.


Example: The payer may deny an appeal with a letter stating the -service is not covered unless the patient has a preexisting condition that the treatment could exacerbate,- Goodwin says. Sometimes when you check the record, you-ll find the patient does have that condition, she adds.

Important: Encourage your physician to document the patient's diagnosis completely -- thorough documentation is invaluable in this sort of appeal.

Bonus: Tracking these requirements will help you submit the proper supplemental information when you first submit your claim.


Limit IMRT Units Reported

Once you-ve determined that you-ve met the coding requirements for IMRT, pay attention to the descriptor for 77418, which specifies that you should report the code -per treatment session.-

One unit -per treatment session- still applies when you treat multiple anatomic sites at that one session. Tip: If the patient receives IMRT for one anatomic area and conventional radiation therapy at another anatomic area at the same session, you should only report the IMRT, says the 2007 CSI Navigator for Radiation Oncology from Coding Strategies Inc.

Hidden trap: If the record indicates compensator-based beam modulation treatment delivery, you should report 0073T (Compensator-based beam modulation treatment delivery of inverse planned treatment using three or more high-resolution [milled or cast] compensator convergent beam modulated fields, per treatment session) instead of 77418.

With compensator-based beam modulation treatment, you still report 77301 (Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specifications) for treatment planning, as you would for IMRT planning. But CPT guidelines tell you not to report 0073T with 77401-77416 (Radiation treatment delivery ...) or IMRT delivery code 77418.


Chart IMRT Codes

In the course of coding IMRT from planning through treatment, you may use the following codes, say The Pritchard Group consultants Mary Lou Bowers, MBA, president and CEO; Linda B. Gledhill, MHA, director; and Barbara Constable RN, MBA, director, in their audioconference for The Coding Institute, -Stellar Strategies for Radiation Oncology Coding-:


CPT               Descriptor

77263               Therapeutic radiology treatment planning; complex

77290               Therapeutic radiology simulation-aided field setting; complex

77014               Computed tomography guidance for placement of radiation therapy fields

77301               Intensity modulated radiotherapy plan (after CT imaging)

77418               Intensity modulated treatment delivery -

76950               Ultrasonic guidance for placement of radiation therapy fields

77417               Therapeutic radiology port film(s)

77336               Continuing medical physics consultation -

77427               Radiation treatment management, five treatments

Smart: Check payer guidelines and National Correct Coding Initiative edits before you code. Some payers require an unlisted-procedure code instead of 76950 for US. Hospitals may also be able to report 77334 (Treatment devices, design and construction ...) and append 59 (Distinct procedural service) on the same day as 77301 (www.cms.hhs.gov/transmittals/downloads/R896CP.pdf).

But don't limit yourself to these codes or code them all automatically -- submit your claim based on the documentation. Example: You-ll most likely report 77300 (Basic radiation dosimetry calculation ...) once per gantry angle. And increasingly, practices are performing and reporting 77421 (Stereoscopic x-ray guidance for localization of target volume for the delivery of radiation therapy) instead of US guidance. Your documentation may also include a physician order and simulation note for a verification simulation (77280, Therapeutic radiology simulation-aided field setting; simple).

Lesson: Pay close attention to local payer guidelines and documentation when you-re reporting IMRT.