Oncology & Hematology Coding Alert

Complexity of planning is your guide to the right code.

When reporting radiation treatment planning, you need to know what guides the classification of treatment planning into simple, intermediate, and complex. Your oncologist may perform complex clinical treatment planning, more often than simple or intermediate. To make things easy, you should focus on the key factors that influence your oncologist’s treatment planning. These may include determining the disease bearing areas and specifying the areas that need to be treated, identifying the type and method of radiation treatment delivery, selection of radiation treatment techniques, and specifying the dose and duration of therapy.

Distinguish Simple vs. Intermediate

You report code 77261 (Therapeutic radiology treatment planning; simple) for simple radiation treatment planning. The term ‘simple’ implies that the planning involves a single defined treatment area of interest. The treatment area may be encompassed in a single port or there may be parallel opposed ports with no or minimal blocking. The portal arrangement however is simple. In addition, note that such treatment planning requires no special tests or their interpretation.

Example: When your oncologist documents radiation treatment planning for simple skeletal bone metastasis, you report code 77261. The diagnosis code here is 198.5 (Secondary malignant neoplasm of bone and bone marrow).

You report code 77262 (Therapeutic radiology treatment planning; intermediate) when your oncologist plans to treat 2 separate noncontiguous treatment areas which require 3 or more converging ports, multiple blocks, or have special time dose constraints. Unlike simple planning, intermediate planning requires interpreting special tests for localizing tumor volume. Additionally, your oncologist also may need to put in a plan for protecting critical or sensitive organs.

Example: You may read that in a patient with prostate cancer, your oncologist planned for a standard four-field pelvis (nonconformal) radiation treatment and also planned radiation therapy for multiple skeletal metastases. In this case, you confirm the noncontiguous treatment areas and report code 77262. You oncologist will also need to localize the skeletal metastasis in the patient. You report ICD-9-CM code 185 (Malignant neoplasm of prostate) for the prostate cancer.

Report 77263 for Complex Plans

For complex treatment planning, you turn to code 77263 (Therapeutic radiology treatment planning; complex). The complexity in the treatment planning lies in 3 or more separate treatment areas, highly complex blocking, custom shielding blocks, tangential ports, special wedges, or compensators. Complex treatment planning may require your oncologist to do special laboratory tests or CT/MRI localization. Additionally, your oncologist may do special planning and mapping to protect the patient’s normal structures. Such planning is usually required for cancers that are complex in distribution regardless of whether the patient is in early or advanced stages.

Examples of complex treatment planning include radiation treatment for surgical sites or planning for retreatment in a cancer patient. Do not jump to code 77263 without adequate documentation to support the necessity of complex planning as documented.

Do Not Bill For Multiple Treatment Plans

Your oncologist may consider rotational or special beam treatment plans and may try to put together a treatment plan that combines multiple therapeutic modalities. You cannot bill for multiple treatment plans in a single course of treatment. Typically, you’ll report treatment planning only once per radiation course,

Example: When a course of therapy involves both brachytherapy and external beam therapy, you cannot report two separate treatment planning codes. You report a single unit of 77263 as this implies combination of treatment options.

Note: The codes 77261-77263 are “professional component only” codes. This means you should not append a modifier 26 (Professional component) or TC (Technical component) to these codes.

What makes good documentation for treatment planning? You must ensure your oncologist provides thorough documentation in support of treatment planning. Good documentation captures diagnosis, site and intent of treatment, reviews of imaging studies and biopsies, medical necessity for the treatment modality(s) selected, dose and fractionation considerations, technique contemplated, and any factors that are likely to affect planning like body size or prior radiation.