Oncology & Hematology Coding Alert

Here's how to earn for 3-D planning, dosimetry calculation, and IMRT.

If you're tearing your hair out when it comes to radiotherapy planning and preparation, then you aren't alone. The problem is you won't find a single code to reflect every step. Instead, you've got three distinct codes - which requires you to know what services each code represents.

Planning and preparation for radiotherapy may involve: simulator and/or CT planning, volume delineation, localization and outlining, creating a treatment plan, authorization of the treatment plan, and a pretreatment verification.

Be Specific for 3-D Planning

When your physician uses 3-D imaging to reconstruct tumor volume and surrounding critical normal tissue from CT or MRI data to prepare for therapy, you should submit code 77295 (3-dimensional radiotherapy plan, including dose-volume histograms).

One code for one treatment:  Payers typically reimburse for this code only once per course of treatment. They may pay again if tumor volume or patient body size changes significantly.

What does 77295 imply? The services included in code 77295 are the following:

• 3-D modeling of the tumor and the surrounding critical structures,
• Designing of shielding blocks,
• Presentation of beam's-eye view,
• Development of 3-D isodose plan, and 
• Evaluation of treatment plans.

In addition: Your radiation oncologist should indicate medical necessity for 3-D planning, sign and date the » »»»» documentation produced by the 3-D software, and retain a copy in the patient's chart.

Dig Deep for Dosimetry Calculations

Submit code 77300 (Basic radiation dosimetry calculation, central axis depth dose calculation, TDF, NSD, gap calculation, off axis factor, tissue inhomogeneity factors, calculation of non-ionizing radiation surface and depth dose, as required during course of treatment, only when prescribed by the treating physician) for dosimetry calculations.

What is dosimetry? "Dosimetry is a mathematical computation of radiation dose at a particular point," says Kelly C. Loya, CPC-I, CHC, CPhT, CRMA, Managing Director of Pinnacle Enterprise Risk Consulting Services ("PERCS"), an affiliate of Pinnacle Healthcare Consulting. Calculations typically include: central axis depth dose, time dose factor, nominal standard dose, gap calculation, off-axis factor, tissue inhomogeneity factors, monitor unit calculation for electron field, and angle.

Keep count of multiple dosimetry calculations:  Some carriers reimburse radiation oncologists each time they perform one of the eight dosimetric calculations and others may pay only once per port, per treatment setup.

Same port: If your radiation oncologist performs two dosimetry calculations on the same port, you may bill 77300 twice for the same treatment area. You should check your payer policies before you submit the claim.

Multiple ports: Suppose your radiation oncologist treats a tumor with nine ports of dosimetry calculations. You would report 77300 nine times, using the same diagnosis code each time. If the patient required further treatment after the tumor's volume changed, for instance, and your oncologist treated with the same nine ports, you could bill for nine additional calculations.

Exception: Your physician may perform dosimetry calculations for two complimentary ports. For example, anterior and posterior ports or right and left ports. In this case, you will report only one unit of code 77300 because the images are calculations of the same size, field, shape and depth.

Target 77301 for IMRT

For intensity modulated radiotherapy (IMRT), you report code 77301 (Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specifications).

What is IMRT? IMRT precisely implies modulation of radiotherapy intensity. IMRT allows physicians to deliver high-dose radiation to some parts of a tumor while delivering lower-dose radiation to areas near sensitive tissues to keep them safe. You will most often see IMRT being used in patients with prostate, breast, head and neck, central nervous system, lung, or liver cancer.

According to the AMA, IMRT planning includes forward planning, inverse planning, or a combination of the two. However, check with your payers. Some carriers require a signed inverse treatment plan for reporting code 77301.

Limit to one unit: You report code 77301 only once per treatment course. Even when your physician is treating a number of targets in the same anatomic site, there is only one planning task.

Documentation: The documentation for IMRT treatment planning (77301) should include the following:

• Permanent record (paper or electronic) of computer-generated inverse treatment plans,
• 3D tumor and critical structure volumes,
• Inverse planning dosimetric or biological objectives,
• DVHs and dose verification, and
• Evidence of physician review and acceptance (signature and date).