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Radiology Coding Alert

4 Tips to Improve Clinical Treatment Planning Pay

Published on Tue Nov 25, 2003

Here's how to report 77261-77263

If you're not sure how to report CPT 77261 -CPT 77263 for clinical treatment planning, you're not alone. Follow four basic clinical treatment coding guidelines and you can send in a clean claim for these services every time.
 
Determining how often to use these professional-only codes and what documentation supports a complex radiation treatment is tricky for many radiation oncology coders. The clinical treatment planning process is a comprehensive cognitive effort that the radiation oncologist performs for every patient, and it involves many distinct and critical steps. For example, your physician may develop tumor mapping, a strategic plan, and the treatment's intent, goal and task by the time he completes the prescription for the radiation therapy, says Susan L. Turney, MD, FACP, medical director of reimbursement at the Marshfield Clinic in Wisconsin.

1. Report One Planning Code Per Course

You should report a clinical planning code once per treatment course. But if your radiation oncologist discovers a new area of disease, such as melanoma (172.x, Malignant melanoma of skin), while treating a patient for an unrelated throat neoplasm (149.x), he may develop a skin cancer treatment plan. In that case, you would report the appropriate clinical planning code, such as 77262 (Therapeutic radiology treatment planning; intermediate), even if you reported it for her throat cancer in the past, Turney says. This type of billing may warrant a hard-copy claim to your payer with a letter from the radiation oncologist that explains that your patient has another form of cancer, unrelated to the first.

If Cancers Are Related, Bill Only Once

Most payers' local medical review policies (LMRPs) dictate that you can report treatment planning only once per treatment course, so proceed with caution if you report them more than once, even if your patient has a secondary cancer, says David Davis, CPC, a coding and reimbursement specialist with Infinity Reimbursement and Research in Alpharetta, Ga.
 
Suppose, for example, that your patient has lung cancer (162.x) that metastasizes into secondary cancer, such as bone metastasis (198.5). Typically, your radiation oncologist would incorporate the metastasis into the original planned radiation therapy, so you would report only the original planning code, Davis says. Because the lung and bone cancers are related (metastases), you cannot report treatment planning more than once.

2. Look in Documentation for Simple or Complex Blocking

Make sure your radiation oncologist documents each aspect of clinical planning and tumor mapping. For instance, your physician should include the following in his or her documentation, says Cindy Parman, CPC, CPC-H, RCC, principal and co-founder of Coding Strategies in Powder Springs, Ga.:

 

  • whether the treatment will require simple or complex  blocking
     
  • what methods your physician plans to use to localize tumor volume
     
  • which special services, such as physics consultations, your radiation oncologist ordered
     
  • the number and size of treatment posts
     
  • which diagnostic tests, such as magnetic resonance imaging (MRI) or computed tomography (CT) imaging scan, your radiation oncologist ordered
     
  • consultations with physicians, such as surgeons.

    Don't confuse the criteria used to determine the clinical treatment planning (77261-77263) with the planning and effort code 77470 (Special treatment procedure [e.g., total body irradiation, hemibody radiation, per oral, endocavitary or intraoperative cone irradiation]). The radiation oncologist may consider incorporating the extra documentation for the special treatment procedure (the extra time and effort required to plan the treatment, if appropriate), in the clinical treatment-planning note. For instance, your physician may cite intraoperative radiation therapy (IORT), for which you should report 77470.
     
    Radiation oncologists use IORT to deliver radiation directly to tumor sites during surgical procedures. For example, your physician may directly visualize and radiate locally advanced colorectal cancer (154.x, Malignant neoplasm of rectum, rectosigmoid junction, and anus) while sparing surrounding tissues.
     
    Code 77470 may also be appropriate when the patient will be treated with a variety of therapy modalities. For instance, Medicare carriers, such as CIGNA Medicare, consider 77470 the appropriate code for hyperfractionation, total body irradiation, per oral or transvaginal cone use, or when your physician manages other modalities, such as brachytherapy or concurrent hyperthermia, in combination with external beam therapy and when documented in the patient's medical record.

    3. Report 77261 for Localized Treatment Ports

    Use 77261 (... simple) when your physician's clinical planning requires a single treatment area localized in a single port or simple parallel opposed ports, with simple or no blocking, such as planning for simple skeletal bone metastasis (198.5) treatment, Parman says.
     
    Look for these additional elements in the physician's documentation when choosing 77261:
     

  • notes on superficial, orthovoltage cobalt and linear accelerator (photon) treatments
     
  • details on the treatment area, such as a secondary malignant neoplasm in the bone.

    Planning simple radiation therapy may not require your radiation oncologist to interpret special tests, such as ultrasounds, nuclear medicine, special procedure x-rays and special laboratory work. Simple treatment planning may only require basic dosimetry calculations (77300, Basic radiation dosimetry calculation, central axis depth dose calculation, TDF, NSD, gap calculation, off axis factor, tissue inhomogeneity factors, calculation of nonionizing radiation surface and depth dose, as required during course of treatment, only when prescribed by the treating physician), instead of complex isodose plans or 3D simulation/plans.
     
    When you think 77262 is the proper code choice, get ready for the planning difficulty to be ratcheted up a notch. CPT defines this as the intermediate planning stage, so you should look for more complex radiation therapy than 77261. Your physician's planning requires either three or more converging ports, two separate treatment areas (noncontiguous), multiple blocks, or special time or dose constraints. You might need to report 77262 if your radiation oncologist treated a standard four-field pelvis (nonconformal) or multiple skeletal metastases in a patient with prostate cancer (185).
     
    To report 77262, planning requires a moderate level of difficulty, which usually means your radiation oncologist will treat two separate areas with three or more con-verging ports.
      
    During planning, your physician must document the protection of critical or sensitive organs, such as the spinal cord or liver, which typically require multiple blocks. Your radiation oncologist may have to interpret special tests like MRI, she adds.

    4. Assign 77263 for Complex Planning

    Using 77263 (... complex) for complex planning means you'll need to make sure the treatment contains highly complex blocking, custom shielding blocks, tangential ports, special wedges or compensators, three or more separate treatment areas, rotational or special beam considerations, and a combination of therapeutic modalities, according to CPT.
     
    Because most radiation therapy treatment regimens are considered complex based on the carriers' descriptions of complex treatment plans, the physician's clinical treatment planning usually achieves the 77263 level, says Deborah I. Churchill, RTT, president of Churchill Consulting Inc., a Killingworth, Conn., consulting firm that offers audits, seminars and electronic coding applications.

    Planning Notes Can Help Documentation

    Churchill recommends that the physician complete a detailed "Treatment Planning Note" for every patient, clearly documenting the clinical planning process, the review of studies, and the subsequent isodose planning level that will be used to provide the optimal treatment.
     
    In addition, if your physician uses a combination of external beam radiation and brachytherapy to treat the same disease, you should report the clinical planning code (77263) only one time.
     
    But if different radiation oncologists in different practices or facilities perform the brachytherapy and external beam radiation, each physician may submit a planning charge.
     
    Suppose your radiation oncologist plans to treat a patient with pancreatic cancer (157.x) using simple brachytherapy (77781, Remote afterloading high-intensity brachytherapy; 1-4 source positions or catheters). To protect the patient's kidney and small intestine from radiation damage, your physician must use special planning to localize the treatment area.
     
    Your radiation oncologist will have to interpret complex tests, such as MRIs, CT scans and other laboratory tests, and the combined documentation may support reporting 77263 on your claim for this service.

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