Radiology Coding Alert

Coders lives became a little simpler a year ago when CPT Codes replaced four radiation therapy codes with a single code 77427 (radiation treatment management, five treatments). Nevertheless, the definition of this code contains nuances that might trip up unwary radiation oncology coders.

Coding radiation therapy management was much more complicated a couple of years ago, acknowledges Lynn C. Esposito, CPC, clinical practice specialist with Hunter Radiation Therapy at the Yale University School of Medicine. Having only one level of service where there used to be four is much easier to manage. But there are certain requirements within 77427 that can be confusing.

Code 77427 was created to describe the professional management component of weekly radiation treatments. The code is assigned once for every five treatments or fractions. Our patients usually come in once a day to receive radiation therapy, Esposito explains. After five of those sessions, or five days, we are able to assign 77427 once.

She notes that the five sessions do not have to occur in a single week. Often a patient will begin treatment on a Wednesday, and then have additional treatments Thursday, Friday, Monday and Tuesday, with Saturday and Sunday off. On the Tuesday, we would bill the five fractions with the previous Wednesday as the date the service was initiated.

Although each patient visit generally constitutes one treatment or fraction, Esposito says the treatment may encompass a number of variables. They may receive the treatment from more than one angle, for instance, or they may even be placed on more than one machine. None-theless, this constitutes one treatment.

Exceptions to this may occur when the specialist is treating patients for some cancers, including head and neck cancers involving sites such as the tonsils, base of the tongue and piriform sinus, according to Anu Gupta, MD, radiation oncologist with Georgetown University Medical Center in Washington, D.C. To treat these advanced-stage oropharyngeal and hypopharyngeal cancers, radiation is delivered to these sites as well as to the surrounding lymph nodes. The dose at each treatment is a little less but must be given twice a day, usually once in the morning and again later in the afternoon.

Even though they occur on the same calendar date, these two sessions are recognized as two treatment fractions, she says. Its medically necessary to deliver the treatment in this manner.

Esposito adds that these two treatments must be six hours apart to constitute two fractions. This is termed hyperfractions or BID for some payers, and providing that the medical necessity is documented in the patients treatment record, treatment management is still reimbursed for each of the five treatment fractions. Therefore, for hyperfractionated treatment, two claims using 77427 can be billed for five calendar days of therapy.

Coding Increments Other Than Five Fractions

Coders must also be aware of nuances to coding treatment cycles in increments other than five. It would be nice if all patients received five, 10 or 20 fractions, Esposito says. But that is generally not the case and coders must be very clear about how to report services in these instances.

If the patient received three treatments beyond a set five (i.e., 13 treatments), coders would bill 77427 three times: once for treatments one through five, a second time for treatments six through 10, and a third time for treatments 11, 12 and 13. However, if the patient received only 12 fractions, you cannot bill those extra two treatments, she says. You assign 77427 for fractions one through five, and for treatments six through 10. But you would have to absorb the costs of management for treatments 11 and 12.

Coders are not allowed to report two units of 77431 (radiation therapy management with complete course of therapy consisting of one or two fractions only). This code is intended for patients whose total therapy is only one or two treatments, she explains. It cant be assigned to left-over fractions from longer courses. Nor may coders attempt to bill the extra two fractions with 77427 and modifier -52 (reduced services).

Documentation Requires Two Components

Documentation for 77427 includes two primary components. During each fraction, the radiation technologist uses a flow chart to record treatment information like the radiation field. There will be five of these documented in the medical record when we assign and bill 77427, Esposito says.

The radiation oncologist must see the patient throughout each cycle of five fractions. In addition, the patient will schedule a formal visit through the clinic once a week for an examination. During this appointment, the physician will document the patients progress. The visit may include services like port film review, chart review, dosimetry review, treatment setup and positioning review, verification of blocks and immobilization devices, care of infected skin, nutritional counseling, fluid and electrolyte management, and pain management.