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Radiology Coding Alert

Avoid Common Mistakes When Reporting Special Services Codes

Published on Tue Jul 01, 2003

If your radiation oncology practice frequently reports special services codes 77321, 77331 and 77470 keep in mind that these codes are called "special" for a reason. You must maintain pristine documentation and follow strict carrier guidelines, because payers' policies for these services vary widely.

Report CPT 77321 Once Per Course

 
  • 77321 Special teletherapy port plan, particles, hemibody, total body. "This service doesn't exactly require 'special' work," says Deborah I. Churchill, RTT, president of Churchill Consulting Inc., a Killingworth, Conn.-based consulting firm that offers audits, seminars and electronic coding applications. "Rather, you should report this code when you use electrons as part or all of the treatment regimen."

    You should report 77321 once per course of treatment. In addition, if the radiation oncologist performs a monitor unit calculation to treat the patient, he or she should also report CPT 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 teaching physician) once per each electron portal treated. If you perform a calculation only, you should simply report 77300 and not 77321.
     
    Although some practices report 77321 for every patient who receives electrons, you should note that some payers will not reimburse for this special service when the treatment consists of "routine" electron fields used for ribs or simple skin lesions, electron boosts for breast cancer or the treatment of lymph nodes.
     
    According to First Coast Service Options' (a Florida carrier) local medical review policy (LMRP), special teletherapy port plans are medically necessary "only when a plan for a special beam consideration is required for the treatment of a neoplasm, such as the use of electrons or heavy particles."

    Use Caution When Reporting Isodose Plans

    • Depending on your carrier's guidelines, you may be able to report 77321 on the same date as an isodose plan (77305-77315), although there are payers that will deny 77321 when reported with these codes, says Carolyn M. Davis, CMA, CPC, CCP, CCS-P, CPHT, RMC, billing supervisor at Oncology Hematology West P.C. Carriers' policies not only differ widely they can also contradict themselves.
     
    The LMRP for Iowa's Part B carrier (Noridian Medicare) states, "The National Correct Coding Initiative bundles 77305, 77310 and 77315 into 77321 and so it will not allow payment for a combination of these codes unless 77321 is for a different volume of interest other than one or the other codes." But the same LMRP also states, "If special teletherapy port plan is used, CPT codes 77305, 77310 and 77315 are not to be billed."
     
    Append -59 to Report Isodose Plan

    Because of the confusion surrounding this issue, you should submit a copy of your documentation with any claims that include both 77321 and one of the isodose planning codes (77305-77315). In addition, you should append modifier -59 (Distinct procedural service) to the isodose plan code (77305, 77310 or 77315) and indicate the separate volumes of interest addressed by the two services to convey to the carrier that this was a separately identifiable service.
     
    If you report 77321, your medical record should include the following information:
     
  • an explanation for the need for a special teletherapy port plan (including the special beam consideration that the patient requires)
     
  • the prepared plan(s), as available
     
  • the qualified medical physicist's and the radiation oncologist's signature on the plan.
    •  
    Churchill recommends that physicians always include a dedicated "treatment planning" note in the patient's medical record to describe the encounter when electrons are used. "Our clients' compliance plans explain that special teletherapy port plans are ordered directly on the treatment prescription, are documented in the treatment planning note and include photograph or radiograph documentation of the electron portal," she says.
     
    This way, anyone who reads the compliance manual will know exactly where to find documentation related to the special teletherapy. Practices must maintain documentation in the patient's medical record that demonstrates the need and reasonableness for the use of the special beam.

    77331 Measures Radiation Amount

     
  • 77331 Special dosimetry (e.g., TLD, microdosimetry) (specify), only when prescribed by the treating physician. This service allows the physician to measure the amount of radiation that the patient has received. To demonstrate the need for special dosimetry, the radiation oncologist must document medical necessity and that the results will be used to accept or modify the current treatment plan, Davis says. "It's not performed as a quality-assurance measure you should only report this code if your documentation reflects medical necessity and is signed by both the radiation oncologist and the medical radiological physicist."
     
    • Most carriers' LMRPs echo this principle. For example, the Palmetto Government Benefits Administrators policy (a South Carolina carrier) states, "This procedure is not to be routinely performed each time the patient is treated."
     
    Avoid Prefilled Blanks on Templates
     
    To demonstrate that you fulfilled medical necessity for your special dosimetry plan, your medical record should include specific details about this service. Churchill offers her clients a specialized form to serve as a guide so that the radiation oncologist does not forget to include any important information.
     
    Churchill reminds practices that all special dosimetry must be ordered by the oncologist, performed and documented, and reviewed by the radiation oncologist. Otherwise, the practice could risk losing reimbursement.
     
    Some practices record standard information for typical patient scenarios, then make multiple copies of such templates before they even see the patient, leaving only the patient's name and date as editable blanks. Insurers do not allow such preprinted templates unless the forms contain simple prompts that must be edited uniquely for each patient (such as "diagnosis," "dosage amount," etc.). If an auditor discovers completely preprinted templates, also known as "cloned notes," the insurer could ask you for a repayment based on your poor documentation.
     
    "I have audited practices, and after reading their documentation I have no idea what they do because they use the exact same notes for each patient," Churchill says. Instead, she suggests using dedicated forms for each procedure that provide blanks in which the physician can describe information specific to the patient. "This makes the information objective rather than subjective, and gives the practice the same information for all patients, allowing better data collection for performance measurements."
     
    A sample form that Churchill provides to her clients for special dosimetry services is located above.

    Report 77470 for Special Procedure
     
  • 77470 Special treatment procedure (e.g., total body irradiation, hemibody radiation, per oral, endocavitary or intraoperative cone irradiation). "This code covers the additional physician planning time in the work that's required for special procedures," Davis says, such as concurrent chemotherapy, brachytherapy procedures, total body irradiation, hyperthermia, or other reasons as defined by your carrier. 
     
    According to the Winter 1991 CPT Assistant, "This code will generally be used whenever any of the special procedures of radiation therapy are performed. It is used to report the extra planning and effort that go into the performance of the special procedure itself. This code may be reported in addition to conventional treatment planning, which is usually complex (77263)."
     
    Empire Medicare (a Part B carrier for New York and New Jersey) advises that you should report this code only once per treatment course.
     
    You should always document the amount of extra time that the physician spends and the specific type of special treatment procedure that he performs. 
     
    For example, the physician's clinical treatment note may state, "Extra planning time and effort were spent developing this patient's treatment plan because it will be necessary to coordinate with the medical oncologist and ensure that the timing of the radiation fractions coordinates with the chemotherapy cycles for maximum tumor destruction."

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