Radiology Coding Alert

Three-dimensional (3-D) tumor simulation treatment planning for cancer patients is a complicated and time-consuming process for radiation oncology practices. Coding professionals must clearly understand the discreet steps and assign the appropriate codes that accurately reflect the work involved.

The concept behind 3-D radiation simulation treatment planning is relatively simple. Before a cancer patient actually receives radiation therapy, 3-D images are used to determine the proper dosage and most effective distribution of the treatment. Creating the plan is a demanding process, however, with multiple steps and complicated requirements.

The American Medical Accounting and Consulting firm (AMAC), based in Marietta, GA, has devised a typical scenario for 3-D radiation simulation treatment planning that outlines each step and coding considerations that will affect how radiation oncology practices may charge for each. AMAC Vice President James E. Hugh, MHA, points out that becoming as familiar as possible with 3-D treatment planning codes is advantageous to a billing professional because reimbursement rates are much higher than traditional radiation treatment planning.

The scenario devised by AMAC, which has specialized in coding, training and auditing radiation oncology practices for more than 17 years, can be used in two circumstances: during the initial set-up for radiation therapy or at boost time. Usually, a patient undergoes initial radiation therapy for a prescribed amount of time, Hugh explains. Then, after the tumor has shrunk or other factors come into play, there will be another boost or cone-down. At that time, another plan is devised for the boost or cone-down.

He points out, however, that the 3-D simulation treatment plan should be used only once during the course of a patients therapy. If you have billed the initial set-up as a 3-D radiation simulation treatment plan, you should bill the boost with conventional radiation oncology planning and simulation coding methods, Hugh says. On the other hand, some radiation oncologists will begin treatment without a 3-D plan. Under these circumstances, the patient could receive 3-D simulation treatment planning at boost time.

Hugh adds that the 3-D radiation simulation treatment plan can be noncoplanar or coplanar.

Common Charging Scenario for 3-D Radiation Simulation Treatment Planning

Monday: The patient is simulated by being placed into a precise treatment position. An immobilization devicelike a vac-lock or alpha-cradleis created while the patient holds that position. When the radiation field is determined, the patient is tattooed to ensure accurate delivery of radiation.

Coding: Depending on the complexity of the process, one of the following codes would be assigned:

CPT 77280 therapeutic radiology simulation-aided field setting; simple

CPT 77285 therapeutic radiology simulation-aided field setting; intermediate

77290therapeutic radiology simulation-aided field setting; complex

In addition, CPT code 77334 would be assigned for the immobilization device (complex, [irregular blocks, special shields, compensators, wedges, molds or casts]).

Late Monday or Tuesday morning: The radiation oncologist would request that the radiology department conduct a computerized tomography, or CT, scan. (This scan would not be performed if one had been done previously.)

Tuesday: The CT images are interfaced by the physics department, which then creates a preliminary plan. The physicist and radiation oncologist confer, and the radiation oncologist provides further input. The final treatment plan is generated, and the patient again is placed on the simulator and the plan checked.

Coding: Coders would assign 77295 (therapeutic radiology simulation-aided field setting; simple, three-dimensional). The simulation uses documented 3-D beams eye view volume-dose displays of multiple or moving beams. Documentation with 3-D volume reconstruction and dose distribution is required.

According to the American College of Radiology, the paragraph describing 77295 includes those procedures that are done to prepare for use of coplanar therapy beams (i.e., the second patient simulation on Tuesday). Code 77295 also includes work done for a therapy isodose plan
(codes 77305-77315) and should not be coded separately.

Wednesday: In the final step of treatment planning, the patient once again is placed on the simulator or accelerator. The placement of the blocks and the patients position are verified. This process provides final confirmation that all parameters are acceptable and that treatment may begin.

Coding: 77280Therapeutic radiology simulation-aided field setting; simplemay be assigned.

Using the 3-D radiation simulation treatment-planning scenario, Hugh notes, radiation oncology practices may bill one simulation code each day, if the simulation activity is recorded in the report.

When radiation therapy planning is conducted without a 3-D component, two basic codes would typically be assigned. Code 77290 would be used to describe therapeutic radiology simulation-aided field setting; complex. And, one of the following isodose planning codes would be assigned:

77305Teletherapy, isodose plan (whether hand or computer calculated); simple (one or two parallel opposed unmodified ports directed to a single area of interest

77310Teletherapy, isodose plan (whether hand or computer calculated); intermediate (three or more treatment ports directed to a single area of interest)

77315Teletherapy, isodose plan (whether hand or computer calculated); complex (mantle or inverted Y, tangential ports, the use of wedges, compensators, complex blocking, rotational beam, or special beam considerations)

Hugh notes that there is an exception to the American Medical Associations rule that a 3-D radiation simulation treatment plan can be billed only once for each patient. If a radiation oncologist treats two primary cancers in one patientpancreatic and brain cancer, for instancethe physician no doubt will conduct two separate planning cycles and can use the 77295 three-dimensional coding scenario for each.

Of course, this second 3-D radiation simulation treatment planlike all other procedures performedmust be adequately documented in the patients medical record.

Possible Income Scenario for 3-D Planning American Medical Accounting and Consulting provides the following example of possible reimbursement based on current allowables for the Atlanta, GA, area in September 1999. Note: The figures below are based on 120 patients using code 77295 with a split of 40 percent commercial patients (48 patients) and 60 percent Medicare (72 patients). Day One: Patient is simulated and an immobilization device is created 772XXUse complexity that is appropriate 77334Immobilization device CPT code Commercial Medicare 77290 $1094 X 48 = $52,512 $547 X 72 = $39,384 77334 $510 X 48 = $24,480 $255 X 72 = $18,360 Day Two: Patients CT images are interfaced by physicist and physician approves with input; patient placed on simulator and simulated again. (77295 includes second simulation on same day and 77315 isodose plan.) CPT code Commercial Medicare 77295 $2,816 X 48 = $135,168 $1,408 X 72 = $101,376 Day Three: Patient placed on simulator or accelerator; blocks are verified and position is acceptable to begin treatment. (77280 need simulation sheet filled out and/or dictated physician simulation notes.) CPT code Commercial Medicare 77280 $545 X 48 = $26,160 $164.56 X 72 = $11,848.32 Total $238,320 $170,968.32 GRAND TOTAL = $409,288.32