Radiology Coding Alert

When treating a particularly difficult case of cancer with a multiservice regimen, the radiation oncologist may feel like Atlas, carrying the weight of the world and a lot of extra treatment management effort on his shoulders.

However, coders who know how and when to code CPT 77470 (Special treatment procedure [e.g., total body irradiation, hemibody radiation, per oral, endocavitary or intraoperative cone irradiation]) may help to lighten the burden. The special treatment code, 77470, is commonly reimbursed by payers but can easily be misused. "If you can document that special treatment planning was used, you should have no problem getting paid," says Carl Bogardus, MD, FACR, president of Cancer Care Network, a billing and coding consulting firm in Midwest City, Okla. Yet, the rules associated with the code lack clear direction, he says.

For example, with "ample documentation," 77470 can be used when treating anesthetized children with radiation therapy, because of the extra time and planning it takes to prepare a child, says Linda L. Lively, MHA, CCS-P, RCC, CHBME, founder and CEO of American Medical Accounting and Consulting in Marietta, Ga.

According to Medicare regulations, this code covers the additional physician effort and work required for the special procedures of hyperfractionation, total body irradiation, per oral or transvaginal cone use, or when other modalities are being managed in combination with external beam therapy, Lively says. These other modalities include brachytherapy, concurrent hyperthermia, planned combination with chemotherapy or other combined modality therapy, stereotactic radiosurgery, intraoperative radiation therapy, and any other special time-consuming treatment plan.

One of the indicated procedures in 77470, known as intraoperative radiation therapy (IORT), is not well-understood by coders. "IORT is designed to increase the intensity of radiation by delivering it directly to the tumor site during a surgical procedure," Lively says. Using radiation during surgery enables the surgeon to see and radiate the tumor through the open wound while protecting any normal tissues surrounding it.

Once the surgeon removes the tumor (partially or completely), IORT can treat any remaining microscopic disease within the surgical wound with high-energy medical linear accelerators, Lively says.

Although IORT was developed in the 1920s, certain insurers still consider this method of therapy to be investigational. The newest linear accelerators direct the radiation to a specific and well-defined body structure, thereby decreasing the risk of infection to open, anesthetized patients, Lively says, so make sure your payers understand the current technology.

Most patients are concurrently treated with high-dose external beam photon irradiation (77401-77416).

IORT has historically been used to deliver a boost dose of radiation to the tumor bed for selected early breast cancers (e.g., 174.x, Malignant neoplasm of female breast) when a lumpectomy is performed. The benefits of this treatment include excellent cosmetic results, freedom from local cancer recurrence, and minimal risk of radiation exposure for hospital personnel. IORT is also covered for locally advanced colorectal cancer (154.x, Malignant neoplasm of rectum, rectosigmoid junction, and anus), Lively says.

Code 77470 should not be used to describe modification of treatment. If there is a change in plan for any reason, the physician should use the appropriate code for simulation field setting (77280-77295) and dosimetry (77300-77331), because these codes more accurately describe the services provided. Modification, say the experts, while calling for the creation of a new treatment plan, does not necessarily require additional time and effort.

Lively advises that you keep these tips in mind when trying to determine if 77470 is appropriate:

It should not be used when chemotherapy follows radiation or radiation follows chemotherapy.

When the patient has another ongoing medical condition such as diabetes, hypertension or chronic obstructive pulmonary disease (COPD), it should not be used because the code is intended for use in radiation treatment and not to account for additional care as a result of other conditions.

It is a one-time-use code and should only be reported once per course of therapy, even if more than one reason qualifies.

Code 77432 (Stereotactic radiation treatment management of cerebral lesion[s] [complete course of treatment consisting of one session]) is a component of code 77470 and cannot be billed using any modifier.

Parman says practices should develop a policy on the use of 77470. It should include the situations when this is to be assigned and the specific area of the chart where supporting documentation will be maintained. Documentation for assignment of 77470 can take many forms. In some cases, the radiation oncologist dictates the qualifier into the initial consultation report, such as when the patient is receiving concomitant chemotherapy. In other situations, the nature of the service performed, such as IORT, will drive its assignment.

The code is normally used along with other radiation treatment management codes, such as 77427. CCI 8.3 edits forbid the use of 77432 and 77470, Lively says.

Some payers may require you to use 77499 (Unlisted procedure, therapeutic radiology treatment management) when billing IORT. Contact your payers directly to determine the extent of their reimbursement.