Radiology Coding Alert

Even though carriers refer to CPT 77427 (Radiation treatment management, five treatments) as a "physician's weekly treatment management," remember that this code includes five sessions, regardless of the actual treatment time period. In fact, CMS even allows you to count multiple fractions on the same day, as long as you document a break between treatment sessions.

Report 77427 for 3-4 Treatments

CMS considers the first five treatment sessions (or fractions) one unit of 77427. But you can report multiple fractions representing two or more treatment sessions that occur on the same day if "the fractions are of the character usually furnished on different days," and you document a break between treatment sessions, according to Section 15022 of the Medicare Carriers Manual.

If you administer three or four additional treatments at the end of a treatment course, you can report a full unit of 77427. But if only one or two fractions remain, Medicare will bundle them into your prior radiation treatment payments, so you should not report them.

For example, if you complete nine fractions during a patient's radiation treatment, you should report 77427 twice, once for the first five fractions and a second time for the remaining four.

According to Jim Hugh, MHA, vice president of American Medical Accounting and Consulting, a coding and reimbursement consulting firm in Atlanta, radiation oncology practices commonly make three mistakes:

How to Use 77427

Radiation treatment management represents the professional services of the physician managing a radiation course. You don't necessarily have to provide these services on consecutive days. Code 77427 includes the physician's ongoing supervision and care of the patient during the entire course of radiation treatment, and each unit of 77427 includes:

According to the February 2000 CPT Assistant , you should not report an E/M code when you report 77427, because it includes your evaluation services.

You should always wait until you administer at least five fractions before you report 77427, and never report treatment services that you scheduled but have not yet performed. Some carriers mandate that you list the first date of the week for each unit of 77427 that you report and that you list each unit of 77427 on separate line items. Other carriers prefer that you list the ending date of treatment, and still others want both the beginning and ending dates, so contact your carriers before rendering these services to determine their preferences.

Some carriers, such as Wisconsin Physicians Service Insurance Corp. (WPSIC), the Part B carrier for four Midwestern states, also require practices to list the number of fractions that they administer in box 19 of the CMS-1500 form.

77427 Versus 77431

Don't confuse 77427 with 77431. Radiation therapy management (77431) refers to complete therapy management and includes fewer than three sessions. You should not use it to report one or two leftover fractions following a radiation treatment course.

Radiation therapy management also includes follow-up patient visits for 90 days after the patient completes radiation therapy, according to CPT coding convention. Most payers will not reimburse you separately for follow-up visits until 90 days after the patient's last radiation treatment. If you see a patient during this period, do not bill for the E/M service.

Get It in Writing

Poor advice from payers also causes radiation practices to misuse treatment management codes. Carriers sometimes tell practices to report 77431 for each leftover fraction or to bill 77427 for each fraction, Hugh says. "CPT guidelines are fairly straightforward, and billing any other way is fraud. If you are told to bill differently, get it in writing, otherwise once your insurer finds out that you have been billing incorrectly, they are going to ask for their money back."

Physician Should Remain On-Site

Although the majority of radiation oncology codes include both technical and professional components, weekly management includes only a professional component. The facility should report daily treatments using the technical-only codes 77401-77416.

Because 77427 represents the physician's management, the physician must document his or her evaluation of the patient. The radiation oncologist does not have to personally examine the patient during each treatment session, but the chart must include documentation of a physician encounter within every five-fraction period that you report. Many practices believe that the physician must see the patient "once a week," but if you report 77427 twice during a one-week period, the physician must see the patient twice during that week. Documentation may include the following:

The February 2000 CPT Assistant states, "The radiation treatment process is a dynamic one Therefore, this may require the personal attendance of the radiation oncologist at treatment setup, and while the patient is treated, to make sure that the treatment devices such as wedges, blocks, and the bolus are utilized properly. The patient's tolerance to treatment is an important consideration in radiation oncology. This may require multiple visits with the patient during the five-treatment time period. During these visits, the radiation oncologist physically examines the patient for amelioration of treatment and disease-related side effects, as well as tumor response to treatment In the simplest of cases, this may require no more than a weekly examination and appropriate prescription writing."

Only a board-certified radiation therapy technician (RTT) may administer radiation treatment, and the physician must be present in the office suite and immediately available to furnish assistance and direction during the procedure.

Section 2075 of the Medicare Carriers Manual states, "X-ray, radium, and radioactive isotope therapy furnished in a nonprovider facility require direct personal supervision of a physician. The physician need not be in the same room, but must be in the area and immediately available to provide assistance and direction throughout the time the procedure is being performed."