Radiology Coding Alert

As Medicare continues to scale back payment for the time-intensive, complex work involved in prostate brachytherapy the transperineal implantation of permanent radioisotope seeds it's more imperative than ever before for radiation oncology coders to know proper coding strategies for each component.

Coding Each Step of Brachytherapy Treatments

"When you are coding a radiation procedure like brachytherapy, you must keep in mind each of the distinct steps involved," says Cindy Parman, CPC, CPC-H, co-owner of Coding Strategies Inc., an Atlanta-based firm. "In most cases, you will be able to assign codes that may include consultation, treatment planning, treatment simulation, dosimetry calculations and isodose planning and, sometimes, additional special services."

Step 1: Consultation

Radiation oncologists usually spend a lot of time with a patient who has been referred for a consultation, says Morgan Hause, CCS, CCS-P, privacy and compliance officer for Urology of Indiana LLC in Indianapolis. "This is the time a physician would spend with the patient prior to deciding whether or not to treat," he says. "This consultation, which usually comes from the urologist, would encompass elements outlined in medical or surgical E/M service codes."

Parman reminds readers to recall the definition of consultation: It's a request from one physician to another physician for an opinion or advice. If the patient is sent to "evaluate and treat," then it is a new patient visit.

Hause reminds coders that if documented counseling and coordination of care comprises more than 50 percent of the time the radiation oncologist spends face-to-face with the patient as it often does then time would determine the E/M level billed.

Due to the intensity of this visit, if the service was completely documented, it would almost always be assigned the most extensive CPT code, 99205 (New patient; office or other outpatient visit) or 99245 (Office consultation for a new or established patient).

Step 2: Clinical Treatment Planning

Once radiation oncologists decide to treat the prostate cancer patient with brachytherapy, Hause says, they will embark on an in-depth treatment planning process. The process includes interpretation of special testing that may have been done, prostate localization and other procedures. "The vast majority of brachytherapy treatment plans will be coded 77263 (Therapeutic radiology treatment planning; complex)," he says.

The American Medical Association added a new code to CPT Codes in 2000 to describe an additional study done in brachytherapy treatment planning. The urologist or the radiation oncologist may perform 76873 (Echography, transrectal; prostate volume study for brachytherapy treatment planning [separate procedure]). "It's for volume and mapping, and gives the physician an idea of where to insert the catheter for the prostate seeds," says Craig McNabb, MBA, BSN, reimbursement manager for radiation for the Atlanta branch office of US Oncology, based in Houston.

In addition, Parman says, only one physician, either the urologist or radiation oncologist, can bill for this US treatment plan. The physician who assists or watches the procedure does not separately charge for his or her participation.

If billing only for the professional component of this procedure, you should submit it with modifier -26 (Professional component), Hause says.

In addition to the clinical treatment planning, Deborah Churchill, president and founder of Churchill Consulting Inc., an auditing and electronic coding consulting firm in Killingworth, Conn., advises reporting code 77470 (Special treatment procedure) with the brachytherapy procedure. This code may be reported only one time per course of therapy per volume. "If external beam 3-D treatment preceded the brachytherapy procedure and 77470 was reported at that time, it would not be reported for the subsequent implant," Churchill says.

Step 3: Simulation

With information from the consultation and treatment planning studies in hand, the radiation oncologist may conduct a simulation to ensure that radiation therapy is delivered only to the diseased tissue. This simulation may be in the form of a pubic arch study, Churchill says. Again, because brachytherapy is an intricate procedure, 77290 (Therapeutic radiology simulation-aided field setting; complex) is most often assigned.

In addition, if a prostate volume study (PVS) is performed transrectally for the purpose of determining the optimal distribution of seeds for treatment, then code 76873 (... prostate volume study for brachytherapy treatment planning) may be used to identify the imaging procedure provided, Churchill adds.

Expert coding opinion is split on whether to use 3-D simulation-aided field setting (77295, Therapeutic radiology simulation-aided field setting; three-dimensional) for prostate brachytherapy. McNabb advises against it; but Parman says that some payers require a beam's-eye view for 77295, while others allow the 3-D reimbursement if documentation supports the medical necessity and use of this equipment.

Again, modifier -26 (Professional component) is required with the simulation code to describe it as a physician service. (When done in a hospital setting, the facility would report the simulation code with the appropriate revenue code to indicate the technical component of the service.) "Plus, it is imperative that the physician participate in the procedure and summarize what occurred for the simulation code to be assigned," Parman says.

Step 4: Dosimetry and Isodose Planning

To determine the proper amount of radiation delivered by the implanted seeds, the physics teams will perform precise calculations based on the radiation oncologist's prescription. The time and effort invested in this stage of treatment is still reflected in codes 77326-77328 (Brachytherapy isodose plan), McNabb says.

"Again, because of the intensity of brachytherapy as a clinical treatment, radiation oncology coders will most often assign 77328 for these activities (Brachytherapy isodose plan; complex [multiplane isodose plan, volume implant calculations, over 10 sources/ribbons used, special spatial reconstruction, remote afterloading brachytherapy, over 12 sources])," McNabb says.

Note: The verbiage has changed in 77328 from "calculation" to "plan" in CPT 2003. This change also affects codes 77326 and 77327.

McNabb hastens to add that coders should NOT report 77331 (Special dosimetry [e.g., TLD, microdosimetry] [specify], only when prescribed by the treating physician). "That is basically an external beam process to measure the dosage received at a given point. The general consensus now holds that it's not an appropriate code for brachytherapy procedures," he explains.

The only time that 77331 would be appropriately reported would be in select cases in which a rectal diode probe is inserted and readings performed, Churchill says.

You may, however, bill for a simple device 77332 (Treatment devices, design and construction; simple [simple block, simple bolus]) for the template for inserting the needles through the perineum, says Jim Hugh, MHA, senior vice president with AMAC, a reimbursement and billing firm based in Atlanta that serves radiation oncology practices and hospitals.

Hugh says that according to the ASTRO/ACR User's Guide 2002, you may employ 77336 (Continuing medical physics consultation, including assessment of treatment parameters, quality assurance of dose delivery, and review of patient treatment documentation in support of the radiation oncologist, reported per week of therapy) under any modality in which the full course of therapy (including brachytherapy) is one or two treatments.

You may also bill 77370 (Special medical radiation physics consultation) with the permanent seed implants if the physician makes a special request if there's a complication with the seed implant, Hugh says. "It's an as-needed code."

Churchill and Parman remind readers that a special physics consult must be ordered, performed by a qualified medical physicist, and some form of report must result, which should be signed and dated by the physician.

Step 5: Treatment

This year, two new HCPCS codes for prostate brachytherapy deliver marked changes in the way hospitals will bill for treatment delivery. Effective Jan. 1, 2003, for hospital APC billing purposes, use the following temporary codes for palladium-103 (Pd-103) and iodine-125 (I-125):

During brachytherapy procedures, a urologist and radiation oncologist often work side-by-side to implant the seeds. Until this year, the urologist who performed the surgical component of the procedure, inserting and placing the needle for the delivery of the seeds, would bill a urology surgical code: 55859 (Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without cytoscopy). And the radiation oncologist, whose special training and approval require him to implant the seeds, would report the treatment procedure with 77778 (Interstitial radiation source application; complex).

But no more. The two new hospital G codes for "permanent prostate seed implants" now encompass the urological code (55859), the application code (77778), and the needles, as well as the seeds themselves, Hugh says. The urologist still bills these codes professionally only hospitals have the codes bundled into one of the new G codes, Parman says.

Hospitals may continue to use 55859 and 77778 when reporting services other than prostate brachytherapy, according to the Code of Federal Regulations, Title 42, Parts 405 and 419, recently issued by the Department of Health and Human Services (HHS). These changes also do not affect procedures for non-Medicare patients.

Medicare will allow hospitals to "continue to report separately other services provided in conjunction with prostate brachytherapy, such as dosimetry and ultrasound guidance." Therefore, to describe the urologist's or radiologist's work in handling the radioactive isotope material and the ultrasound guidance used to ensure the correct placement of the seeds, hospital outpatient coders may still assign 77790 (Supervision, handling, loading of radiation source) and 76965 (Ultrasonic guidance for interstitial radioelement application).

There is no separate charge for supervising the handling of the seeds performed by the physicist. And everything, as always, must be documented.

Step 6: Postoperative Services

A second brachytherapy isodose plan or simulation may be performed after the seeds have been placed, about one month after the procedure. "This is done to measure the dose actually delivered to the prostate, as opposed to what the preplan indicated," Hause says. Coders may report 77328 a second time when the isodose plan is performed and documented or a second 77290 for a post-implant simulation, McNabb adds.