Radiology Coding Alert

While the definition and counting of most radiological services or procedures assigned a CPT Code are relatively straightforward (e.g., a chest x-ray, angiogram, MR, or CT), the complexity of a course of radiation therapy requires development of a unique coding approach to describe and enumerate radiation oncology services.

Weekly clinical management is one of seven sections in the CPT-4 devoted to describing the services of radiation oncologists. The seven sections are consultation, treatment planning (772xx), physics (773xx), treatment delivery (77401 to 77417), weekly clinical management (77419 to 77499), hyperthermia (776xx), and brachytherapy (777xx). The weekly clinical management of radiation therapy to treat malignant neoplasms and certain non-malignant conditions is a highly technical and complex process that usually requires management of a course of treatment over an extended period of time. Combinations of codes from multiple sections of CPT Codes are often used to describe a course of radiation therapy.

Useful Terms Defined

It is important to clarify terms before reviewing the coding rules that apply to clinical weekly management.

Weekly clinical management is based on a weekly unit of treatment equal to five (5) fractions.

A fraction of a weekly unit is one session of radiation therapy.

Fractionalization is dividing the total treatment plan (or course of treatment) into the total number of sessions the patient will receive.

Hyperfractionation is defined as dividing the daily
dose into smaller doses that are given more than once a day.

Radiation is usually given once a day in a dose that is based on the type and location of the tumor. If the therapy plan calls for more than one treatment to be given per day to an area, treatments are usually separated by four to six hours. Studies of hyperfractionation are in progress to see if it is as effective or even more effective than therapy once a day. In certain tumors, the early results are encouraging. Some reports suggest that hyperfractionation therapy is becoming a more common way to provide radiation treatments.

8 Rules to Correctly Code Weekly Clinical Management

To confirm the coding rules that apply to weekly clinical management, we reviewed the American College
of Radiology (ACR) guidelines and consulted with
Linda Lively, MHA, president and CEO of American Medical Accounting and Consulting. Livelys firm has specialized in coding, training and auditing for radiation oncology practices for over 16 years. We also checked policies published by some local Medicare carriers. Of course, guidance in CPT was considered as well. So,
given the terms defined above and review of sources, the basic rules are:

1. Claim one weekly treatment code for every 5 fractions or sessions of radiation therapy (77419, 77420, 77425, 77430, or 77431, as appropriate).The sessions do not have to be on consecutive days.

2. If final billing for a course of treatment leaves 3 or 4
fractions beyond a multiple of 5, Medicare will reimburse 1 weekly unit of treatment (rounding up). Example: 18 fractions equal 4 weekly services.

3. If final billing for a course of treatment leaves 1 or 2 fractions beyond a multiple of 5, Medicare will not make additional payment (rounding down).Example: 6 fractions equal 1 weekly service.

4. Indicate the appropriate weekly clinical management code based on level of complexity as 77420, simple; 77425, intermediate; or 77430, complex. Complexity depends on the number of treatment areas, ports, and blocking:

A) Simple management involves a single treatment area, single port or simple blocks.

B) Intermediate is two separate areas, three or more ports on a single area, or use of special blocks.

C) Complex management is three or more separate treatment areas, highly complex blocking, tangential ports, wedges, rotational compensators or other special beam considerations. For example, the patient is treated with four field hole pelvis technique for the first four weeks of therapy. The treatment is then modified to a single anterior and posterior boost field for the remaining two weeks of treatment. This would be coded as four weeks of Intermediate Treatment Management (77425), with the last two weeks coded as Simple Treatment Management (77420). If the number of fractions for any of these weeks of management is other than exact multiples of 5, the rules of 2 or less, 3 or greater still hold in terms of assigning the complexity level to that particular week of management.

5. For the date of service, indicate the date of the first session through the date of the last session.

6. When the total treatments consist of only 1 or 2 fractions, use code 77431 (radiation therapy management with complete course of therapy consisting of 1 or 2 fractions only). Do not use 77431 to fill in the last week of a long course of therapy.

7. For a patient treated with hyperfractionated treatment, use the total number of fractions or sessions to determine the number of weekly clinical management units. Remember hyperfractionation is delivery of radiation treatments more than once daily, usually two separate sessions separated by 6 hours. For example, a patient is receiving hyperfractionated treatment and is being treated in the morning and afternoon of the same day for two weeksa total of 20 sessions or fractions. A total of 20 fractions of treatment divided by 5 equals 4 sets of intermediate treatment management (code 77425 times 4).

8. What if the treatment course is interrupted? If the course of treatment is interrupted for more than a few days but the patient continues to be seen and evaluated regularly by the radiologist before reinstating treatment, these visits may be reported with E/M codes 99211-99215. Appropriate notes must document such visits. Weekly management codes cannot be claimed during this time when no treatments are being delivered.

Hyperfractionated Radiation Therapy

According to ACR guidance, additional items that may be valid to code for services delivered during hyperfractionated therapy, if performed, include:

77262: therapeutic radiology treatment planning; intermediate;

77285: therapeutic radiology simulation-aided field setting; intermediate;

77300: basic radiation dosimetry calculation, central axis depth dose, TDF, NSD, gap calculation, offaxis factors, tissue inhomogeneity factors, as requested during course of treatment, as often as necessary;

77370: special medical radiation physics consultation (if needed)

Note: Although these terms, policies and rules have emphasized Medicare patients, these rules also provide the basis for dealing with all payers. As always, coders are advised to direct questions to their specific payers and confirm the rules summarized here.

Will Codes Change in 2000?

Coders should be aware that reliable sources suggest the codes for weekly clinical management of radiation therapy are likely to be combined to develop a single weekly management code. The new CPT code under development appears to be on schedule for implementation as a new CPT code next year. Work on the new code, which may be described as radiation treatment management, five treatments, is ongoing in the AMA s Relative Value Update Committee with input from all the key professional organizations representing radiation oncology including ACR, the American College of Radiation Oncology (ACRO), and the American Society for Therapeutic Radiology and Oncology (ASTRO). Look for announcements and instructions in the next two issues when coding changes for 2000 are unveiled later this year.