Radiology Coding Alert

Experts show how to select consult, isodose and treatment planning codes

The next time your radiation oncologist plans a prostate brachytherapy implant, make sure you know how to report the physician's services - or risk denials for these costly procedures.

Radiation oncologists may use either low-dose brachytherapy (CPT 77778 , Interstitial radiation source application; complex) or high-dose brachytherapy ( 77784 , Remote afterloading high-intensity brachytherapy; over 12 source positions or catheters) to treat prostate cancer (185, Malignant neoplasm of prostate). The physician's consultations, isodose and clinical treatment planning can be even more difficult to report than coding the actual seed implantation, but a few simple tips can help you navigate these procedure codes.

1. Don't Overlook Brachytherapy Consultations

Radiation oncologists often perform consultations at the request of other physicians, such as urologists or oncologists, usually regarding whether the patient is a good candidate for radiation therapy.

Brachytherapy always requires a complete evaluation to determine whether the procedure is appropriate. During the evaluation, the radiation oncologist determines the best treatment regimen for the patient, which may include external beam irradiation followed by brachytherapy or brachytherapy alone. Only a radiation oncologist can make this determination, based on various factors such as the tumor size and location, and the patient's age or overall health status.

You should report a consult (99241-99245) or new patient visit (99201-99205) based on the radiation oncologist's E/M documentation. The level of decision-making normally drives the code choice, as long as the physician documents all required elements, says Deborah Churchill, RTT, owner of Churchill Consulting Inc., a consulting firm in Killingworth, Conn. "The risk will always be high. The level of decision-making will depend on the number of treatment options the physician considers and will usually be moderate (99244) or extensive (99245)."

The number of studies that the physician reviews or orders is another consideration in choosing the consultation level, Churchill says. "Because only two of the three elements must be achieved (risk, number of treatment options, number of studies ordered or reviewed), the level of the consult will be determined by the physician's documentation."

2. Choose 77263 for Clinical Treatment Planning

Following the radiation oncologist's consultation, the physician will plan the brachytherapy treatment process. The planning process generally includes interpreting special tests and prostate localization procedures.

For the physician's clinical treatment planning, report 77263 (Therapeutic radiology treatment planning; complex), because insurers generally define brachytherapy alone or in combination with other treatment modalities as a complex planning service. As with any other service, medical record documentation must support the level of clinical treatment planning that you report.

Procedures Include Physician Management

You should not report physician management codes for brachytherapy procedures, because the procedure codes (77776-77778 and 77781-77784) already include those services, unless the individual carrier's policy allows you to report both a brachytherapy professional component and therapy management.

For example, First Coast Options' (a Florida Part B carrier) policy states, "Radiation treatment management (77427) may be reported every fifth treatment with remote afterloading brachytherapy (HDR). It may also be billed after every fifth treatment of combination therapy (e.g., three HDR and two external beams). Radiation therapy management (77431) should be used if the complete course of therapy consists of one or two sessions."

3. Report 76873 for Implant Planning

The radiation oncologist should also perform volume and mapping services so the physician will know where to insert the catheters for the prostate seeds, says Craig McNabb, MBA, BSN, reimbursement manager for the Atlanta branch office of US Oncology. If the physician performs a prostate volume study, report 76873 (Ultrasound, transrectal; prostate volume study for brachytherapy treatment planning [separate procedure]).

If your radiation oncologist performs a CT pubic-arch study instead, you should report 76370 (Computed tomography guidance for placement of radiation therapy fields). Pubic-arch studies help physicians determine the prostate's volume and determine whether the cancer has spread outside of the prostate gland. The study also allows the physician to assess the potential for pubic bond interference when implanting the seed.

Tip: Physicians perform prostate volume studies before they implant seeds, so you should report the volume study or pubic-arch study on the date that the physician performs it. Don't report 76873 on the same day as a seed implantation code, such as 77778 (Interstitial radiation source application; complex), because the National Correct Coding Initiative bundles 76873 into 77778, and no modifier can bypass the edit.

If the physician performs a simulation to confirm the brachytherapy source placement at the time of the implant, you can report 77290 on the same date that you implant the seeds, but you must attach a copy of the final fluoroscopy printout to the patient's file for documentation purposes, Churchill says. The physician should also dictate a simulation note as a separate document or paragraph in the brachytherapy procedure report.

4. Look to 77326-77328 for Brachytherapy Isodose Planning

After reviewing the volume study or pubic-arch study, radiation oncologists perform brachytherapy isodose planning to determine how many seeds the patient requires, and where he should place them.

If the radiation oncologist recommends brachytherapy treatment, you should report 77328 (Brachytherapy isodose plan; complex [multiplane isodose plan, volume implant calculations, over 10 sources/ribbons used, special spatial reconstruction, remote afterloading brachytherapy, over 12 sources]) for the physician's isodose planning.

Radiation oncologists may also perform post-seed-implant isodose plans four to six weeks after implanting the seeds. If the physician uses 3-D planning at that encounter, you should report 77295 (Therapeutic radiology simulation-aided field setting; three-dimensional) instead of the complex isodose code, when your payer allows it.

Carriers decide whether to reimburse 3-D simulation/planning for prostate seeds based on their individual interpretations of 77295. If the carrier indicates that beam's-eye view (BEV) is required when reporting 77295, you should not report it for the brachytherapy planning.