Radiology Coding Alert

A novel application for a conventional cancer treatment is being adopted throughout the country and in some areas being reimbursed by Medicare and commercial payers.

Brachytherapy in which a source of radiation is placed next to or inside an affected body part is commonly used to treat some types of cancer (e.g., prostate). Late in 2000, the Food and Drug Administration approved a device that allows this treatment to be used with patients suffering from coronary artery disease (CAD), who are at risk for restenosis of arteries treated with balloon angioplasty or stent placement. Early clinical studies, however, have not produced definitive results about the effectiveness of this modality.

Intravascular brachytherapy is an innovative approach and is viewed in some circles as one of the more promising treatment options, says Lynn C. Esposito, CPC, clinical practice specialist with Hunter Radiation Therapy at the Yale University School of Medicine. Although ultimately not used, intravascular brachytherapy was reportedly one of the treatment modalities recently considered to treat Vice President Dick Cheneys cardiac episode.

Intravascular brachytherapy is performed typically by both a cardiologist and radiation oncologist, although some interventional radiologists (I/R) are also performing the procedure and assume the role otherwise undertaken by the cardiologist. The cardiologist or I/R performs the angioplasty and places the catheter. The radiation oncologist, who holds the Nuclear Regulatory Commission licensure to handle the source, assists in placing the radioactive seeds.

Esposito points out that there are no specific procedure codes for this service, although the American College of Cardiology (ACC) has applied to CPT Codes for new ones, which will potentially be in the Cardiovascular section of the CPT Manual . The absence of codes has resulted in three disparate approaches to reporting intravascular brachytherapy appropriately:

1. Some radiation oncology coding experts strongly recommend using CPT 77799 (unlisted procedure, clinical brachytherapy) to cover the entire procedure, arguing that other coding scenarios represent inappropriate upcoding.

2. Other practices, like Espositos, have followed the advice of professional organizations like the American Society of Therapeutic Radiology and Oncology (ASTRO) and are assigning a series of related radiation oncology codes to describe each step of the service. (The explanation that follows reflects ASTROs recommendations.)

3. Still others agree with the use of radiation oncology codes up to the point of assigning them for the treatment portion of the service, but then recommend assigning the unlisted procedure code for that final component (Step 4 below).

Because of these diverse approaches, practices should work closely with payers to determine what is acceptable in their area.

Coders Hopeful of Reimbursement

Although brachytherapy is approved by the FDA, many coders anticipate claim denials because the ICD-9 codes supporting medical necessity for brachytherapy are cancer-related, not CAD-related. Many predict that we wont be paid for these procedures because the diagnosis codes wont line up with the procedure codes, Esposito warns.

Nonetheless, Donna Gullikson, CPC, coding supervisor for Medical Computer Business Systems, a national billing company based in August, Ga., is one of many coders reporting reimbursement for intravascular brachytherapy. We recently received payment from one carrier, she notes. Were cautiously optimistic and were taking this to be a positive indication that the treatment will be accepted. We will have to wait and see if this truly indicates a policy decision that will become universally adopted.

Therapy Complements CAD Treatment

Esposito notes that many patients suffering from CAD are treated with angioplasty, which is sometimes followed by the placement of a stent to support the affected artery walls. Between 30 and 50 percent of patients treated with angioplasty experience additional narrowing of the artery walls, while 15 to 25 percent of patients with stents require additional treatment because of restenosis at the stent site. Patients who develop restenosis after coronary stenting are at particularly high risk for additional medical complications after repeat revascularization procedures. In this particular group of patients, several clinical studies have shown that intravascular brachytherapy may reduce the need for additional angioplasty procedures or by-pass surgery, as well as reduce the incidence of myocardial infarction, recurrent angina or sudden death due to restenosis.

Intravascular brachytherapy is generally performed immediately following angioplasty. The angioplasty catheter is removed and the intravascular brachytherapy catheter positioned in the previously blocked area. Once the catheter is in place, a beta or gamma radiation source (i.e., seeds) is delivered to the treatment site through the device and remains in place for the prescribed time from two to 30 minutes, depending on the radiation source and its activity. When the treatment is completed, the radiation sources and catheter are removed. No radiation remains in the body. Imaging studies may be obtained to determine if additional treatment is required.

Coding the Radiation Therapy

As with clinical brachytherapy for prostate cancer, several sets of radiation oncology codes may apply to an intravascular application. In addition to these codes, radiation oncologists may bill an E/M code (e.g., established outpatient visit codes 99211-99215, or outpatient consultation codes 99241-99245) if they provide a significant, separately identifiable service to the patient before the decision for intravascular brachytherapy is made.

Alternatively, the cardiologist or interventional radiologist may perform these E/M services. The level of the outpatient visit would be based on the documented level of history, exam and medical decision-making.

1. Clinical Treatment Planning
When physicians decide to treat a restenosis with brachytherapy, they must do in-depth treatment planning. This includes interpretation of special testing that may have been done, stenosis localization and other procedures, as well as devising a specific therapeutic course. According to Gullikson, treatment planning is coded from the 77261-77263 series. In most cases, intravascular brachytherapy treatment plans will be coded 77263 (therapeutic radiology treatment planning; complex), she says, because of the complexity of services and the high of risk associated with the procedure.

2. Simulation
Using information from the treatment plan, the radiation oncologist will conduct a simulation to ensure that the radiation therapy is delivered precisely to the affected arterial wall. Simulation of source placement using a catheter and other devices often is generated from angiographic images. Again, because brachytherapy is an intricate procedure, 77290 (therapeutic radiology simulation-aided field setting; complex) is most often assigned. Lower-level simulation codes are 77280 and 77285.

Modifier -26 (professional component) is required with the simulation codes to describe it as a physician service. (When done in a hospital, the facility would report the simulation code with the appropriate revenue code to indicate the technical component of the service.) The physician must participate in the procedure and summarize what occurred for the simulation code to be assigned.

3. Dosimetry and Isodose Planning
To determine the proper amount of radiation that will be delivered, radiation oncologists perform precise calculations, according to Gullikson. Code 77300 (basic radiation dosimetry calculation, central axis depth dose, TDF, NSD, gap calculation, off axis factor, tissue inhomogeneity factors, as required during course of treatment, only when prescribed by the treating physician) reflects the physician work required for these precise types of dosimetry calculations.

In addition, a code from the 77326-77328 series (brachytherapy isodose calculation) may be assigned. Gullikson notes that 77327 ( intermediate) is most commonly used. Modifier -26 would be appended to report these codes.

4. Treatment
According to Esposito, coders may assign one of two treatment codes for the procedure. In her practice, a code from the 77781-77784 series to describe remote afterloading high-intensity brachytherapy is most often assigned. Specific codes depend on the number of source positions or catheters.

Because intravascular brachytherapy is analogous to endocavity radiation applications, some coders may assign conventional intracavitary implant codes 77761 (intra-cavitary radiation source application; simple), 77762 ( intermediate) or 77763 ( complex) if low-dose sources are threaded into the arterial catheter. To describe the radiologists work in handling the radioactive isotope material, coders would assign 77790 (supervision, handling, loading of radiation source) in addition to this code.

Note: It is not appropriate to assign 77790 with the high-dose codes 77781-77784.

Assigning Additional Codes

Some coders report 77470 (special treatment procedures [e.g., total body irradiation, hemibody radiation, per oral, endocavitary or intraoperative cone irradiation) in some instances, a practice supported by ASTRO. Their rationale is that this code reflects the additional effort and work required in special procedures like brachytherapy.

Also, a few specialty coders note that 77370 (special medical radiation physics consultation) and 77336 (continuing medical physics consultation, including assessment of treatment parameters, quality assurance of dose delivery, and review of treatment documentation in support of the radiation oncologist, reported per week of patient therapy) may be reported when appropriate in cases involving non-Medicare patients. These two codes are often regarded as mutually exclusive, however, and in this instance, only one may be reported on any given date of service.