Radiology Coding Alert

With a little help from savvy coders, radiation oncology centers will be able to justify the serious investment in equipment and training that the popular new intensity-modulated radiation therapy (IMRT) requires.

Two planning and daily treatment codes added in 2002 CPT 77301 (Intensity-modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specifications) and 77418 (Intensity-modulated treatment delivery, single or multiple fields/arcs, via narrow spatially and temporally modulated beams [e.g., binary, dynamic MLC], per treatment session) are contributing to IMRT's fast track with radiation oncology facilities.

IMRT promises to be superior to conventional radiation therapies when treating tumors that must be precisely targeted to protect surrounding tissues and structures.

"Everyone is getting it or installing it," says Jim Hugh, MHA, director of Atlanta-based AMAC, a coding and billing consulting firm, and author of several articles on IMRT reimbursement.

The simple message for radiology coders is that IMRT uses a computer optimization process to deliver a more precise radiation dose to the tumor while sparing the surrounding normal tissues, says Deborah I. Churchill, CPC, president and founder of Churchill Consulting Inc., an auditing and electronic coding consulting firm in Killingworth, Conn.

Fuggeddabout Reporting 77301 With Other Treatment Planning

2002 CPT text describes IMRT planning code 77301 with great specificity. 77301 properly describes a permanent record of computer-generated inverse treatment plans, including 3-D tumor and critical structure volumes, inverse planning, dosimetric or biological objectives, dose-volume histograms and dose verification.

Because IMRT requires specialized hardware and planning software to provide inverse planning, 77301 is needed to describe the work necessary to prepare for safe and effective treatment.

77301 entirely replaces any other planning code. From a clinical standpoint, when planning IMRT for an entire course of radiation therapy, there is usually no need to perform any other isodose planning, so it makes sense for the IMRT code 77301 to limit the use of standard isodose planning codes 77305-77321, Churchill says. Evidence of physician review must be available, and treatment centers will have to show extensive verification, experts say.

77301 Bundling Has One Slip Knot

The CCI now states that for freestanding centers 77301 is bundled in with several other codes, including daily and special treatment plans and special port plans. The following procedures that are performed on the same day by the same provider are among the codes bundled with 77301:

And CCI edits restrict reporting codes 77300, 77305-77315 and 77321 with 77301. Bundling grumbling may also arise when IMRT is required for a boost.

Carriers and experts disagree on whether you are allowed to report only one IMRT plan for a given "course" of therapy. Some sources allow an additional plan if there is clinical indication to change the treatment plan, such as would be encountered in "boost" situations. Churchill says it would be more cost-effective to begin with an external course of therapy and utilized IMRT for the boost. Whether IMRT will be allowed as a boost in the real world remains a carrier issue, Churchill says. Scrutinize your LMRPs and communicate clearly with your carrier regarding the clinical efficacy of reporting IMRT planned boosts following conformal therapy.

In general, the only code in the CCI restrictions that seems to be clinically appropriate to report with 77301 is 77300, the basic dosimetry code. The CCI Edits may allow for this code to be reported on a different day if the work is ordered and properly documented.

However, both Hugh and Churchill stress that work should always be reported on the day that it is performed and documented in the medical record. Never manipulate dates for collection purposes. "Only if these procedures are performed on different days, using a separate software system, may you bill both codes," Hugh says.

Bill 77418 Daily

IMRT delivery is billed daily with 77418, which pays about five times more per day than standard therapy and, as such, replaces all other daily codes. Once you start billing 77418, obviously you can't bill the rest of the regular photon therapy codes, Hugh says.

Other codes that should be bundled with 77418 include:

All of the above codes are modifier -59 exempt, meaning you can't use the modifier to unbundle services.

And once you start a patient's treatment, until 90 days after the end of treatment, all E/M codes are bundled. Hugh reminds doubters to look at the first paragraph in the radiation oncology section in the CPT book, which explicitly states that listings in this section include "normal follow-up care during course of treatment and for three months following its completion."

Note also that IMRT requires large numbers of port films, but Medicare pays for only one per week. Some other payers will pay for more than one, Hugh says, so coders have to be dexterous about submitting the correct number to Medicare and the correct number to non-Medicare payers.

Deal With Wimpy Weekly Code

Today, a radiologist receives the same weekly management reimbursement for a skin lesion as for a complicated IMRT case, Churchill laments. For weekly treatment management, only one physician code exists for 2002 and 2003 77427. She says that although "there has been some conversation" about reinstating the 77419 conformal management code to reflect "the extra work involved in such complex cases as IMRT," now only 77427 is available.

IMRT Is Not Experimental

Some insurance companies are calling IMRT experimental and investigational, even though Hugh says that "it is emphatically not." Medicare started paying on Jan. 1, 2002, and payers who are behind the clinical curve need to be educated. When you're faced with recalcitrant insurers, Hugh says, you should submit your case to the radiation oncologist on the Carrier Advisory Committee, as well as the American College of Radiology (ACR) and ASTRO.

Because IMRT is popular with the public, Hugh warns, people may be tempted into overuse when a simpler approach, like a simple 3-D conformal therapy, would be more appropriate. A typical coder in an average, non-IMRT-focused center should see between 15 and 25 percent of the patients being treated with IMRT, Hugh says. "If the coders see a super-high utilization, like 50 percent, they should be concerned about the documentation being able to support the medical necessity."