Radiology Coding Alert

Because clinical brachytherapy often offers significant advantages over radiation beam therapy, it's being used more frequently to treat a variety of forms of cancer. A complex process, brachytherapy must be coded based on each stage to ethically optimize reimbursement.

There is no comprehensive code assigned for brachytherapy, explains Cindy Parman, CPC, CPC-H, co-owner of Coding Strategies Inc., an Atlanta-based firm that supports 1,000 radiologists and 350 physicians from other specialty areas. "Each component of the therapy is assigned its own code. Often, a coder will use seven or more codes to reflect the work involved." The multistep process typically involves a consultation with the patient, treatment planning, treatment simulation, dosimetry calculations and treatment management.

Radiation oncologists meet with patients who are candidates for brachytherapy, Parman says. "This is an intense and time-consuming meeting. The physician performs all the key components of an E/M service, taking a history, performing a physical examination, and considering various treatment options." Coders assign an office visit code to reflect this appointment. "In most cases, this is a level-five E/M service (e.g., 99205, New patient, office or other outpatient visit; CPT 99215 , Established patient, office or other outpatient visit; or 99245, Office consultation, new or established patient) because of the intensity of the history and examination elements and the complexity of the medical decision-making," she says.

This E/M visit determines whether the patient will benefit from brachytherapy, Parman adds. "The next step involves highly detailed treatment planning, which includes interpretation of testing that had been done previously, localization of the area to be treated, and other procedures."

CPT Codes provides three codes to describe the professional treatment planning for clinical brachytherapy: CPT 77261 (Therapeutic radiology treatment planning; simple), 77262 ( intermediate) and 77263 ( complex). In most cases, Parman says, coders assign 77263 because of the complicated nature of brachytherapy planning.

Note: A complete explanation of how to determine which level of treatment planning to report, "Unravel the Secrets of Radiation Treatment Planning," appeared on page 93 of the December 2001 Radiology Coding Alert.

When coding interstitial brachytherapy for treatment planning with prostate cancer patients, coders may be able to report 76873 (Echography, transrectal; prostate volume study for brachytherapy treatment planning [separate procedure]) in addition to the treatment planning code. In some facilities, the urologist instead of the radiation oncologist performs echography, and only the performing physician may bill the professional component of this service with a modifier -26 (Professional component).

Simulation coding is determined by the complexity of the service. Four codes are available, each representing a higher level of simulation. When the simulation involves a single treatment area with either a single port or parallel-opposed ports, use 77280 (Therapeutic radiology simulation-aided field setting; simple). For two separate treatment areas with three or more converging ports, report 77285 ( intermediate). For simulation of three or more treatment areas with tangential portals, use 77290 ( complex). CPT 2002 also states that when rotation or arc therapy, complex blocking, or custom shielding blocks are used, as well as when brachytherapy source verification, hyperthermia probe verification or contrast materials are involved, you should report the complex code.

Parman says that clinical brachytherapy generally requires complex simulation. "In other instances, radiation oncologists may use 3-D simulation (77295, three-dimensional) instead of the more traditional methods." 3-D simulation is controversial, however, with some radiation oncologists believing it is valuable only with external beam radiation, not brachytherapy. Others maintain they would never consider doing brachytherapy without a 3-D simulation. "Payers also have widely varying policies on this issue," she notes. "Coders need to be very aware of both carrier and physician preferences."

Before assigning a simulation code, Parman advises, coders should ensure that the radiation oncologist personally participated in the process. "The physician should have documented his or her presence in the patient record and summarized what occurred in a simulation note."

Modifier -26 is required with the simulation codes to describe it as a physician service. When simulation is performed in a hospital setting, the facility would report the procedure with the appropriate revenue code to indicate the technical component of the service.

After the simulation, the physics team joins the radiation oncologist to determine the proper amount of radiation to deliver during brachytherapy. "An isodose plan is necessary for the physician to determine the exact distribution of radiation around the brachytherapy radiation sources," Parman says. You should report this treatment with 77326 (Brachytherapy isodose calculation; simple [calculation made from single plane, one to four sources/ribbon application, remote afterloading brachytherapy, 1 to 8 sources]), 77327 ( intermediate [multiplane dosage calculations, application involving 5 to 10 sources/ribbons, remote afterloading brachytherapy, 9 to 12 sources]) or 77328 ( complex [multiplane isodose plan, volume implant calculations, over 10 sources/ribbons used, special spatial reconstruction, remote afterloading brachytherapy, over 12 sources]).

You should choose the treatment code (77750-77799) based on the type of radioactive source and the delivery method used during clinical brachytherapy. "Treatment using liquid radioactive sources is reported with 77750 (Infusion or instillation of radioelement solution)," Parman says.

Use 77761-77763 for simple, intermediate and complex intracavitary radiation source applications. "This treatment consists of placing the radioactive sources within a body cavity such as the vagina, uterus, lung, esophagus, biliary system or other cavity that can be entered without major surgical procedures," she notes. For interstitial radiation source application, where seeds, needles, ribbons or wires containing radioactive materials are inserted directly into body tissues, report 77776-77778. To designate the physician service, append modifier -26. If ultrasound guidance is used to ensure proper placement of interstitial sources, report 76965 (Ultrasonic guidance for interstitial radioelement application) with modifier -26. For ultrasound placement of radiation therapy fields used for applications other than interstitial, report 76950 (Ultrasonic guidance for placement of radiation therapy fields).

"The intracavitary applications are left in place over a period of days while they deliver relatively low-intensity radiation directly into the tumor. Often, they're used with radiation beam therapy to bring the total dose up to a desired level," Parman says. When brachytherapy and beam therapy (77401-77418) are used, you may report both treatment modalities separately. However, only one physician treatment planning code should be reported because the overall plan encompasses both therapies.

In addition, coders may report 77470 (Special treatment procedure [e.g., total body irradiation, hemibody radiation, per oral, endocavitary or intraop-erative cone irradiation]). This code covers the additional physician effort and work required for the special procedures of hyperfractionation, total body irradiation, per oral or transvaginal cone use, brachytherapy, concurrent hyperthermia, planned combination with chemotherapy or other combined modality therapy, stereo-tactic radiosurgery, intra-operative radiation therapy, and any other special time-consuming treatment plan.

Freestanding centers may assign 79900 (Provision of therapeutic radiopharmaceutical[s]) when they supply the agents. To describe the radiation oncologist's work in handling the radioactive isotope material, you should use 77790 (Supervision, handling, loading of radiation source). This code is not valid with high-dose-rate brachytherapy services (77781-77784).

When treating certain cancers, radiation oncologists may be required to surgically implant devices like vaginal cones, oral catheters or tubes. These procedures are billed separately when performed by the radiation oncologist. "When there are no CPT codes that precisely describe some of these implantations, use unlisted codes [e.g., 42299 (Unlisted procedure, palate, uvula)]," Parman says.

Similarly, radiation oncologists may work with other specialists (e.g., urologist, gynecologist or surgeon) to implant devices or deliver the radiation therapy. When the procedure requires the services of a second physician, each physician bills the portion of the service he or she performed. Alternatively, if the service is identified by one code and jointly performed, modifier -66 (Surgical team) or -62 (Two surgeons) may be required.

After the initial treatment, complex simulation for source verification and isodose planning may be repeated. "It's not uncommon for the radiologist to conduct a post-treatment isodose calculation," Parman says. It is appropriate to code and bill for this service when the medical record supports the necessity of the post-treatment isodose plan. Modifier -26 should again be appended.

Coders should also note that the treatment codes (77750-77799) include many hospital services (e.g., admission, daily visits and discharge services). None of these services are reported in addition to brachytherapy codes.