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Radiology Coding Alert

Take a Break to Report Two Radiation Treatments

Published on Thu May 01, 2003

It's official: You can report multiple radiation treatment sessions (CPT 77401 -CPT 77416 ) on the same day as long as there has been a distinct break in therapy services and the individual sessions are of the character usually furnished on different days.

On April 2, CMS released Program Memorandum (PM) A-03-020, which states, "Codes 77401 through 77416 may be reported more than once per date of service only when radiation treatment is provided during completely different sessions. Only one of these codes may be reported for each treatment session no matter how many areas are treated or no matter how much radiation is delivered."

This PM corrected CMS'Jan. 3 transmittal (A-02-129), which incorrectly advised radiation oncologists to report these codes only once per date of service.

Look at the 'Nature of the Services'

Although CMS does not define "completely different sessions," most Medicare carriers agree that you must maintain a six-hour break between the radiation treatments. In addition, the patient's medical record must clearly document the medical necessity of separate session scheduling (also referred to as "BID" or "hyperfrac-tioning"). Empire Medicare's (the Part Acarrier for New York, Massachusetts, Delaware and Connecticut) policy echoes most others'when it states that the individual sessions must be "of the character usually furnished on different days."

"You have to look at the nature of the radiation services," says Deborah I. Churchill, RTT, president of Churchill Consulting Inc., a Killingworth, Conn., consulting firm that offers audits, seminars and electronic coding applications. "To bill two radiation treatment codes, the separate sessions have to be of the type of services that you would normally perform on different days."

"Suppose you treat a patient in the morning with two separate areas," Churchill says. "This constitutes only one treatment delivery code because you would normally address both of these areas during one session."

If you administer two completely unique treatments to the patient on the same day, however, you should report two separate treatment encounters using the  appropriate  code(s). For example, "If a patient had a head or neck cancer, such as T1 cancer of the larynx (161.0-161.9), we might administer a lower-than-normal dosage of radiation to the patient, but we do that twice a day," says Diane Corder, RTT, facility administrator at Gwinnett County Radiation Therapy Center in Lawrenceville, Ga. "The per-treatment dosage is lower, but the overall dosage is higher than normal. The one caveat that the insurer requires is that we allow a minimum of six hours between therapies so the normal cells can recuperate." If you meet those requirements, you can report both codes on the same date.

Churchill agrees. "The standard 'BID'break, based on utilization guidelines, is approximately six hours. This technique is generally applicable when treating the following conditions:

  • Lymphomas, as well as head and neck tumors

  • Certain brain tumors in children, particularly those in the brain stem

  • Rapidly growing tumors not responsive to single daily fractions

  • Malignant tumors of the genitourinary and respiratory systems, as well as gynecologic malignant tumors and progressive tumors involving the breast."

    Select Code Based on Energy, Areas

    To select the appropriate radiation treatment code (See "Radiation Treatment Delivery Codes Defined" in article 4), you should first determine how many areas you treated. " 'Area' refers to the total volume within the body to which the radiation therapy is directed," Churchill says. "For example, if you treat the breast with tangent fields and the supraclav, that is still considered one area." Code 77401 refers to a superficial delivery; 77402-77406 suggest a single treatment area; 77407-77411 refer to two separate treatment areas; and you should report 77412-77416 if you delivered treatment to three or more areas.

    Churchill adds that two factors determine the level of treatment delivery. "One criterion is the energy. The other is the complexity of the treatment based on the number of volumes and beam-modifying devices. Immobilization is not a determinant in the daily treatment level, whereas electrons are always considered a complex treatment level." If you report volumes that you treat with two energies, insurers require that you should always report the single highest energy used.

    Examples Clarify the Issue

    Example 1: Suppose you administer complex portal arrangements via photons using 11-Mv radiation to each of three separate treatment areas. Your options are as follows:

    A.) Report one unit of 77414 to denote the complete radiation treatment session using 11-19 MeV.

    B.) Report three units of 77414 to signify the three treatment areas to which you delivered 11 MeV.

    C.) Report one unit of 77412, one unit of 77413 and one unit of 77414 to achieve the total 33 MeV administered.

    The answer is "A." Because you administered the radiation to all three treatment areas during one session and not during "completely different" sessions, you should report only one unit of 77414.

    Example 2: Suppose you administer 6 Mv to a patient's neck using a custom shielding technique at 7 a.m. At 4 p.m. on the same day, you administer an additional photon treatment at 6 Mv to the patient's neck using a smaller open-portal arrangement. Which of the following codes should you report?

    A. One unit of 77404 because you combined the initial 6-MeV dosage to the second 6 MeV on a single treatment area, thus totaling 12 MeV.

    B. One unit of 77413 for the morning session and one unit of 77403 for the afternoon, both based on the energy and beam-modifying devices used for each of the two separate sessions

    C. Two units of 77408 to represent two separate sessions of 6-MeV radiation treatment administered to two treatment areas.

    The answer is "B." Because you maintained a six-hour break and you performed the type of services that you would normally perform on separate days, you can consider each session independently and report your services based on the energy and complexity of the treatment. You would therefore report 77413 (because of the complex blocking) for the morning session and 77403 (single area open portals) for the afternoon session at the appropriate energy levels. In addition, you should not "add up" the amount of energy you administer (as was the case in option "A") to total a higher level of MeV than your machine is capable of delivering, because this is incorrect coding.

     

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