Radiology Coding Alert

Knowing the rules will boost your 77401-77416 coding confidence You could be forfeiting $100 each time you overlook reporting radiation treatment more than once a day. We've compiled everything you need to know about radiation oncology coding to determine when you should--and shouldn't--code radiation treatment multiple times. Master CMS Multiple-Treatment Rule You may report CPT 77401 through 77416 more than once per date of service only when the patient receives radiation treatment "during completely different sessions," says CMS program memorandum A-03-020 (on page 8, available at www.cms.hhs.gov/manuals/pm_trans/A03020.pdf).

Unfortunately, CMS doesn't define "completely different sessions." Best bet: Typically, payers want a six-hour break between twice-daily radiation treatments, says Pamela Moore, CPC, patient representative at Moll Cancer Center in Ohio. And if you have a three-times-daily order, payers usually want a four-hour break. Double the Treatment, Double the Funds Doctors order treatment two (BID)--or three (TID)--times a day according to protocol for the specific type of cancer treatment, says Marc Halman, administrative director of the University of Michigan department of radiation oncology.

Example: A Connecticut Medicare patient presents with liver cancer. Protocol calls for two treatments (complex) eight hours apart on the same date of service, using 20 MeV each time.

Solution: In this case, report the code for treatment twice, Halman says. Because you are using 20 MeV on one site, claim two units of 77416 (Radiation treatment delivery, three or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, special particle beam [e.g., electron or neutrons]; 20 MeV or greater).

Here's why: You have documentation of a break in treatment, meaning you have two separate sessions. Note: Empire Medicare (Part A carrier for New York, Massachusetts, Delaware and Connecticut) holds a policy similar to many other payers, claiming that the individual sessions must be "of the character usually furnished on different days." (See the policy at www.empiremedicare.com/Newypolicy/policy/RD013E_FINAL.htm.)

You also have the doctor's order for twice a day, which is a must, Moore says. You should look for documentation of the medical necessity for twice-daily treatment in the consult note and a prescription order for twice a day to support coding treatment two times in one day, she adds.

Helpful: In the rare circumstance that your doctor's protocol calls for a shorter-than-usual break between treatments, don't accept your payer's limit without a fight, Halman says. Your best chance of preventing a denial for the second treatment is to show your payer the protocol and the medical necessity for this treatment.

Don't overlook: Providers often talk about "weekly management," but 77427 (Radiation treatment management, five treatments) specifically says "five treatments," Halman says. If your physician orders twice-a-day treatment and sees the patient every five treatments, you should report 77427 [...]