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 every five treatments, or two and a half days.

Important: Be sure you have documentation that the physician evaluated the patient during that two-and-a-half- day period to meet 77427's requirement for management every five treatments. The physician is probably used to seeing the patient every five days and may not realize that isn't sufficient when you are coding twice-daily treatment.

Report 1 Unit for 1 Treatment Session
 
Quick quiz: Your department administers complex portal arrangements via photons using 14 MeV radiation to two separate treatment areas during one session. How many units of 77409 should you report?

Solution: If you administer 14 MeV radiation to two areas at one session, report one unit of 77409 (Radiation treatment delivery, two separate treatment areas, three or more ports on a single treatment area, use of multiple blocks; 11-19 MeV).

Reason: You only report one radiation treatment delivery code "for each treatment session no matter how many areas are treated or no matter how much radiation is delivered," according to Program Memorandum A-03-020. Even if you treat one site on one machine, take the patient down the hall, and then treat another site on a separate machine, you should consider this one session and therefore report one code, Halman says.

Don't miss: If the physician orders more than one energy level for a session, you should code only for the highest energy treatment, Moore says.

Choose Code Based on Energy and Complexity

You select most treatment codes based on the number of treatment areas and the amount of voltage. When determining how many areas you treated, remember that if radiation therapy is directed at contiguous body parts, payers consider this to be one area. In the majority of cases, you'll choose a code from the following list:

• 77402-77406--Radiation treatment delivery, single  treatment area, single port or parallel opposed ports, simple blocks or no blocks ...

• 77407-77411--Radiation treatment delivery, two separate treatment areas, three or more ports on a single treatment area, use of multiple blocks ...
 
• 77412-77416--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)....

Unlike 77402-77416, code 77401 (Radiation treatment delivery, superficial and/or ortho voltage) doesn't give a measured voltage. This code refers to a superficial treatment unit, sometimes known as ortho voltage, which physicians used on skin lesions in the past, Halman says. Now, you're more likely to see physicians use electrons, so you'll rarely report 77401, Halman says.

What to do: When documentation indicates the physician used electrons, report the proper code from the 77412-77416 series. The highest complexity indicator drives treatment delivery code assignment, so you also use 77412-77416 for the use of wedges, compensators, or custom blocks.