Coding Questions

A breast patient is treated via tangent portals, which are planned with 3D planning. Can the electron boost be reported with 77321?

We are a hospital based facility that employs a private physician group. We currently charge a facility room charge to correspond with the physician consults and follow ups. Can we also charge a facility bill when our nurses assist the physicians during their weekly on treatment evaluation and management of their patients?

Our physician orders alternating types of IGRT. Cone beam CT is ordered for Monday, Wednesday, and Friday, and stereoscopic is ordered for Tuesday and Thursday. Is there a problem reporting two types of IGRT in the same course?

Can a boost plan be reported with IMRT via code 77315?

Can an electron boost be reported with IMRT?

We alternate the type of imaging performed, using cone beam CT some days and stereoscopic on others. Is there any problem in reporting both types?

Can we bill a second 77301 during the same course if there is significant change to the patient's anatomy and a second CT is acquired? We often see this in our head and neck cases.

Can 2 IGRT's be billed on the same DOS for 2 different volumes of interest? For example: CBCT on a spine and IGRT on shoulder fields?

With respect to IMRT device charges; does 77338 replace the 77334 charges for a 6 field MLC IMRT or is it in addition to the 6 device charges?

I have read the November Newsletter several times as have the therapists and the physics staff regarding the IMRT Device Code 77338. We are of the opinion that it can be used in conjunction with the number of IMRT Complex Devices Code 77334 created for the number of IMRT TX fields treated. Please confirm what we should be billing for our IMRT Devices. We have Linear Accelerators using MLC. We frequently treat 6 to as many as 14 IMRT fields.

Does this code only apply to Medicare patients? Can we code 77334 devices for other insurances in the IMRT case?

We are currently treating a patient who cannot lie on the treatment table so we are using an unordinary set up position. In order to ensure accurate treatment, we are taking pre-treatment port films that the physician is reviewing. The physician is dictating a daily simulation note. Is it appropriate to bill for a simple simulation everyday that the patient is treated?

Can weekly simulation be reported for orthogonal port films to check the isocenter?

Our physician draws the shielding for a 4-field pelvis and we are reporting a complex isodose plan, code 77315. However, the physician feels that the blocks he is drawing are conformal and 3D planning should be reported. What criteria do we need to report 3D?

Can a therapist do the final summary chart check including the part asking if the completed chart was reviewed by physics? The dosimetrist and physicist do the weekly chart check.

What is the latest regarding 77321? Our doctors' dictation includes information about their thought process for the determining of an energy at the time of the electron simulation. The electron simulation dictation includes details about the procedure via ultrasound, establishing gantry and collimator angles, skin marks and cone size. The physician also documents the estimated depth of the cavity and chest wall, which determines the electron energy prescribed. Do you think that the above documentation would cover the use of the code 77321, or would you recommend a separate note?

We have a patient who is being treated to two different sites on two different machines. One sight is treated on the Linac and the other sight is being treated on our Tomotherapy machine. How should we proceed with the billing for this individual?

We are freestanding cancer center and we split bill. The technical component is billed by the center and the physician bills the professional component separately. The nurse is the employee of the center and handles the intake of the follow up and the consults. Can we charge a nurse visit on the technical component side?

After reading your August 2009 Newsletter, I want to make sure we are billing correctly. When confirming a 3D plan for the first time are you now saying bill that as 77280 instead of 77290?

Please discuss special physics consult in regards to IMRT. Currently, out physicists do a QA check and add data from the phantom work on a worksheet titled 'special physics consult'. Is this work appropriate for a special consult, as the work is for the individual patient?

Please comment on reporting immobilization for IMRT

Are we allowed to charge for a cGy composite plan in addition to a 3D plan or any boost plan where a composite plan is performed?

Our physicians want to schedule two confirmation simulation procedures. They want to confirm the isocenter in one session, and then have the patient return the following day to have the blocks confirmed. What is your opinion of this?

Is it necessary for the radiation oncologist to review and sign the documentation for stereoscopic 77418-TC? If so, must this be done prior to the patient's next treatment?

When performing SBRT, do we treat this like other treatment codes as far as documentation, or do the physicians need to do a daily procedure note for each treatment?

We are a freestanding center and will now be doing prostate volume studies here at our center instead of in the hospital. If we charge for the ultrasound, can we still charge for the complex simulation (77290) that day also? There is only one study that results (the ultrasound).

We do fusion frequently, and it is a nearly automated process in our department and normally performed by the dosimetrist. I have been asked about billing for this now that the CPT Assistant (May 2009 Issue) indicates that a special physics consult can be reported for this service.

We have a patient with right and left breast cancer. We are treating both breasts on the same visit one right after the other. Can we charge for two treatments/same day?

What professional and technical services can be billed by the APRN?

We acquire CT data on our dedicated CT simulator to establish the ports for an open spine field. The field arrangement may be PA only, or opposed. Can we report 77295?

We have a PET/CT. Some patients may already have a PET scan, which we are fusing with the CT. What would we report if another PET scan were acquired for planning purposes?

A Pt had HDR to each foot with same applicator (and same treatment plan). How should this be reported?

When performing a tandem/ovoid insertion in preparation for an HDR application, the GYN is not always present. Is it appropriate for the radiation oncologist to charge code 57155 for the insertion of the applicator, or is this service bundled with the HDR application codes?

Is it appropriate to bill for multiple treatment devices for Tomo? I have been informed by the department manager that multiple units can now be billed since Version 3.0 has the ability to print out the sinogram images. Just because the image can now be produced & printed, should it be billed? The planning has not changed. Or, is the sinogram just like a fluence diagram?

At a recent billing seminar, our physicians were informed that it was appropriate to bill a treatment device charge for every segment within each beam when doing forward planning, e.g., breast. Is that true?

There seems to be some controversy on what can be billed for an IMRT plan treated with Rapid Arc. If the planning system can extract control points for the arc, can each of these control points be billed for an MU Calc and MLC or is the plan only billed for one MU and one MLC?

In the past, we have had patients come back for a scheduled visit at which time the MD sees the patient, obtains the informed consent, and then sends the patient for a simulation. We charge a follow-up charge and simulation charge on the same day. We have not being paid for the follow-up on the same day as the simulation. If we were to use a modifier 25 would this make a difference or is this just a CCI EDIT?

We sometimes use a product called 'AccuForm cushion', which conforms to the back of a patient's head and is not reusable for other patients. Most often, we use this device with a custom mask. Can this device be reported in addition to the mask? If this were the only device, what level would we report?

We bill 77427 every fifth fraction, as long as the physician has documented their on treatment visit at some point during the five fractions reported. Our physicians typically see the patient on a set day during the week (ex. every Monday). If the patient starts treatment on Monday, and is seen on Monday, can we bill the weekly management on Friday (this is the fifth treatment)?

Are we able to bill this physics charge after the last treatment is given?

Our isodose plans and MU calculations via a second algorithmic calculation are combined into a single electronic document. Can our physicians sign a cover page for all of the work?

Can we report code 77011 for our SRS cases?

We heard that the CT data acquisition code 77014 could no longer be charged at the initial simulation if it is used for IMRT treatment planning. Is that correct, can we no longer charge it for IMRT patients?

Our LCD does not mention 77421 for IGRT. Should I be reporting it?

Is it appropriate to combine the Simulation request, treatment planning and the field verification all on one sheet with one date? Which function should the date on the sheet reflect?

January 1, we implemented the NEW HDR treatment codes, based on the number of channels that are used for the treatment. For the planning codes, are they remaining the same? If so, that would mean that for the plan we base it on the number of source positions and not the number of channels. It seems inconsistent to bill treatments based on the channels and the plan based on the number of source positions. Are there other new codes that would affect us?

Can you advise if a special medical physics consult (77370) may be reported if we are validating the control points for IMRT?

Is there a professional charge for Cone-beam? If so, which is the right CPT code?

We wanted to confirm current billing guidelines regarding the use of 77295. Our physicians want to bill this for our tangent breast cases. Do critical structures have to be outlined by the physician in the treatment planning system in order to bill this? Would the outlining of the liver and lung on a right breast case qualify for 77295 if all the DVH's and 3D renderings were done according to guidelines?

We understand the MD must be present in real-time for review of images to bill the global code, as this code requires personal supervision (level 3). Can you comment on the appropriateness of a PA providing this real-time supervision and then billing the global charge?

In your last newsletter, you spoke about physician requirements in the department. We have Medical Oncologists and Radiation Oncologists on site but there are times where they cover for each other, i.e., symptom management. We don't ever do this coverage for anything else i.e. simulations or new starts on the units, but if a patient is having problems we will have them see their medical oncologist if the radiation oncologist is not available. From the newsletter it seems like to be able to treat patients at a site, we will need to ensure that a radiation oncologist is in the suite to treat any patients at all times. Is this correct?

We have a Physician Assistant. Can he see the patients for the OTV visits each week, or must the actual physician see them in order to charge the weekly management code at the end of their treatments?

Guidelines for supervision of cone beam CT treatments indicate that a physician needs to be "on site" but not personally present in the room for charging for this procedure. However, if the physician that "ordered/planned" the cone beam CT is not on site, and the "treatment" is charged to a different physician on site, but the "images" are reviewed and approved by the physician that ordered/planned the treatment (who is not on site at the time of the treatment) under which physician should the 77014 be charged? The actual treatment charge would go to the physician on site, and logically I would think that the 77014 should be charged to this same physician. However, if the physician that ordered/planned the course (who is not on site) approves the images, then the documentation would show a different physician than the one that was actually on site.

When a pt is treated prophylactically to their whole brain after being treated for lung cancer, what is the appropriate ICD-9 code to bill? We had been billing V07.8.

In treating palliative cases of bony mets, the physicians order treatment plans. Most, often, there are no MLCs or hand blocks. Dosimetry prints a plan with multiple images. The 1ST page is axial, coronnal and saggital views with isodose lines. Other pages that are printed are; additional page of one other important CT slice, (different than the 1ST page) then smaller images of many other slices. DDR is demonstrated also. There usually is one posterior beam. When I read 77305 Criteria, it only talks about points that would be used in an irreg plan. 77310 says multiple beams. Since we review the dose along so many images, I think that we should be billing 77310. What is your recommendation?

Can you tell me how we will bill for rapid arc treatments, say for a prostate patient? Now, we bill an IMRT plan, and calcs/devices for every gantry angle. How will Rapid Arc be different?

Looking at your comparison of 2009-2008 RVUs from the July-August newsletter, the code 77014 was missing. Can you give me the proposed RVUs for the CPT code 77014, both professional and technical?

We are treating a patient on our Tomotherapy machine. This patient is about mid way through their prescribed course. The physician has made a change to one of the volumes and the whole course had to be re-planned. Is there a planning charge we can submit for reimbursement for services rendered? We have already charged a 77301. I know what the literature states but we were wondering if there is another avenue we can go down to receive payment for services.

We have a SBRT patient that will require seven treatment days. The patient has two separate lung lesions. One lesion is prescribed three fractions; the other lesion is prescribed four fractions. Due to the length of treatment time for each lesion, only one lesion will be treated per day. Therefore, seven SBRT treatments will be required. How should we bill this SBRT course?

When a resident or nurse practitioner sees the patient on the weekly visit in conjunction with the MD, how should the dictation read?

Please advise me on what are the appropriate codes to charge for fusion. Our new dosimetrist feels we are missing some charges - currently we only charge 77370. Any advice you can give will be appreciated.

What are the proper dosimetry charges for a field-in-field breast plan? In a case that we have a plan with bolus and one without, do we charge for each?

When the patient has a plan that cannot be implemented, and a new plan is done, is it appropriate to bill for any other services that may have to be re-done such as a CT sim?

A plan has been performed, approved by the physician and then billed. When the patient comes in they cannot tolerate the positioning and have to be re-planned. Is that initial plan billable?

What is billable if a machine goes down and the patient has to be re-planned on another machine?

We have been unsuccessful in obtaining a payable Medicare CPT code that represents our oncology consults since January. Should we consider stop charging the consults at the hospital technical level?

I have a Quadex error on 77336-59 and 77370 on the same date. Can you tell me what the problem is with this combination?

We are told that there is an edit for 77470 and 77432, but I do not see a CCI edit for this. Is this true?

Currently we charge 77370 for all fusion cases, regardless of physics staff intervention. Is this correct? When can we charge 77470 for fusion?

Does this Physics chart check code date of service (DOS) need to be reported on the date that the check is done or may it be reported once every five treatments? Example: Chart check is done after treatment 6 and then after treatment 10, four days later. Should we code after the sixth treatment and then after the tenth treatment, or can we code on the 5th and 10th?

Please clarify when the professional component of code 77014 is reported

During a prostate seed implant, the urologist and oncologist work together to place the needles. Can they both report code 55875? If yes, is a modifier required?

When we are doing a 3D plan [77295] for brachytherapy, can we also charge for the CT data acquisition [77014] and the complex simulation code [77290]? If yes, what about the Edits.

Patient has simulation done on a dedicated CT simulator for chest-wall irradiation. We bill 77014 and a 77290 on the first day. Dosimetry then plans the tangents, supraclav and IMC. Codes 77315, 77300s, and 77334 are billed. When the physician reviews the plan (during the planning process), the physician has dosimetry add an electron field to IMC for accurate dose. The patient is treated with photons to IMC, electrons to follow to IMC. The question is can you bill a virtual simulation for the electron or is it included in the CT sim?

I know that the charge for removing the balloon catheter for MammoSite patients is included in the surgeon's insertion fee. However, would it be appropriate to charge under code 77799 if the radiation oncologist removed it, instead of sending the patient back to the surgeon for removal?

I know that the charge for removing the balloon catheter for MammoSite patients is included in the surgeon's insertion fee. However, would it be appropriate to charge under code 77799 if the radiation oncologist removed it, instead of sending the patient back to the surgeon for removal?