Target Accurate Coding for Interstitial Device Placement

By Erin Goodwin, CPC, and G.J. Verhovshek, MA, CPC

Radiation therapy must target cancerous cells precisely, while sparing as much surrounding healthy tissue as possible. Placing small metal “seeds” (typically made of gold or stainless steel), called fiducial markers, at the exact site of a malignancy allows the radiation oncologist to pinpoint that location when delivering radiation. In simple terms, the markers serve as landmarks. To ensure correct placement, the markers are implanted under imaging guidance.

Location and Method Matters

Placement of fiducial markers may be coded as a separately reimbursable procedure. Which code you select (and whether you may additionally report imaging guidance) will depend on the location and, in some cases, the method of placement.

For intrathoracic (e.g., lungs or pleura) placement by a percutaneous approach, select 32553 Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), percutaneous, intra-thoracic, single or multiple. Code 32553 is a standalone code, and does not include imaging guidance. You may report imaging guidance separately:

  • For ultrasonic guidance, use 76942 Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation.
  • For fluoroscopic guidance, use 77002 Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device).
  • For CT guidance, use 77012 Computed tomography guidance for needle placement (eg, biopsy, aspiration, injection, localization device), radiological supervision and interpretation.
  • For MRI guidance, use 77021 Magnetic resonance guidance for needle placement (eg, for biopsy, needle aspiration, injection, or placement of localization device) radiological supervision and interpretation.

If the marker is delivered by a bronchoscope via the airway, instead report 31626 Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with placement of fiducial markers, single or multiple. As a standalone code, 31626 includes fluoroscopic guidance and moderate sedation, when performed. This code is appropriate, for instance, when the physician places fiducial markers to help visualize lung wedge biopsy.

For the abdomen, omentum, pelvis (excluding the prostate), peritoneum, or retroperitoneum, select an appropriate code by method of insertion:

  • For laparoscopic placement, select +49327 Laparoscopy, surgical; with placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), intra-abdominal, intrapelvic, and/or retroperitoneum, including imaging guidance, if performed, single or multiple (List separately in addition to code for primary procedure). This is an add-on code reported with the code for the concurrent abdominal, intrapelvic, and/or retoperitoneal laparoscopic procedure.
  • For percutaneous placement, report 49411 Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), percutaneous, intra-abdominal, intra-pelvic (except prostate), and/or retroperitoneum, single or multiple. This standalone code includes moderate sedation, when provided, but does not include imaging guidance. You may report guidance separately using 76942, 77002, 77012, or 77021, as appropriate.
  • For open placement by surgical incision, report +49412 Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), open, intra-abdominal, intrapelvic, and/or retroperitoneum, including image guidance, if performed, single or multiple (List separately in addition to code for primary procedure). This is an add-on code reported with the concurrent open abdominal, intrapelvic, and/or retoperitoneal procedure code. Code 49412 includes imaging guidance.

For example, the American Medical Association’s (AMA’s) CPT® Changes 2011: An Insider’s View, describes a scenario in which a 67-year-old female “is found at the time of laparotomy to have an unresectable pancreatic adenocarcinoma in the head of the pancreas. Tracking fiducial implants are placed for later stereotactic radiation treatment.” The planned laparotomy is reported as the primary procedure, with 49412 as an add-on to describe placement of the fiducial markers.

For fiducial marker placement into the prostate, report 55876 Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), prostate (via needle, any approach), single or multiple. This is a standalone code and does not include imaging guidance. You may report guidance separately using 76942, 77002, 77012, or 77021, as appropriate to the type of imaging used.

For any location not described by one of the above codes, turn to HCPCS Level II code C9728 Placement of interstitial device(s) for radiation therapy/surgery guidance (e.g., fiducial markers, dosimeter), for other than the following sites (any approach): abdomen, pelvis, prostate, retroperitoneum, thorax, single or multiple. This standalone code describes any approach, but does not include imaging guidance. You may report guidance separately using 76942, 77002, 77012, or 77021, as appropriate.

Fiduciary Marker Placement Coding at a Glance

APPROACH

SITE

Intrathoracic Abdomen, omentum, pelvis (excluding prostate), peritonem, retroperitoneum Prostate Other
location
Percutaneous 325532 494112,3
Bronchoscopy 316263
Laparoscopic 493271
Open 494121
Any approach 558762 C92782

1. Add-on code: Report in addition to primary procedure

2. Report imaging guidance separately

3. Includes moderate sedation

Multiple Markers Won’t Change Coding

Codes 31626, 32553, 49327, 49411, 49412, 55876, and C9278 all describe placement of one or more markers. Don’t report multiple code units if the physician places more than one marker at a given location.

Marker Supply Isn’t Included

Placement codes do not include supply of the markers (e.g., A4648 Tissue marker, implantable, any type, each). The supply would be reported by the facility, not the performing physician. In the hospital outpatient setting, Medicare states that the payment for placements includes the implantable devices. Private payers may provide separate payment for fiducial markers; check with your payer for instruction.

 

Don’t Confuse Markers with Radioactive Seeds

Some types of cancer may be treated by implanting radioactive interstitial devices, which may be delivered by needle or catheter, at the site of cancerous cells. These radioactive “seeds” affect the malignant tissue directly. For example, 55875 Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without cystoscopy describes placement of needles or catheters into the prostate to allow delivery of such radioactive devices. Do not confuse these interstitial devices with fiducial markers; fiducial markers do not deliver radiation, but act as guides in the delivery of external radiation therapy.

Erin Goodwin, CPC, is the director of radiation reimbursement at South Carolina Oncology Associates, PA. She has worked in oncology for over 13 years. She is an active member of her local AAPC Chapter, Capitol Coders, in Columbia, S.C. where she was the new member development officer in 2008.

G.J. Verhovshek, MA, CPC, is managing editor at AAPC.

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2 Responses to “Target Accurate Coding for Interstitial Device Placement”

  1. Laurie Paul says:

    This is a very good article. I am struggling with my Interventional Radiologist who placed a wire and injected methylene blue anterior to the lesion (in the lung), the pulmonologist came in and did the thoracoscopy with biopsy and a thoracostomy. The services for the Radiologist were billed using 32405, which I don’t believe is correct since he did not do a biopsy. What code would I use for the placement of the wire and marking of the nodule. 32553 does not seem right either. Thank you for your assistance.

  2. ASaiz says:

    You’ll find a lot of suggestions and better answers to your question in the Member Forums.

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