Radiation Oncology: Everything Old Is New Again
Get an overall understanding of hospital and freestanding center radiation oncology payments.
By Cindy C. Parman, CPC, COC, RCC
The quote, “Change always comes bearing gifts,” by Price Pritchett, PhD, accurately captures coders’ feelings when final regulations, code updates, and other reimbursement changes occur, each year. This year, radiation oncology has experienced some of the biggest coding changes since the procedure codes were first written. To sharpen your radiation oncology coding skills, take a look at the “gifts” born in 2015.
New and Revised Procedure Codes
The three 2014 codes for simple, intermediate, and complex teletherapy isodose plans (77305, 77310, and 77315) have been replaced with two codes for simple and complex teletherapy isodose plans:
77306 Teletherapy isodose plan; simple (1 or 2 unmodified ports directed to a single area of interest), includes basic dosimetry calculation(s)
77307 complex (multiple treatment areas, tangential ports, the use of wedges, blocking, rotational beam, or special beam considerations), includes basic dosimetry calculation(s)
77306 and 77307 include basic dosimetry calculations, which means 77300 Basic radiation dosimetry calculation, central axis depth dose calculation, TDF, NSD, gap calculation, off axis factor, tissue inhomogeneity factors, calculation of non-ionizing radiation surface and depth dose, as required during course of treatment, only when prescribed by the treating physician is no longer reported in addition to the isodose plan.
The three 2014 codes for brachytherapy isodose plans (77326, 77327, and 77328) have also been replaced by new codes:
77316 Brachytherapy isodose plan; simple (calculation[s] made from 1 to 4 sources, or remote afterloading brachytherapy, 1 channel), includes basic dosimetry calculation(s)
77317 intermediate (calculation[s] made from 5 to 10 sources, or remote afterloading brachytherapy, 2-12 channels), includes basic dosimetry calculation(s)
77318 complex (calculation[s] made from over 10 sources, or remote afterloading brachytherapy, over 12 channels), includes basic dosimetry calculation(s)
These codes define the levels for remote afterloading brachytherapy in terms of channels, rather than sources. Like the teletherapy isodose plan codes, these brachytherapy plan codes include basic dosimetry calculations.
Treatment Delivery, Image Guidance, and Motion Tracking
Although the new procedure codes for treatment planning are used in all practice settings (hospitals, freestanding cancer treatment centers, or physician offices), there are different Medicare treatment delivery and image guidance codes for hospital and freestanding radiation centers in 2015.
For hospital billing on the UB04 claim form, the existing intensity-modulated radiation therapy (IMRT) treatment delivery codes (77418, 0073T) have been replaced by two new codes (77385 and 77386, see Table 1) for simple and complex treatment delivery, both of which include image guidance and motion tracking (when performed). This means that image-guided radiation therapy (IGRT) — such as cone-beam computed tomography (CT), CT on rails, stereoscopic imaging or ultrasound (US) guidance, and intra-fraction motion tracking — is no longer separately reported by the hospital when IMRT treatment is performed.
|77385||Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; simple|
|Prostate, breast, and all sites using physical compensator-based IMRT|
|All other sites, if not using physical compensator-based IMRT|
The 2014 CPT® Category III code for intra-fraction localization and tracking (0197T), 77421, and 76950 were deleted effective January 1. Instead, 77387 Guidance for localization of target volume for delivery of radiation treatment delivery, includes intrafraction tracking, when performed is reported by the hospital when the patient receives standard external beam therapy.
Remember: The technical component of 77387 is not reported with IMRT treatment.
Code 77387 includes all image-guidance modalities (CT, kV/kV, US, etc.) and all motion tracking (e.g., gating, 3D positional tracking, etc.). Although the technical component of IGRT is included in the new IMRT codes, you may continue to report the professional component of image guidance, as long as all ordering and documentation criteria are met.
The radiation treatment delivery codes billed by the hospital also are restructured for 2015. There is still a single code for superficial and orthovoltage treatment, but there are now only three codes for treatment delivery at any dose greater than or equal to 1 MeV. Previously, there were 12 codes based on both the complexity and the MeV. The revised treatment delivery codes billed by the hospital are:
77401 Radiation treatment delivery, superficial and/or orthovoltage, per day
77402 Radiation treatment delivery, >1 MeV; simple
Physicians and freestanding centers (claims submitted on the CMS-1500 form) do not report any of the new CPT® treatment delivery or image guidance procedure codes for Medicare patients. These entities report HCPCS Level II codes for 2015. These codes have the same definitions as their CPT® counterparts (most of which have been deleted), as shown in Table 2.
|2014 CPT® Code||2015 HCPCS Level II Code||Description|
|76950||G6001||Ultrasonic guidance for placement of radiation therapy fields|
|77421||G6002||Stereoscopic X-ray guidance for localization of target volume for the delivery of radiation therapy|
|77402||G6003||Radiation treatment delivery, >1MeV; simple|
|77406||G6006||20 MeV or greater|
|77407||G6007||Radiation treatment delivery, >1 MeV; intermediate|
|77411||G6010||20 MeV or greater|
|77412||G6011||Radiation treatment delivery, >1 MeV; complex|
|77416||G6014||20 MeV or greater|
|77418||G6015||Intensity modulated treatment delivery, single or multiple fields/arcs, via narrow spatially and temporally modulated beams, binary, dynamic MLC, per treatment session|
|0073T||G6016||Compensator-based beam modulation treatment delivery of inverse planed treatment using 3 or more high resolution (milled or cast) compensator, convergent beam modulated fields, per treatment session|
|0197T||G6017||Intra-fraction localization and tracking of target or patient motion during delivery of radiation therapy (e.g., 3D positional tracking, gating, 3D surface tracking), each fraction of treatment|
Remember: Although Medicare requires these HCPCS Level II codes during 2015, physicians and freestanding office-based cancer treatment centers may be required to report the new CPT® procedure codes for other payers.
Hospital Regulatory Issues
To improve the accuracy and transparency of payment for certain device-dependent services, the Centers for Medicare & Medicaid Services (CMS) implemented a policy this year that establishes 28 comprehensive ambulatory payment classifications (APCs) to pay prospectively for the most costly hospital outpatient device-dependent services. A comprehensive APC, by definition, provides a single payment that includes the primary service and all adjunct services performed to support the delivery of the primary service, even if the components span several days.
This means hospitals must continue to report procedure codes for all services performed on a single claim, and receive a single payment for the total service. For radiation oncology, single-fraction stereotactic radiosurgery codes 77371 Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based and 77372 Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; linear accelerator based are reimbursed through a comprehensive-APC, and intraoperative radiation therapy codes 77424 Intraoperative radiation treatment delivery, x-ray, single treatment session and 77425 Intraoperative radiation treatment delivery, electrons, single treatment session are included in the payment for the surgical procedure.
Proton Beam Therapy
CMS also finalized the APC proposals affecting the proton beam therapy services for 2015, resulting in the national reimbursement changes shown in Table 3.
|77520||Proton treatment delivery; simple, without compensation||$872.37||$507.55||-41%|
|77522||simple, with compensation||$872.37||$1,071.95||21%|
Physician/Freestanding Center Regulatory Issues
Since 1992, Medicare has paid for the services of physicians, non-physician practitioners, and certain other qualified healthcare professionals under the Medicare Physician Fee Schedule (MPFS). The Estimated Impact Table that projects payment increases or decreases by specialty states that in 2015 radiation oncology physicians will experience an estimated 1 percent increase in Medicare reimbursement and that freestanding radiation oncology centers will have approximately the same reimbursement as in 2014.
CMS did not finalize its proposal to remove the radiation treatment vault from the direct practice expense (PE) input and to treat it as part of the infrastructure. CMS stated in the final rule that it understands the essential nature of the vault in the radiation therapy services provision and its uniqueness to a particular piece of medical equipment, but is not convinced either of these factors concludes the vault should be considered medical equipment for purposes of PE methodology under the MPFS. CMS says in the final rule that it intends to further study the issues raised by the vault and how it relates to PE methodology.
Get the Full Extent of Changes
To better understand the full extent of coding and reimbursement changes affecting radiation oncology, review your CPT® and payer guidance. Bookmark specialty society and college pages, and monitor industry publications to ensure you are current with reimbursement changes, as well. And make sure to review the 2016 proposed rules, which may be available for inspection as you read this article.
Cindy C. Parman, CPC, COC, RCC, is principal and co-founder of Coding Strategies, Inc., in Powder Springs, Ga. Her professional career in healthcare includes 20 years of commercial group health insurance experience, where she managed claims processing and customer service. Parman served as president of AAPC’s National Advisory Board, and is a member of the Dallas, Ga., local chapter.