Oncology & Hematology Coding Alert

What's your payer's rule on 77301 and forward planning? A lot of work goes into planning intensity modulated radiotherapy (IMRT) -- roughly $2,000 worth, according to Medicare. But if you don't know your payer's precise definition of IMRT planning and which codes bundle into the service, your claims are doomed.  Here are the rules you need to know to send in clean claims every time. Watch Out for Payer/AMA -IMRT- Discrepancies The appropriate code for IMRT planning is 77301 (Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specifications).

Payers often have very specific medical-necessity requirements for 77301, such as adjacent important dose-limiting structures or failure of conventional techniques to reduce organ at risk margins.

Important: When you have documentation of IMRT planning, but the patient's diagnosis doesn't meet the payer's medical-necessity requirements, you absolutely should not -downcode- the service to a 3D plan (77295, Therapeutic radiology simulation-aided field setting; 3-dimensional) to receive reimbursement, says Cindy Parman, CPC, CPC-H, RCC, co-owner of Coding Strategies Inc. in Powder Springs, Ga., and president of the American Academy of Professional Coders National Advisory Board.

The Office of Inspector General requires you to report the services provided ( see -OIG Compliance Program for Individual and Small Group Physician Practices- at oig.hhs.gov/authorities/docs/physician.pdf).

Hidden trap: The AMA, which publishes CPT codes, and your payer may have different ideas about what constitutes IMRT planning.

-According to the AMA, IMRT planning includes forward planning, inverse planning, or a combination of the two. Insurance payers- policies tend to state that -a signed inverse treatment plan- is required when reporting code 77301,- Parman says.

Solution: Get your payers- rules on IMRT planning in writing and stick to them.

Checking payer policies is also important simply because IMRT is an emerging technology and payer and coding policies adjust to deal with problems that arise as practitioners use the codes, says Karen Beard, CPC, CHCC, Georgia Society of Clinical Oncology director and senior associate with Medical Management Associates. Term: IMRT precisely delivers radiation to tumors and allows physicians to deliver high-dose radiation to some parts of a tumor while delivering lower-dose radiation to areas near sensitive tissues to keep them safe. You-ll most often see IMRT used for patients with prostate, breast, head and neck, central nervous system, lung, or liver cancer. Include Multiple Services in 1 Unit of 77301 You should only report 77301 once per treatment course, Beard says.

Even when you treat a number of targets in the same anatomic site, you only have one planning task, so you should only report one unit of 77301, she says.
 
Watch for: The planning process takes place over a period of time with multiple steps, but you should not -bill components of the planning [...]