Oncology & Hematology Coding Alert

Practices that routinely bill for simple simulations (77280) may be undercoding, leading to lost revenue. Because of advances in technology, radiation oncologists are able to treat more than one area at a time using an array of devices, all of which characterize intermediate (77285) or complex (77290) simulation. 
 
"Today's reality dictates that there are very few simple simulations," says Margaret Hickey, MS, MSN, RN, OCN, CORLN, an independent coding consultant and the former clinical director for the Tulane Cancer Center in New Orleans.
 
Simulations now include a number of ports, more than one axis, and multiple and custom blocking, thus leading to a higher-level simulation code. The code for simple simulation should be reserved for block check simulations or those with non-custom blocking or no blocking at all.
What Is a Simulation?
A simulation is ordered by the radiation oncologist to determine the size and location of treatment ports, which are designed to direct radiation to the tumor areas and protect outlying areas. They may be performed on a dedicated simulator, a radiation therapy treatment unit, CT scanner, or diagnostic x-ray machine, all of which visualize and define the exact treatment area.
 
Like many radiation oncology procedures, simulations are made up of a technical and professional component. Append modifier -26 (professional component) to 77280-77290 if the physician group is not employed by the same company that owns the equipment and/or the physicians do not own or lease the equipment. You may bill for the technical and professional component if the practice owns the equipment by reporting the simulation code only.
 
According to Cindy Parman, CPC, CPC-H, principal and co-founder of Coding Strategies, a coding consulting firm in Dallas, Ga., each code has distinct characteristics:
Code 77280:
Superficial orthovoltage, cobalt linear accelerator treatments
  A single treatment area with either a single port or parallel opposed ports
  Simple or no blocking
  Only one or two films are produced.

Code 77285:  Superficial orthovoltage, cobalt linear accelerator treatments
  Three or more converging ports on a single treatment area
  Two separate treatment areas
  The equivalent of multiple standard blocks
  Two or more films of each area, with or without fluoroscopy
  Tangential ports without devices or with a single pair of premanufactured wedges. (This is a payer-specific item. Some Medicare carriers state that simulation without use of devices or any premade devices is a simple simulation.)
Code 77290:  Three or more treatment areas
  Rotation or arc therapy
  Highly complex blocking in cases such as total body or hemibody irradiation, special wedges or compensators, custom shielding blocks, complex immobilization and multi-leaf collimation 
  Brachytherapy source verification
  Hyperthermia probe verification
  Use of any contrast material with or without fluoroscopy
  Tangential ports, oblique fields, rotational or special beam considerations.
How Are They Billed? [...]