Oncology & Hematology Coding Alert

Capture an extra $50 for oncologist-performed volume and mapping

Applying a -one-size-fits-all- approach to prostate brachytherapy coding will likely lead you to claims disaster. Instead, you-ll want to approach each case as unique, and carefully identify which of the related -- but separately reportable -- services describing the full course of prostate brachytherapy treatment your radiation oncologist provides.

Begin the Process With Proper E/M Selection

As with nearly all therapeutic services, your first coding challenge for prostate brachytherapy will be to assign an appropriate E/M service code to describe your provider's initial patient assessment.

This initial encounter will typically involve an in-depth, high-level service because the oncologist must evaluate the patient carefully to determine his suitability for brachytherapy and/or to rule out other modalities, such as external beam treatments.

At times, the patient will visit the oncologist at the request of a urologist or other specialist. If this is the case, consider a consultation code as your first option.

Consultation codes do not differentiate between -new- and -established- patients, but they are dependent upon place of service. For an office our other outpatient consultation, look to 99244 or 99245 (Office consultation for a new or established patient-). For a consultation with an inpatient, check out 99354 or 99255 (Inpatient consultation for a new or established patient).

Remember that to meet the requirements of a consultation service, you must have a written consult request from the referring physician that lists the reason for the consultation, says Suzan Berman-Hvizdash, CPC, CPC-E/M, CPC-EDS, physician educator for the department of surgery at the University of Pittsburgh Medical Center. In addition, the oncologist must render an opinion on the patient's condition or suitability for treatment, and he must share this information in a report back to the requesting physician.

Use caution: CMS has reported that as many as three-quarters of consult claims fail to meet the minimum requirements for a consultation service, and the Office of Inspector General (OIG) has placed consultation coding at the top of its enforcement agenda for many years running. If documentation does not contain a consult request, along with the reason for that request and the consulting physician's opinion in a report back to the requesting physician, you shouldn't report a consult.

Tip: Keep watching Oncology and Hematology Coding Alert for complete instructions on consult reporting.

Often, an attending physician will refer the patient to the oncologist for discussion of treatment options with no intention of continuing to treat the patient. In such a case, the attending physician is not requesting a consult, but simply giving a -refer and treat- order. You cannot claim a consult for such an E/M service, Berman-Hvizdash notes.

If documentation cannot support a consultation, or if a patient -self-refers- to the oncologist, you should instead select the appropriate standard E/M code. For example, for an established patient, look to 99214 or 99215 (Office or other outpatient visit for the evaluation and management of an established patient-). For a new patient, select 99204 or 99205 (Office or other outpatient visit for the evaluation and management of a new patient-).

Documentation must substantiate level of service: Although an initial exam for prostate brachytherapy should qualify easily for a level IV or V service, your code selection must ultimately depend on the strength of the physician's documentation.

Move Next to Treatment Planning

For each course of treatment, you may report one unit of treatment planning. This may occur, for instance, following E/M examination that confirms the patient's suitability for therapy. CPT provides three codes to describe this service, depending upon the level of planning complexity:
- 77261 -- Therapeutic radiology treatment planning; simple
- 77262 -- ... intermediate
- 77263 -- ... complex.

Clinical treatment planning can involve -interpretation of special testing, tumor localization, treatment volume determination, treatment time/dosage determination, choice of treatment modality, determination of number and size of treatment ports, selection appropriate treatment devices and other procedures,- according to CPT.

CPT further provides guidance on how to select the level of service (simple, intermediate or complex), as determined by the number of treatment areas, ports and blocks, as well as the need to consider special beams or combined therapeutic modalities.

Compare your physician's documentation against the criteria set forth in CPT to select an appropriate treatment planning code. In most cases, you should find that prostate brachytherapy will qualify for -complex- treatment planning (77263).

Documentation tip: -Clinical treatment planning is an area of scanty documentation specialty-wide, but what I would expect to see is a review of imaging studies completed to date, review of biopsy information, selection of treatment modality (seeds vs. IMRT vs. cryotherapy, etc.) and medical necessity for the option selected,- comments Cindy C. Parman, CPC, CPC-H, RCC, co-owner of Coding Strategies Inc. in Powder Springs, Ga. -Also, the physician should list anything unique to the patient such as treatment to a surgically altered gland, prior radiation to the same anatomic site, staging issues, patient body size issues, etc.-
 
Stick to One Planning Claim per Treatment

Remember that you may report only a single unit of clinical treatment planning (77261-77263) per course of treatment, even if that treatment involves multiple radiation therapy modalities.

Therefore, if the patient had a course of external beam treatment or other radiation modality prior to the brachytherapy, for which you previously reported a treatment planning code, you may not report another unit of treatment planning for the brachytherapy.

Medicare payer guidelines state this limitation explicitly. For instance, Empire Medicare, Part B Carrier for New York and New Jersey, states in its local coverage determination for prostate brachytherapy, -When brachytherapy is used as an adjunct to [external beam radiation therapy], a single complex plan (77263) is reported to indicate that both modalities were utilized.-

Watch for Possible Volume Study

The radiation oncologist may perform a volume and mapping study to determine where to insert the catheter for the prostate seeds, for which you should separately report 76873 (Echography, transrectal; prostate volume study for brachytherapy treatment planning [separate procedure]).

Modifier alert: You should apply modifier 26 (Professional component) to 76873 if the physician performs this procedure in a facility setting.

It's not a sure thing: Only one physician can claim 76873. I-m some cases, a urologist, rather than the oncologist, may perform the volume and mapping study -- meaning that the urologist, rather than the oncologist, would report 76873.  

Report Special Procedures, With Documentation

Depending on the strength of your physician's documentation, you may find that you are able to report special treatment procedures 77470 (Special treatment procedure [e.g., total body irradiation, hemibody radiation, per oral, endocavitary or intraoperative cone irradiation]) as part of brachytherapy treatment.

Code 77470 describes (documented) planning and effort involved in performing the special procedure. For example, you may be able to report 77470 if your physician documents hyperfractions due to complicated brachytherapy, concurrent treatment of multiple sites or retreatment of a site.

You should report 77470 only once per course of therapy per volume. For instance, if external beam 3-D treatment preceded the brachytherapy procedure and you reported 77470 at that time, you would not report the code again for a subsequent implant.

Be sure to append modifier 26 to 77470, when billed, to indicate that the oncologist provided the -professional- portion of this service only.

Next month: More prostate brachytherapy coding, from simulation through treatment and beyond.