Oncology & Hematology Coding Alert

The key to getting paid for simulations in radiation oncology no matter how many are performed is documenting all changes in the treatment field. Otherwise, payers will have a difficult time determining the medical necessity of multiple simulations, says Jim Hugh, MHA, senior vice president with AMAC, a reimbursement and billing firm based in Atlanta.

In addition, a high reimbursement rate is associated with three-dimensional simulations (77295) and its tempting for physicians to perform these. However, radiation oncologists must be sure the procedure falls into the narrow guidelines payers have set, says Margaret Hickey MS, MSN, RN, OCN, CORLN, an independent coding consultant and former clinic director at Tulane Cancer Center in New Orleans.

There is no question that a simulation, 77280-77290, is an integral part of radiation treatment planning. It is used prior to radiation treatment to determine the size and location of initial treatment ports that are used to direct the radiation at tumors without destroying surrounding tissues and organs.

A simulation note (a specific document) should be included for each one performed and include the following:

The date;

The reason (this may include initial simulation, block check and subsequent simulations as a result of changes in field setting);

A summary of the procedure including patient position, identification of field location and critical structures blocked;

A description of any customized immobilization equipment; and

A summary of fluoroscopy and contrast used.

While documenting changes in the treatment field is important to reimbursement, revisions such as portal changes that are the result of poor or unsatisfactory initial simulations should not be documented or billed, because payers do not expect to pay for mistakes or poor services. In addition, you should not bill for additional simulations if only minor changes are made to the port size without changes in beam (radiation) such as amount or placement.

Each level has its own set of rules and conditions as follows:

Simple:

Code 77280 is used to describe the most straightforward use of a simulator, including superficial simulation, orthovoltage, cobalt, and linear accelerator treatments. It should also be used when radiation treatment is limited to a single area with either one port or parallel, opposed ports.

Blocking under this code is either simple or non-existent. However, the code can be used for block checking and is then billed separate of the first simulation. This procedure is usually performed afterwards to verify the accuracy of custom blocks before treatment begins.

It is important to remember that not every setup requires a block check simulation and that this procedure is usually limited to the complicated treatment fields where there are multiple blocks or if a specific problem with the current blocking is [...]