Oncology & Hematology Coding Alert

Reporting IMRT as conformal treatment for coverage will land you in hot water

Tracking payer requirements for intensity modulated radiotherapy (IMRT) is no picnic, but putting these tips to work will keep your IMRT claims clean every time.

Common problem: Payers have very strict rules about when they will pay for IMRT. People often ask, if the insurance company pays for conformal treatment for this diagnosis, can we bill the conformal and get paid for that -- even though we are doing IMRT? -The answer is no,- says Erin Goodwin, CPC, CMC, with South Carolina Oncology Associates.

Bill the service provided, she says. Exception: The only time you should deviate from CPT guidelines is when your insurance company instructs you in writing to do so, Goodwin says.

Remember: For IMRT daily treatment delivery, you should look to 77418 (Intensity modulated treatment delivery, single or multiple fields/arcs, via narrow spatially and temporally modulated beams, binary, dynamic MLC, per treatment session).

Head Off Denials With Supplemental Documentation

Knowing an individual payer's coverage rules can help you send in an accurate claim that meets the payer's requirements. You can learn coverage rules a number of ways:


1. Check your local policy. When an Illinois practice started getting denials for IMRT prostate for BCBS patients not receiving more than 75 Gy, coders were perplexed. But a quick look at the BCBS Web site informed them that the policy was updated in March 2006 to say that the payer considers IMRT medically necessary for the following indications:

- Non-metastatic prostate cancer for escalation >75 G

- Head and neck cancer, specifically patients with nasopharyngeal carcinoma, and disease located at the unilateral base of the tongue/tonsils with limited neck lesions

- Central nervous system (CNS) lesions with close proximity to the optic nerve or brain stem.


As the first bullet point explains, Illinois BCBS only considers IMRT medically necessary for -Non-metastatic prostate cancer for escalation >75 Gy.-

Don't forget: If the physician documents IMRT, you must report IMRT, regardless of whether the payer will cover it for the patient's condition.


2. Verify benefits early.  Every plan may be different, so some coders recommend verifying benefits before treatment and holding on to that information if you need
to appeal.


3. Work through appeals. Goodwin has determined that BCBS in her state often requires proof of some kind of preexisting heart problem to cover IMRT for the left breast. Denials sometimes offer enough information to explain payer requirements for preexisting conditions, but working through the appeals usually offers more information, Goodwin says.


Example: The payer may deny an appeal with a letter stating the -service is not covered unless the patient has a preexisting condition that the treatment could exacerbate,- Goodwin says. Sometimes when you check the record, you-ll [...]