Oncology & Hematology Coding Alert

You may have only one chance to report simulation per treatment course, so nab the right code the first time by focusing on the number of ports, treatment volumes, and treatment devices.

CPT provides four simulation codes to choose from:

• 77280 -- Therapeutic radiology simulation-aided field setting; simple

• 77285 -- ... intermediate

• 77290 -- ... complex

• 77295 -- ... 3-dimensional.

Each code has both professional and technical components, so be sure to append modifier 26 (Professional component) when reporting only the physician's services, says Erin Goodwin, CPC, CMC, director of radiation reimbursement at South Carolina Oncology Associates in Columbia.

If your coding software doesn't alert you automatically when modifier 26 is an option,

see if you can enter notes manually for a pop-up reminder, suggests Jennifer Crowell, CPC, CCC, CEMC, lead hospital coordinator for a Spokane, Wash., practice. Hidden trap: CPT Assistant (October 1997) offers the typical number of films you'll see for a particular complexity level, but remember that the number of films doesn't determine which code you should use. You should look at the number of ports, treatment volumes, and treatment devices to support your code choice.

The first code in the series, 77280 (... simple), is appropriate for a single treatment area "with either a single port or parallel opposed ports" and simple or no blocking, according to CPT guidelines preceding the simulation codes.

Usually, simple simulation produces one to two films, CPT Assistant states. Tip: In the digital age, you may see providers refer to either "films" or "DRs" (digitally reconstructed radiographs), says Goodwin.

If the simulation involves three or more converging ports (directed at a single treatment area), two separate treatment areas, or multiple blocks, CPT guidelines state that 77285 (... intermediate) is the appropriate code.

You may see two or more films for intermediate services, with or without fluoroscopy, CPT Assistant states. But remember not to let the number of films guide your code choice. The difference between global 77285's national Medicare rate ($317.39) and global 77280's national Medicare rate ($184.30) is $133.09. You don't want to lose out on that money if you downcode or be stuck paying it back if you upcode.

To report 77290 (... complex), the simulation should involve three or more treatment areas, tangential ports, rotation or arc therapy, complex blocking (such as hemibody or inverted Y), custom shielding blocks,brachytherapy source verification, contrast use, or hyperthermia probe verification, CPT states.

Contrast use explained: "Simulation requiring the use of contrast agents in a body cavity or organ system (such as placement of contrast material within the bladder,rectum, other portions of the [gastrointestinal] or [genitourinary] tract, or intravenous contrast material to outline the kidney) will constitute a complex simulation. Metallic wires, markers, and rods are not considered contrast agents," according to CPT Assistant.

Payer preferences: Note that payers may consider 77290 (global national Medicare rate $491.59) appropriate for initial brachytherapy source verification but may ask you to report 77280 for subsequent verifications, which results in roughly a $300 difference. Payers also may consider tangential ports without devices or with pre-made wedges to be an intermediate (77285) simulation, rather than complex, which equals roughly a $174 difference.

The final code in the series, 77295 (... 3-dimensional),requires documentation of "computer-generated 3-D reconstruction of tumor volume and surrounding critical normal tissue" from CT or MRI data to prepare for therapy, CPT guidelines explain.

Must haves: To report 77295, your system must be able to perform 3D modeling of the tumor and the surrounding critical structures, design shielding blocks, present a Beam's eye view (BEV), produce a 3-D isodose plan, and evaluate treatment plans. But be sure the physician indicates medical necessity for 3-D planning before you report the code. Necessity is often based more on the structures the oncologist wants to protect than on the tumor volume to be treated. The physician should also sign and date the documentation produced by the 3-D software and retain a copy in the patient's chart.

BEV is key to 3-D simulation. Documentation should show 3-D BEV "volume-dose displays of multiple ormoving beams," CPT states. In BEV, the provider sees contours as though her eye is at the radiation source looking along the beam.

Payoff: The national Medicare rate for global 77295 is $691.40 in 2009, roughly $200 more than the national Medicare rate for global 77290 ($491.59).