Oncology & Hematology Coding Alert

Radiation treatment planning is complex work " so you might be tempted to turn to 77263 every time. But you've got to be sure your documentation makes the grade first, or you could risk upcoding accusations.

Start with the basics: After the radiation oncologist decides radiation therapy is appropriate for the patient, the oncologist must embark on the "comprehensive and often intense undertaking" of determining the course of treatment, according to AMA's CPT Assistant (October 1997). Treatment planning allows the oncologist to determine how best to deliver radiation to the tumor while protecting healthy tissue.

The appropriate codes for planning the treatment course are the following:

• 77261 -- Therapeutic radiology treatment planning; simple

• 77262 -- ... intermediate

• 77263 -- ... complex.

These codes are "professional component only" codes, meaning you should not append a modifier 26 (Professional component) or TC (Technical component) to them, says Kristie Star, CPC, with coding and compliance at Wisconsin-based Wheaton Franciscan Healthcare.

Typically, you'll report treatment planning only once per radiation course, states AMA's CPT Assistant (Fall 1991).

Tip: Be sure not to confuse isodose plans, sometimes called "treatment planning," with the services 77261-77263 describe. You may report isodose plans (77305-77315) several times during the therapy course, assuming you have proper documentation.

You should use 77261 (... simple) for a defined treatment area. "The planning requires no interpretation of special tests for localization of the tumor volume. The volume of interest can be encompassed with simple portal arrangements and minimal blocking," states the October 1997 CPT Assistant.

For example, you may find documentation for simple skeletal bone metastasis (198.5, Secondary malignant neoplasm of bone and bone marrow) planning merits 77261.

Medicare's national rate for this code is roughly $71.

Choose 77262 (... intermediate) for three or more converging ports, two separate treatment areas (noncontiguous), multiple blocks, or special time dose constraints. Unlike simple planning, intermediate planning does require interpreting special tests for localizing tumor volume. The oncologist also may need to factor in protecting critical or sensitive organs, the October 1997 CPT Assistant article states.

You might need to report 77262 if your radiation oncologist treated a standard four-field pelvis (nonconformal) or multiple skeletal metastases in a patient with prostate cancer (185, Malignant neoplasm of prostate).

Medicare's national rate for this code is roughly $107.

Apply 77263 (... complex) for highly complex blocking, custom shielding blocks, tangential ports, special wedges or compensators, three or more separate treatment areas, rotational or special beam considerations, and a combination of therapeutic modalities, according to CPT. Complex planning requires interpreting complex tests (CT or MR localization, special lab tests, etc.), CPT Assistant (October 1997) states. The oncologist also must perform special planning and mapping to protect the patient's normal structures.

You also may find documentation supports 77263 when the oncologist is retreating tissue or treating a surgical site, the October 1997 article indicates.

Caution: Oncologists may perform complex clinical treatment planning, more often than simple or intermediate, says Star.

But you shouldn't code 77263 automatically every time. Be sure the documentation supports your code choice.

Medicare's national rate for this code nears $158.