Oncology & Hematology Coding Alert

Question: What CPT and ICD-9 codes should I report for management of eight treatment fractions for a patient with upper-lip cancer (vermillion border)?

New Jersey Subscriber

Answer: According to official ICD-9 guidelines, you should report V58.0 (Encounter for other and unspecified procedures and aftercare; radiotherapy) when the patient's encounter is for radiation treatment.
 
The appropriate ICD-9 code for the documented neoplasm is 140.0 (Malignant neoplasm of lip; upper lip, vermilion border).
 
You should report two units of 77427 (Radiation treatment management, five treatments) for the treatment management, provided the physician documents the appropriate patient evaluation during the first five-fraction -week- and again during the final three fractions of treatment.
 
Why: The descriptor for 77427 says -five treatments.- CPT guidelines instruct you to report 77427 for three or four fractions beyond a multiple of five at the end of a course of treatment. Translation: You want to report eight treatment fractions, and eight minus the five treatments described by one unit of 77427 leaves you with three treatments.
 
You should report an additional unit of 77427 for these three treatments -- just be sure your documentation supports all eight fractions.
 
If you had a total of seven treatments, however, you would report only one unit of 77427. CPT guidelines say not to report an additional one or two units separately.
 
Watch for: You may hear five fractions referred to as a -week- of treatment, but don't assume -week- means seven days. A -week- of radiation therapy is defined as five fractions, regardless of the actual number of days required to administer the five fractions.
 
Example 1: A patient has BID (twice a day) treatment. You may report 77427 every two and a half days if you have a patient evaluation note for each five-fraction therapy week.
 
Example 2: A patient has three treatment fractions during a calendar week, but then has a three-day break from therapy. The radiation -week- is not complete until the patient resumes treatment and receives two additional fractions.
 
Bottom line: In radiation, a -week- has nothing to do with a seven-day calendar week, so base your coding on the actual number of treatments rather than on days or weeks.