Part B Insider (Multispecialty) Coding Alert

Published on Mon May 10, 2004 PDF

But beware the long arm of the OIG

Providers often misunderstand the rules for billing professional management of radiation therapy (77427) because the rules are so different than for other codes. But if you understand this code properly, you can maximize your coding for it and boost your reimbursement.
 
Practices often misunderstand the workings of 77427, which covers one physician management service per five sessions of radiation therapy. So for every five sessions, you're entitled to bill 77427 once. But also, if the patient has three or four sessions at the end of the treatment regimen, you can bill a complete unit of 77427 for that final treatment "week."

But if you have only two sessions left over after a treatment, you can't bill 77427 for them. Nor can you bill 77431 (radiation therapy management with complete course of therapy consisting of one or two fractions only) for those leftover sessions -- that code is just for complete care.

The HHS Office of Inspector General's latest work plan says a recent review uncovered "a high percentage of overpayments to physicians" for radiation therapy management. The OIG is examining the issue again to see if the problem persists.

One of the biggest problems some practices have is automatically posting services when they haven't actually documented five treatment sessions, says Deborah Churchill with Churchill Consulting in Killingworth, CT.

Oftentimes, practices have their computers set up to autopost a bill every five treatments, even if the physician didn't see the patient. The patient will come in for 35-40 sessions during a course of treatment, and usually the doctor will be scheduled to see the patient on a particular day of the week. But sometimes, the physician goes on vacation, the patient leaves without seeing the doctor, or the doctor doesn't see the necessity of seeing the patient during the first week of treatment.

Also, sometimes the patient may feel sick and miss a day of treatment, so five sessions may take longer than a week, notes Churchill. If this happens, then the first day of the next actual week may be the last day of the previous set of five sessions, and the schedule of physician billing should be pushed back one day as a result. 

Sometimes, patients are treated twice a day, and the physician can see the patient twice a week and bill 77427 twice in one week, Churchill adds. "Their notes also have to correspond to the five-fraction period they're recording," so there should be two notes for that week.