Part B Insider (Multispecialty) Coding Alert

Published on Mon Sep 11, 2006 PDF

Experts warn:  Make sure documentation proves medical necessity

Certain types of cancer require two or more radiation treatments a day. Here's the lowdown on how to tell when--and how--you can report multiple treatments.

You may report codes 77401-77416 more than once per date of service only when the patient receives radiation treatment "during completely different sessions," says CMS program memorandum A-03-020 at www.cms.hhs.gov/transmittals/downloads/A03020.PDF.

The problem: CMS doesn't define "completely different sessions." Best bet: Payors usually want a six-hour break between twice-daily radiation treatments, explains Pamela Moore, CPC, patient representative at Moll Cancer Center in Ohio. And if you have a three-times-daily order, payors usually want a four-hour break.

Scenario: A Connecticut Medicare patient presents with liver cancer. Protocol calls for two treatments(complex) eight hours apart on the same date of service, using 20 MeV each time.

What to do: In this case, report the code for treatment twice, explains Marc Halman, administrative director of the University of Michigan department of radiation oncology. Because you are using 20 MeV on one site, claim two units of 77416 (Radiation treatment delivery, three or more separate treatment areas...).

Reason: You have documentation of a break in treatment, meaning you have two separate sessions. You also have the doctor's orders for twice a day, which is a must, stresses Moore. You should look for documentation indicating medical necessity for twice-daily treatment in the consult notes and a twice-daily prescription order to support coding treatment two times in one day, she adds.