Radiology Coding Alert

Clinical brachytherapy the transperineal implantation of permanent radioisotope seeds has become widely accepted as an effective treatment for prostate cancer. It is a highly time-intensive procedure, involving multiple steps, and requires radiation oncology coders to clearly understand proper coding strategies for each component to avoid claim denials.

We find that our physicians at a nearby cancer center are using seed implantation for about 50 percent of the cases they see, says Remo Peshkepia, director of client services for Healthcare Management Partners in Irvine, Calif., which provides billing and management support to four cancer centers and 11 radiation oncologists throughout the state. As a result, he notes, coding professionals must become familiar with the complex nature of the procedure to achieve appropriate reimbursement.

Briefly stated, brachytherapy is a treatment for prostate cancer in which radioactive seeds are delivered by a needle and permanently placed in the prostate gland. The seeds emit radiation that destroys one or both strands of DNA within the cancer cells so the tumor can no longer grow. The number of seeds and the dose of radiation are calculated precisely to be most effective against the cancer while preserving nearby healthy tissue.

Brachytherapy generally is used by itself when the tumor is encapsulated in the prostate and has not metastasized. It may be used in combination with the more traditional external beam radiation. Instances in which the combined modality treatment is used are determined by the pathological staging of the cancer.

Coding Each Step of Brachytherapy Treatments

When you are coding a radiation procedure like brachytherapy, you must keep in mind each of the distinct steps involved, advises Cindy Parman, CPC, CPC-H, co-owner of Coding Strategies Inc., an Atlanta-based firm that supports 1,000 radiologists and 350 physicians from other specialty areas. In most cases you will be able to assign about seven or more codes, which may include consultation, treatment planning, treatment simulation, dosimetry calculations and isodose planning, treatment management and, sometimes, additional special services.

Step 1: Consultation

According to Parman, radiation oncologists likely will spend a great deal of time when a patient has been referred for a consultation. This is the time a physician would spend with the patient prior to deciding whether or not to treat, she says. This consultation would encompass elements outlined in medical or surgical evaluation and management service codes. But because of the intensity of this visit, it would almost always be assigned the most extensive CPT Code , 99205 (new patient; office or other outpatient visit) or 99245 (office consultation for a new or established patient) because the radiation oncologist would likely spend two hours or more with the patient, and the decision-making would be of high complexity.

Step 2: Clinical Treatment Planning

Once radiation oncologists decide to treat the prostate cancer patient and decide that brachytherapy is the best option, Peshkepia says, they will embark on an in-depth treatment planning process. This includes interpretation of special testing that may have been done, prostate localization and other procedures. The vast majority of brachytherapy treatment plans will be coded 77263 (therapeutic radiology treatment planning; complex), he says.

Other therapeutic radiology treatment planning codes that may be reported in some situations include 77261 (simple) and 77262 (intermediate).

The American Medical Association added a new code to CPT this year to describe an additional study done in brachytherapy treatment planning. The new code is 76873 (echography, prostate volume study for brachytherapy treatment planning [separate procedure]), Peshkepia says. The ultrasound is used to visualize and map the prostate, which allows us to determine the precise needle location to deliver the seeds.

Step 3: Simulation

With information from the consultation and treatment planning studies in hand, the radiation oncologist will conduct a simulation to ensure that radiation therapy is delivered only to the diseased tissue. Again, because brachytherapy is an intricate procedure, 77290 (therapeutic radiology simulation-aided field setting; complex) most often is assigned. Some practices rely on three-dimensional simulation instead of the more traditional approach and would code these services with 77295 (therapeutic radiology simulation-aided field setting; three-dimensional).

Whether a radiation oncologist uses 3-D varies greatly from practice to practice, Parman explains. Some physicians believe that 3-D simulation is valuable only when you are using external beam radiation, not brachytherapy. Others will say they would never consider doing brachytherapy without a 3-D simulation. Payers also have widely varying policies on this issue, so coders need to be very aware of both carrier and physician preferences.

She adds that modifier -26 (professional component) is required with the simulation codes to describe it as a physician service. (When done in a hospital setting, the facility would report the simulation code with the appropriate revenue code to indicate the technical component of the service.) Plus, it is imperative that the physician participate in the procedure and summarize what occurred for the simulation code to be assigned, Parman says.

Step 4: Dosimetry and Isodose Planning

To determine the proper amount of radiation delivered via the implanted seeds, the physics teams will perform precise calculations based on the radiation oncologists prescription. The time and effort invested in this stage of treatment is reflected in codes 77326-77328 (brachytherapy isodose calculation), according to Peshkepia. Again, because of the intensity of brachytherapy as a clinical treatment, radiation oncology coders will most often assign 77328 for these activities (brachytherapy isodose calculation; complex [multiplane isodose plan, volume implant calculations, over 10 sources/ribbons used, special spatial reconstruction, remote afterloading brachytherapy, over 12 sources]).

Parman adds that coders also may be able to report 77331 (special dosimetry [e.g., TLD, microdosimetry] [specify], only when prescribed by the treating physician). These are special isodose planning techniques that practices may opt to employ, she explains. This code is not an add-on code per se, but it is treated as such by most payers to reflect the extra physician work required for these precise types of dosimetry calculations.

Step 5: Treatment

During brachytherapy procedures, a urologist and radiation oncologist often work side-by-side to implant the seeds. The urologist usually performs the surgical component of the procedure, inserting and placing the needle for the delivery of the seeds (i.e., urology surgical code 55859, transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without cytoscopy). The radiation oncologist must implant the seeds because these specialists are the only ones trained and approved for handling radioactive substances in a clinical setting.

The treatment procedure is usually reported with 77778 (interstitial radioelement application; complex), says Peshkepia. In addition, ultrasound guidance is used to ensure the seeds are placed correctly, and that would be assigned 76965 (ultrasonic guidance for interstitial radioelement application). Parman says coders would add a -26 modifier to both 77778 and 76965 to indicate the professional component.

To describe the radiologists work in handling the radioactive isotope material, coders also would assign 77790 (supervision, handling, loading of radioelement), Peshkepia notes.

Step 6: Postoperative Services

Peshkepia also points out that a second brachytherapy isodose plan is performed after the seeds have been placed, about one month after the procedure. This is done to measure the dose actually delivered to the prostate, as opposed to what the pre-plan indicated. Coders may report 77328 a second time when this service is performed and documented.