Wiki IMRT 77431

awyche0603@yahoo.com

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Is anyone having an issue with getting IMRT code 77431 (Radiation therapy management with complete course of therapy consisting of 1 or 2 fractions only) paid by insurance? We are using code 77427 for fractions up to 5, however when we only do 1 or 2 fractions we are suppose to be able to use 77431. Does anyone know of a guideline that would prevent this?

Example, a patient comes in for prostate cancer radiation treatment all week so we use 77427, the following week patient only gets 2 treatments Monday and Tuesday. Patient canceled for rest of week, so we bill 77431. That's 2 fractions but insurance keeps denying as included with 77427. What am I missing? We are not using code 77431 to fill in the last week of therapy so I don't know what other guideline they are using. Below is the code descriptions. Should we be waiting to bill IMRT until all Radiation has been completed? Which would be 40 weeks. Please help if anyone knows. Thank you

Range Specific Guideline 77427
Radiation treatment management is reported in units of five fractions or treatment sessions, regardless of the actual time period in which the services are furnished. The services need not be furnished on consecutive days. Multiple fractions representing two or more treatment sessions furnished on the same day may be counted separately as long as there has been a distinct break in therapy sessions, and the fractions are of the character usually furnished on different days. Code 77427 is also reported if there are three or four fractions beyond a multiple of five at the end of a course of treatment; one or two fractions beyond a multiple of five at the end of a course of treatment are not reported separately.

Range Specific Guideline 77431
Radiation therapy management with complete course of therapy consisting of 1 or 2 fractions only
(77431 is not to be used to fill in the last week of a long course of therapy)
 
77431 would be billed if there are ONLY one or two fractions billed in the total course of treatment. It's for the complete course of treatment.

If your course includes more than the two fractions (which in the example above would be the situation - you're billing 77427 for the previous week), you can't bill 77431 at all. Try not to tie a week in your head to the code. 77427 is to encompass every 5 fractions of treatment, regardless of time frame. I have had instances where 5 fractions of treatment may take several weeks to complete due to the patient health status. Let me know if you need further clarification.
 
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