Wiki IMRT code 77431 Issues

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)
 
Hello, I think there is confusion of what constitutes a radiation treatment "week". A treatment "week" is described as 5 treatments. there can be weekends, or missed days, between the treatments.
77427 is reported 1 X per 5 treatments - not 1 X per Mon-Friday calendar "week". Basically, you count 5 treatments, then report the 77427. It does not matter what day of the week the count of 5 starts - for example if a patient has Treatment 1 on Wed, Treatment 2 on Thurs, Treatment 3 on Friday - there only 3 of 5 delivered... nothing to report yet. It won't be until after Treatment 4 on Monday and Treatment 5 on Tuesday that the 5-treatment interval is complete, and eligible for 1 X 77427. Then the count of 5 starts again.

77431 is used only when a treatment course is prescribed for 1 or 2 treatments only. It's not meant to fill in between 77427's, or at the end of a treatment course when only 1 or 2 treatments extend past a count of 5 (like 32 treatments delivered).
 
Hello, I think there is confusion of what constitutes a radiation treatment "week". A treatment "week" is described as 5 treatments. there can be weekends, or missed days, between the treatments.
77427 is reported 1 X per 5 treatments - not 1 X per Mon-Friday calendar "week". Basically, you count 5 treatments, then report the 77427. It does not matter what day of the week the count of 5 starts - for example if a patient has Treatment 1 on Wed, Treatment 2 on Thurs, Treatment 3 on Friday - there only 3 of 5 delivered... nothing to report yet. It won't be until after Treatment 4 on Monday and Treatment 5 on Tuesday that the 5-treatment interval is complete, and eligible for 1 X 77427. Then the count of 5 starts again.

77431 is used only when a treatment course is prescribed for 1 or 2 treatments only. It's not meant to fill in between 77427's, or at the end of a treatment course when only 1 or 2 treatments extend past a count of 5 (like 32 treatments delivered).
Thanks Hodgeskm!
 
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