Draft Article - Billing and Coding: Radiation Therapies (DA59350)

CPTcodes 77280-77290 Simulation aided field settings should not be reported for verification of the treatment field during the course of IMRT.The respiratory motion management simulation CPTcode 77293 is an add-on code and cannot be billed on its own. This code describes the physician work and resources involved in acquiring a respiratory correlated or 4D CT simulation study for conformal planning. It should be billed, as applicable, with either CPTcode 77295 or 77301 on the same date of service, even though the work may take place over many days. The work involved in +77293 includes physicians, therapists, dosimetrists and physicists and has both a professional and a technical component. The work is performed both in the simulator and in dosimetry. The add-on code +77293 is part of the simulation and isodose planning process, not part of treatment delivery. This code is only charged once per 3D or IMRT plan. Medicare does not provide separate technical payment for this service in the hospital outpatient environment.Basic radiation dosimetry 77300 (Basic radiation dosimetry calculation central axis depth dose calculation, TDF, NSD, gap calculation, off axis factor, tissue inhomogeneity factors, calculation of non-ionizing radiation surface and depth dose, as required during course of treatment, only when prescribed by the treating physician) is a separate and distinct service from IMRT planning and should be reported accordingly. The radiation dose delivered by each IMRT beam must be individually calculated and verified before the course of radiation treatment begins. 77300is billed once for each IMRT beam or arc up to a limit of 10. This code is used to report dosimetry calculations that arrive at the relationship between monitor units (or time) and dose, and the physicians verification, review and approval. The documentation must contain the independent check of each field, separate from the computer-generated IMRT plan.) In step and shoot or compensator based IMRT treatment courses, 1 unit of 77300 can be charged per gantry angle. Therefore, the units of 77300 charged would correspond to the number of gantry angles in the IMRT plan, frequently up to 10 units. In volumetric modulation arc radiotherapy (VMAT) treatment courses, a patient is usually treated with 1 or 2 arcs; some brain treatments require a third arc. Therefore, there are 1 to 3 charges of 77300 for a typical VMAT plan. Supporting documentation should accompany a claim for more than 10 calculations on a single day.CPTcode 77338 was established to report multi-leaf collimator (MLC) design and construction for IMRT. It captures the radiation oncologist work of designing and fabricating the device, the practice expense of physicist and dosimetrist staff, and the equipment that is used for this design and fabrication. This code is reported only once per IMRT plan. There is no separate accounting for gantry angles or other beam arrangements. Additional IMRT plans during a course of care would warrant additional reporting of 77338. 77334, in IMRT, would be used to report an immobilization device constructed at the time of simulation.Image-guided radiation therapy (IGRT) services should not billed with SRS or SBRT services (77371, 77372, 77373, 77432, 77435) as they are already bundled into these codes.CPTcode 77387, guidance for localization of target volume for delivery of radiation treatment delivery, includes intrafraction tracking when performed. This CPTcode, however, was not assigned a reimbursement value in the Medicare Physician Fee Schedule. Instead, providers are instructed to report IGRT services using the following HCPCS G-codes and CPTcode as appropriate:G6001G6002G601777014These codes can also be used to report the professional component of IGRT services for providers in a hospital setting by attaching the -26 modifier to the codes.Hospitals do use CPTcode 77387 per the Hospital Outpatient Prospective Payment System (HOPPS). This technical component is reported with the -TC modifier. However, the technical component of IGRT code 77387 is bundled into IMRT delivery codes 77385 and 77386.77387-TC should always be reported when image guidance is performed with conventional (non-IMRT, non-SRS/SBRT) CPTcodes 77402, 77407, and 77412. However, 77387-TC is not reimbursed separately in the hospital setting because it is packaged into the Ambulatory Payment Classification with the treatment delivery service with which it is performed. Reporting the service is still important as the data is collected by CMS and might be utilized in future HOPPS rate-setting.Most freestanding centers will report claims under the Medicare Physician Fee Schedule, and therefore, will report G-codes for treatment delivery and IGRT to the Medicare payer.The 2020 HOPPS final rule lowered the supervision level required for hospital-based therapeutic services, including radiation therapy services, from direct to general supervision.However:This general supervision policy does NOT apply when:Radiation therapy is delivered in a freestanding center;The work of radiation treatment management is performed;Brachytherapy (CPTcodes 77770-77772), stereotactic radiation therapy (CPTcodes 77371-77373) and other services described by CPTcodes requiring that the radiation oncologist personally provide the services are performed;Diagnostic services, such as image guidance, are performed; orA hospital determines that radiation therapy services require direct supervision.Direct supervision requires that the physician be immediately available to provide assistance throughout the duration of the procedure. General supervision means the procedure is furnished under the physicians overall direction and control, but the physicians presence is not required during the performance of the procedure. This contractor will take this opportunity to interpret immediate availability within the context of direct supervision since clarification is often requested. The provision of direct supervision means that the provider must be able to be physically present and able to furnish assistance and direction throughout the performance of the procedure. In turn, the physician must only be doing work that is immediately interruptible and furthermore, immediacy is clarified as meaning the provider can be at bedside within 1-2 minutes. Any interval longer than that is simply not judged to be immediate by this A/B MAC.Recall that regardless of supervision requirements, many CPTcodes describe specific work. As an example, the work described by CPTcodes 77427, 77431, 77432, 77435, and 77469, radiation treatment management, must be provided personally by the radiation oncologist, who is ultimately responsible for the entirety of patient care. Thus, the weekly management of patients receiving radiation therapy, which involves all technical and medical aspects of managing the patient through a treatment course, is always conducted under the direct supervision of a radiation oncologist, who must continue to independently document her or his involvement in the process. Additionally, direct supervision associated with the delivery of brachytherapy and stereotactic radiation therapy remains.If state scope of practice requirements do not prevent advance practice providers from supervising the delivery of radiation therapy services, then it is up to the discretion of the hospital or organization to determine appropriate supervisory requirements based on a general supervision requirement. But again, the work described by CPTcodes 77427, 77431, 77432, 77435 and 77469 must be provided personally by the radiation oncologist, who is ultimately responsible for the entirety of patient care. Thus, the weekly management of patients receiving radiation therapy, which involves all technical and medical aspects of managing the patient through a treatment course, is always conducted under the supervision of a radiation oncologist, who must continue to independently document her or his involvement in the process.If occurring, the radiation oncology physicians treatment protocol must indicate parameters under which treatment may proceed at the discretion of the qualified technical personnel, and clearly indicate situations under which the qualified radiation oncology physician must be contacted before treatment is provided. Again, such discretion cannot supersede federal or state regulations.The qualified radiation oncology physician must review and approve guidance images that were produced prior to each daily treatment within 24 hours or prior to the next treatment delivery.