Major Reasons for Denial
- Services performed for diagnoses not listed as covered in this policy or for excessive frequency will be denied as not medically necessary. Frequency is considered excessive when services are performed more frequently than generally accepted by peers and the reason for additional services is not justified by documentation.
- Indications not listed as covered under the Coverage Indications, Limitations, and/or Medical Necessity section will be denied as not medically necessary.
- When a hospital inpatient is transported to a freestanding facility for therapy, the technical component of the radiation oncology services cannot be paid to the freestanding facility. Unless the patient is discharged from the hospital and treated at the freestanding facility as an outpatient, this payment will be denied.
- Appeals for denied claims must be accompanied by that portion of the patient’s medical record that documents the reason for the service. It is not necessary to provide a complete medical record. Also, note all documentation must be specific to the patient being treated or the claim will be denied.
Billing and Coding Guidelines
Treatment planning is a one-time charge per course of therapy. Billing for multiple treatment plans for a single course of treatment is not allowed. This is a professional service only and the physician is responsible for all the technical aspects of the treatment planning process.
- CPT code 77261 is used when the volume of interest to be treated is clearly defined and easily encompasses the tumor while excluding normal tissue and structures. Simple planning requires a single treatment area of interest encompassed in a single port or simple parallel opposed ports with simple or no blocking.
- CPT code 77262 is used when there is a moderate level of planning difficulty involved. It requires three (3) or more converging ports, two (2) separate treatment areas, multiple blocks, or special time dose constraints.
- CPT code 77263 is used when complex treatment planning is involved. Complex planning requires highly complex blocking, custom shielding blocks, tangential ports, special wedges or compensators, three (3) or more separate treatment areas, rotational or special beam considerations, or a combination of therapeutic modalities.
Simulation may be carried out on a dedicated conventional stimulator or CT scanner, radiation therapy treatment unit (e.g., linear accelerator), or using diagnostic imaging equipment (e.g., fluoroscopy, CT, MR). The complexity of the simulation is based on the number of ports, volumes of interest, and the inclusion and type of treatment devices. The number of films taken per treatment, the modality from which the images for simulation are obtained, and the use of fluoroscopy are not determinants of complexity. Portal changes based on unsatisfactory initial simulation(s) are not reported as additional simulations.
- Use CPT code 77280 to report simple simulation of a single treatment area. A treatment area is a contiguous anatomic location that will be treated with radiation therapy.
- Use CPT code 77285 to report intermediate simulation for two (2) separate treatment areas.
- Use CPT code 77290 to report complex simulation for three (3) or more treatment areas, or any number of treatment areas if any of the following are involved: particle, rotation, or arc therapy; complex blocking; custom shielding blocks; brachytherapy simulation; hyperthermia probe, verification; any use of contrast materials.
- Use CPT code 77293 as an add-on code for respiratory motion management simulation.
Use CPT code 77295 to report a 3-dimensional radiotherapy plan, including a dose-volume histogram. This code also includes those procedures done in preparation for use of coplanar therapy beams and, therefore, CPT codes 77280, 77285, and 77290 are not separately payable on the same date. It also includes the work done for a teletherapy isodose plan (CPT codes 77306-77307) and accordingly, codes 77306-77307 should not be billed separately. Code 77295 may be billed once per treatment course per treatment volume.
Basic radiation dosimetry, calculation, central axis depth, TDF, NSD, gap calculation, off-axis factor, tissue inhomogeneity factors, as required during the course of treatment but only when prescribed by the treating physician. This service is considered to be medically necessary for each treatment port and if a patient has off-axis calculations, calculations for different depth doses, different volumes of interest, secondary film dosimetry, abutting volumes of interest, or any other situation requiring individual point calculations of radiation dosage.
This procedure need not be routinely performed each time the patient is treated. Basic dosimetry calculations (CPT code 77300) may be reported as many times as the calculations are performed. The typical course of radiation therapy will require from one to six dosimetry calculations, depending on the complexity of the patient’s problem. However, radiation treatments to the head/neck, prostate, and Hodgkin’s disease may require eight or more calculations.
A teletherapy isodose plan is considered medically necessary for a given course of radiation therapy to a specific volume of interest. The typical course of radiation therapy will require from one to three isodose plans. Usually, only one plan per volume of interest will be sufficient, though some patients may require multiple teletherapy plans during the course of therapy. Situations that may require an extra teletherapy plan include the need to change the machine or volume of interest. Toward the end of treatment, due to clinical variations of the patient, another plan may be required.
- Use CPT code 77306 for a simple teletherapy isodose plan when there are one or two unmodified ports directly at one volume of interest. This code includes basic dosimetry calculations.
- Use CPT code 77307 for a complex teletherapy isodose plan when multiple treatment areas, tangential ports, the use of wedges, blocking, rotational beams, or special beam considerations will be used. This code includes basic dosimetry calculations.
- Special teletherapy port plan, particles, Hemi-body, the total body uses CPT code 77321. Only one plan should be billed per treatment course.
Special dosimetry (e.g., TLD, microdosimetry), CPT code 77331 is considered medically necessary once per port when the physician determines that it is necessary to have a measurement of the amount of radiation that a patient has actually received at a given point, with the final results being utilized to accept or modify the current treatment plan.
This procedure will generally be reimbursed one time per port per course of treatment when prescribed by the treating physician. The physician must specify the type of special dosimetry. When special dosimetry is employed, the usual frequency will vary from one to six, consistent with the number of dose calculations. This code (CPT 77331) may be used more than once per day per treatment course.
A deep understanding of the Oncology billing and coding guidelines is critical for proper payment. We have discussed the rest of the billing and coding guidelines in the next part of the article. In case of any assistance for Oncology medical billing and coding, you can contact us at 888-357-3226/ firstname.lastname@example.org