Answers to Your Radiation Oncology Coding Questions

Our recent webinar, “An Auditor’s Rockstar Guide to Radiation Oncology Coding,” brought up some great questions, so we answered them for you! 

1

Question: 

Complex Treatment Devices 

Can 77334 TC and 26 be billed on different days? 

Answer: 

CMS has covered Complex Treatment Devices extensively under the Billing and Coding Guidelines. Please click on the reference link below for full details. 

Reference: 

https://downloads.cms.gov/medicare-coverage-database/lcd_attachments/34652_13/L34652_RAD014_BCG.pdf 

  

2 

Question: 

There was a previous OIG report in which a complex simulation code was billed several days prior to the IMRT planning code and it was considered unbundling.  Is there a timeframe associated with the unbundling of codes in relationship to the IMRT planning?    

Answer: 

CPT® codes 77280, 77285, and 77290 describe the process of defining relevant normal and abnormal target anatomy and acquiring the images and data necessary to develop the optimal radiation treatment process for the patient. These codes may be billed separately if they are not a part of the IMRT treatment plan and may not be billed with CPT® 77301. 

Reference: 

https://med.noridianmedicare.com/web/jfa/topics/radiology-radiation-oncology/intensity-modulated-radiation-therapy-imrt-billing#simulation-aided-field-setting 

 

3 

Question: 

What are the documentation requirements for 77334? 

Answer: 

CPT® code 77334 is for complex treatment devices, design, and construction that include customized, single-use bolus, such as wax molds conformed to a particular patient body part; customized blocks (low temperature alloy); customized compensators; wedges; molds or casts; custom-made immobilization devices, or eye-shields. Custom-made immobilization include restraining devices such as aquaplast and alpha cradle. The use of passive restraints such as straps, pillows, sandbags, etc. are not billable. 

Reference: 

https://downloads.cms.gov/medicare-coverage-database/lcd_attachments/34652_13/L34652_RAD014_BCG.pdf 

 

4 

Question: 

What if there is a retreat of the same or adjacent area and the provider orders a special physics consult 77370 for the additional work? 

Answer: 

Special Medical Radiation Physics Consultation 

CPT® 77370 may be billed separately, for example, when a special physics assessment is needed during the course of therapy. A medical physics consultation could also be appropriate where it applies to another modality (e.g., an accompanying "boost" with external beam) but it may not be billed with CPT® 77301 if it is part of the plan development. 

Reference: 

https://med.noridianmedicare.com/web/jfa/topics/radiology-radiation-oncology/intensity-modulated-radiation-therapy-imrt-billing 

 

5 

Question: 

Can a “Coding Bible” or “Red Book” be created for other multi-specialty groups? 

To answer your question: 

Yes, I would recommend using the following format as an outline, however, you can customize this format based upon your coding style: 

  1. Create your Table of Content (This is your first page) 
  2. Name of Specialty Group 
  3. Include Regulatory Guidelines 
  4. Include Payor Guidelines 
  5. Include the General Coding Conventions & Legal Guidelines 
  6. Include an updated ICD 10 “Cheat Sheet” 
  7. Include the Coding Worksheet for the specific specialty group (worksheet should include CPT® codes specific to your specialty) 
  8. Label each medical record/plan document separately with the corresponding CPT® code 
  9. De-identify the patient information if copies are made 
  10. Code capture according to supporting documentation/authentication 
  11. Run the Bill-to-Treat Report Verification 
  12. Audit Worksheet (independently audit your own work) 
  13. Check NCCI edits, duplicate entries, correct modifiers, units, treatment codes, etc. 
  14. Verify documents have been authenticated by the provider(s)
    • Create tabs for your “Coding Bible/Red Book”
    • Include any additional information that you deem helpful in coding correctly
    • The above is not all inclusive, however, provided as a base to help you get started in creating your own “Coding Bible/Red Book.” 

 

6 

Question: 

Is there a training course for coders/auditors for Radiation Oncology? 

Answer: 

If you are looking for a specific program for Radiation Oncology, I would recommend the American Society for Radiation Oncology (ASTRO). ASTRO has a program that offers courses, webinars, and seminars that are amazing. 

Reference: 

https://www.astro.org/Daily-Practice/Coding 

 

7 

Question: 

How frequently can IMRT service can be billed to treat cancer for a particular site? 

Answer: 

An IMRT plan (CPT® 77301) is billable only one time during a course of therapy. In rare cases, billing a second IMRT plan during the same course of therapy may be warranted.   

If performed, an additional statement from the physician supporting medical necessity is required and must be present within the patient’s medical record.  

In the event additional IMRT planning is performed without a new CT data set, the IMRT plan (CPT® 77301) is not billable.    

Reference: 

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE18013.pdf 

 

8 

Question: 

You discussed the red folders that are commonly used by Coders, do you have specific format that you can share to utilize this tool for our specialty group? Thank you. 

Answer: 

Here is an answer from the webinar host, La Tanya M. McNair. "Yes, I would recommend using the following format as an outline, however, you can customize this format based upon your coding style:

  • Create your Table of Content (This is your first page)
  • Name of Treatment Plan i.e., IMRT, Brachytherapy, etc.
  • Include Regulatory Guidelines
  • Include Payor Guidelines
  • Include the General Coding Conventions & Legal Guidelines
  • Include an updated ICD 10 “Cheat Sheet”
  • Include the Coding Worksheet for the specific plan (worksheet should include CPT® codes specific to plan)
  • Label each medical record/plan document separately with the corresponding CPT® code
  • De-identify the patient information if copies are made
  • Code capture according to supporting documentation/authentication
  • Run the Bill-to-Treat Report Verification
  • Audit Worksheet (independently audit your own work)
  • Check NCCI edits, duplicate entries, correct modifiers, units, delivery codes etc.
  • Verify documents have been authenticated by the provider(s)
  • Create tabs for your “Red Book”
  • Include any additional information that you deem helpful in coding correctly

    The above is not all inclusive, however, provided as a base to help you get started in creating your own “Red Book.” 

 

9 

Question:  

How frequently can one IMRT plan service be billed for one cancer treatment? Can we bill additional IMRT plans for the follow up or booster services for the same diagnosis treatment? 

Answer: 

IMRT Treatment Planning CPT® 77301 is typically reported only once per course of IMRT. However, I have found the following guidance that may be helpful. 
 
While individual payer guidelines always take precedence, CPT® Changes 2002: An Insider’s View states the following, “Only one intensity modulated radiotherapy plan may be reported for a given course of therapy to a specific treatment area. However, if there is a clinical indication to change the treatment plan, because of either changes in clinical condition or the need to change the parameters of treatment, such as would be encountered in ‘boost’ situation, then the additional plan would be reported.” 
 
In general, a new CT (or other imaging modality) dataset is required to obtain payment for a second three-dimensional plan, and we believe that this will also be the case for an IMRT boost plan. If the IMRT plan is generated from the same CT dataset as the original IMRT plan, then only one plan will typically be reimbursed by insurance carriers. However, if medical necessity is documented that indicates the need to obtain a new CT dataset (a second set of CT slices for treatment planning) after the initial course of therapy in order to complete the second IMRT plan, then it is possible payers will allow for both the original and boost IMRT plans." 
 
Reference(s): 
https://downloads.cms.gov/medicare-coverage-database/lcd_attachments/30316_8/030110_00143_L30316_RAD014_revised_cbg.pdf#:~:text=%28Dose%20plan%20is%20optimized%20using%20inverse%20or%20forward,typically%20reported%20only%20once%20per%20course%20of%20IMRT. 
 
https://www.aapm.org/government_affairs/cms/documents/codingfaqsfinal01-08.pdf 

 

10 

Question: 

How frequently can 77338 (MLC Device) be billed (per IMRT plan or any other max limit) for treating cancer at the same site or same diagnosis? 

Answer: 

IMRT Treatment Device (77338) – Professional and Technical 

77338 Multileaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction per IMRT plan. 
 
The IMRT device code was developed to account for the work and practice expense unique to the design and construction of a multileaf collimator device used for intensity modulated radiation therapy (IMRT). This code is to be billed only once per MLC-based IMRT plan, regardless of the number of ports constructed for the plan. An IMRT device (CPT 77338) may be billed for a boost plan even if the IMRT plan (CPT® 77301) is not billable. 
 
Standards for CPT® 77338

 

11 

Question:  

Re IMRT Plans - It was my understanding that special dosimetry could be billed as long as it was not the same DOS as the treatment plan. Can you attach the link to the CMS site stating this is now bundled? 

Answer: 

When IMRT is furnished to beneficiaries in a hospital outpatient department, that is paid under the hospital OPPS, hospitals must remember that CPT® codes 77014, 77280, 77285, 77290, 77295, 77306 through 77321, 77331, and 77370 are included in the Ambulatory Payment Classification (APC) payment for CPT® code 77301 (IMRT planning). You should not report these codes in addition to CPT® code 77301, when provided prior to, or as part of, the development of the IMRT plan. The charges for these services should be included in the charge associated with CPT® code 77301, even if the individual services associated with IMRT planning are performed on dates of service other than the date on which CPT® code 77301 is reported." 
 
Reference: 
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/SE18013.pdf 

 

12 

Question: 

When a patient is receiving IMRT, are the list of bundled codes (considered a part of the IMRT planning) allowed be billed if performed on a different day? A recent OIG report mentioned if they were done prior to the IMRT planning code they should not be, but what if one of those codes is billed after the IMRT code?  

Answer: 

According to the OIG, the CMS Medicare Claims Processing Manual specifies the services included in the bundled payment for IMRT planning when they are performed as part of the development of an IMRT treatment plan (e.g., imaging). Such services may not be billed separately, regardless of whether they are billed on the same or a different date of IMRT planning (the Manual, chapter 4, §§ 200.3.1 and 200.3.2). 

 

13 

Question: 

What is a Bill-to-Treat Report? 

Answer: 

A Bill-to-Treat Report is a report coders/auditors use to indicate services that have been billed and/or coded within the organization’s billing system. This report can be used as a visual tool to help coders/auditors identify missed revenue opportunities or capture coding errors.  Information found on this report includes Dates of Services, ICD-10 Codes, CPT® Codes, Modifiers, Units, Fees, the provider’s number, the patient’s name, POS location, etc. 

 

14 

Question: 

Can the MLC device code (77338) be reported more than once per IMRT plan? 

 Answer: 

IMRT Treatment Device (77338) – Professional and Technical 

77338 Multileaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction per IMRT plan. 

The IMRT device code was developed to account for the work and practice expense unique to the design and construction of a multileaf collimator device used for intensity modulated radiation therapy (IMRT).  This code is to be billed only once per MLC-based IMRT plan, regardless of the number of ports constructed for the plan. An IMRT device (CPT® 77338) may be billed for a boost plan even if the IMRT plan (CPT® 77301) is not billable.  

Standards for CPT® 77338  

  • CPT® 77338 is billable as a quantity of one (1) only. 
  • CPT® 77338 may only be billed one (1) time per IMRT plan created. 
  • CPT® 77338 is billable in conjunction with an IMRT plan (CPT® 77301) only and not with any other type of isodose planning.  In the event of an IMRT boost, the treatment device is allowed even though the additional plan may not be allowed. This code is reserved for MLC based IMRT devices only. 
  • One (1) IMRT treatment devices (CPT® 77338) may be approved per phase of medically necessary, MLC-based IMRT treatment. 

Reference(s): 

https://downloads.cms.gov/medicare-coverage-database/lcd_attachments/30316_8/030110_00143_L30316_RAD014_revised_cbg.pdf 

https://www1.radmd.com/media/289730/treatment-devices-coding-standard-77332-77333-77334-77338-eff-010115.pdf 

https://www.medicalbillersandcoders.com/articles/best-billing-and-coding-practices/billing-and-coding-guidelines-for-intensity-modulated-radiation-therapy-imrt.html 

 

15 

Question: 

How are treatment devices (77332 Breast board) billed? 

How are units billed for 77300 basic radiation dosimetry calculation?  

Answer: 

According to CMS, treatment devices (77332-77334), designs, and construction may be charged during a course of therapy when documentation substantiates multiple volumes of interest/ports, the use of custom-made devices, and/or the necessity of replacement devices.  Providers should bill for devices at the beginning of the treatment course and then may bill again later, in the course of treatment, when additional or new devices are required. 

Multiple immobilization devices are allowed as billable on the same day of service.  For example, a breast board and a Vac-Lok™ are two devices that are both billable, the Vac-Lok™ at complex 77334 and the breast board is simple at 77332.  Another example, an Aquaplast® mask (CPT® 77334) and a bite block (CPT® 77333) may be billed on the same date of service.   

According to CMS, 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. Calculations are typically charged at a rate of one unit of CPT® code 77300 for each unique verification calculation (generally one per port, arc, path, or gantry angle). 

Reference: 

https://downloads.cms.gov/medicare-coverage-database/lcd_attachments/34652_13/L34652_RAD014_BCG.pdf 

  

16 

Question: 

Is there a code for 2D radiation therapy? 

Answer: 

According to the American Medical Association (AMA) CPT® 2022, radiation treatment delivery with conventional X-ray or electron beam is assigned levels of complexity based on the number of treatment sites and complexity of the treatment fields, blocking, wedges, and physical or virtual tissue compensators.  CPT® codes for conventional external beam radiation treatment delivery range from 77401 – 77412. *Please be sure to check your payor policy for applicable G-codes. 

Reference: 

https://www.astro.org/Daily-Practice/Reimbursement/Practice-Management-Resources/Basics-of-Coding 

 

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