A Simple Isodose Plan Checklist for Auditing Radiation Oncology

Radiation Oncology Coding

Coding Radiation Oncology services can be confusing, especially if the coder doesn’t know how to read an isodose plan. What’s an isodose plan? It’s a graphic display of a patient’s anatomy, including the radiation distribution based on a prescribed dose and plan of care created by a radiation oncologist. For example, a 3-dimensional radiotherapy plan (CPT 77295) or an Intensity Modulated Radiotherapy Plan (CPT 77301). Use this simple checklist to ensure you’re knowledgeable, specific, and have the whole picture. Having this checklist at your disposal just might help you pass a radiation oncology audit.

What type of isodose plans are drawn for radiation oncology patients?

It is advantageous for medical coders and auditors to know the various type of treatment plans, as knowing the different treatment deliveries can prepare the medical coder to identify clinical documentation that supports medical necessity and help to accurately capture daily or weekly radiation oncology billing codes, immobilization devices, units, and modifiers during the various phases of treatment.

There are several types of plans created to target cancer areas that include, but are not limited to the following:

• • • External Beam Radiation Therapy (EBRT) – Breast Cancer & Lung Cancer (small cell and non-small cell) – Early stages of Prostate Cancer – Colon or Rectal Cancer, etc.
    • Intensity-Modulated Radiation Therapy (IMRT) – Often used in tumors that are near structures like the spinal cord – head and neck cancers such as oropharyngeal, nasopharyngeal, or laryngeal.
    • Stereotactic Body Radiation Therapy (SBRT) – early-stage lung cancers – when cancer has spread to the liver or adrenal gland.
    • Image-guided Radiation Therapy (IGRT) - Tumors can shift inside the body because of breathing and other movements. Image-guided radiation therapy (IGRT) may allow doctors to locate and track tumors at the time of treatment and deliver more precise radiation treatment.
    • And Brachytherapy (using seeds implanted in the patient’s body) *is typically used to treat Prostate Cancer and Uterine Cancer.

Radiation Treatment Delivery Codes

Additionally, knowing how to properly read and interpret an isodose plan can be the determining factor in passing or failing an audit. Audit scores are often calculated based on the number of errors found during the audit review. Coding daily radiation treatment delivery codes account for a sizable percentage of the audit totals and, therefore, must be coded correctly to pass an audit.

Billable IMRT Codes

When coding radiation oncology services using an IMRT Isodose Plan, the medical coder should look for clinical documentation to support the following codes; however, please be advised that the following codes may have state or payor-specific guidelines.

• E&M Visit 99XXX
• Treatment Planning 77263
• Special Treatment Procedure 77470
• Special Physics Consultation 77370
• Complex Simulation 77290
• Immobilization Devices 77334
• IMRT Isodose Plan 77301
• MLC (multi-leaf collimator) for IMRT, i.e., Beam Modifiers 77338
• Basic Radiation Calculations 77300 x_
• Verification Simulation (simple) 77280
• Radiation Treatment Delivery 77385 IMRT (simple) or 77386 IMRT (complex)
• Weekly Radiation Treatment Management 77427
• Weekly Medical Physics 77336

Quality Coding

There are several factors contributory to quality Radiation Oncology coding that include, but are not limited to:

• Weekly coding
• Month End Coding
• Knowledge of the organizations benchmarking goals
• Knowledge of the organization’s revenue cycle
• Knowledge of what to code, i.e., type of plans/boost plans
• Knowledge of Treatment Plans vs. Type of Cancer, i.e., prostate, breast, pancreatic, etc.
• Knowledge of supporting documentation
• Knowledge of state/payor specific coding guidelines
• Knowledge of when to hold/release charges
• Knowledge of billable units and modifiers
• Knowledge of codes that bundle
• Knowledge of timely signature requirements

Failed Audits

There are several factors contributory to failing Radiation Oncology coding audits that include, but are not limited to:

• Unbundling Services
• Missing Treatment Plans
• Missing provider signatures
• Releasing charges without proper signatures
• Lack of knowledge in identifying Isodose Plans (IMRT, IGRT, Electron, 2D, 3D, etc.)
• Billing incorrect daily treatments, i.e., IMRT vs. 3D treatments
• Incorrect usage of modifiers, i.e., Technical “TC” vs. Professional “PC.” 
• Duplicate Billing, i.e., Treatment Laterality LT Arm vs. RT leg or AM/PM Treatment Sessions

OIG (Office of Inspector General) Reports / Civil Monetary Penalties

According to OIG Reports, Radiation Therapy groups have paid millions for allegedly violating the Civil Monetary Penalties Law by submitting false claims due to but not limited to the following:

• The use of incorrect CPT code(s)
• Incorrect dates of service
• Duplicate billing
• Incomplete documentation
• Services were not rendered
• Services were unbundled
• Lacked documentation to support the necessity of the services
• Missing or unsigned treatment order

Fitting the Puzzle Pieces

Coding radiation oncology is like “putting together a puzzle.”  Once you know the sequence of events, coding for these services is like riding a bike. The medical coder should know the daily or weekly treatment delivery codes captured according to the supporting clinical documentation. Medical coders’ progress reports should be visual to quickly identify codes that have been captured vs. codes that are quality for capture depending on state/payor guidelines and chart-specific supporting documentation.

Daily or weekly treatment delivery codes that should be captured according to the supporting clinical documentation:

• The Daily IMRT Treatment Delivery 77386
• The Daily IGRT Treatment 77387-26 or G-code (depending on payor) - (code depends on the payor and if image signed within 24 hours of previous treatment)
• The weekly physics 77336
• The weekly management 77427
• Simulation 77280 (if new treatment area or @boost treatment)
• Calculations 77300 (as applicable)

Audit Manager Software

Healthicity’s Audit Manager Software can be instrumental in successfully auditing Radiation Oncology services rendered, as data elements within the software can be utilized to build documentation and procedure checklists for robust reporting of critical findings and recommendations to aid provider groups in creating action plans to combat potential fraud, waste, and abuse.

References

• The Accreditation Process: Radiation Oncology (Revised 06/02/2021) - https://accreditationsupport.acr.org/support/solutions/articles/11000062793-the-accreditation-process-radiation-oncology-revised-6-2-2021-
• Radiation Therapy Pays $3.5 Million for Allegedly Violating the Civil Monetary Penalties Law - https://oig.hhs.gov/fraud/enforcement/healthone-radiation-therapy-at-red-rocks-agreed-to-pay-35-million-for-allegedly-violating-the-civil-monetary-penalties-law-by-submitting-false-claims-for-radiation-and-oncology-services/
• https://www.cancer.org/cancer/prostate-cancer/treating/radiation-therapy.html
• https://www.hopkinsmedicine.org/health/conditions-and-diseases/prostate-cancer/radiation-therapy-for-prostate-cancer
• https://www.cancercenter.com/treatment-options/radiation-therapy/external-beam-radiation
  

Learn more on this subject in our webinar, "An Auditor’s Rockstar Guide to Radiation Oncology Coding."

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