Section 8 Radiation Oncology Dosimetry CPT Codes 77300 - 77370

1. Section 8Radiation Oncology Dosimetry CPT Codes 77300 - 77370 Susan Vannoni 3:15 to 4:00 PM Section #8 031314 Modified For 04-10-14 81

2. 2 Basic Dosimetry Calculations (External Beam) 77300 77300 Basic Radiation Dosimetry Calculation. This procedure may be billed any time during a course of radiation therapy, andas many times as necessary. 77300 IS A GLOBAL BILLING CODE

3. 3 Occurrence Rate 2013 • 77300 4.01 per case, conventional treatment • 77300 1.31 Electron treatment • 77300 5.38 per case, all modalities • 77300 6.05 per case IMRT (did not change with switch to use of 77338) • The averages is about 1.58 Dosimetries per conventional block, 77334, and 1.01 per 77338 for IMRT. • These ratios are lower for 2013 due to a drop in the average number of IMRT beams being used per case.

4. 3 Computer Versus “Hand” Calculations Only one 77300 may be charged for the required two independent means of calculating the basic dosimetry.

5. NIB Computer calculations (Varis/Aria)

6. 5 MU CHECK IS COMPUTER GENERATED, BUT IS CONSIDERED A SECOND (HAND) DOSE CALCULATION

7. Documentation Requirements 9 • Documentation in the medical record must include an explanation of the need for multiple basic dosimetry calculation . • Each calculation should be identified specifically as to its necessity, i.e., central axis depth dose, critical organ dose, off-axis dose, abutting fields, etc. This statement may need to be on the comment line of the HCFA 1500 form for payment by Medicare • ONLY ITEMS USED CLINICALLY MAY BE BILLED

8. 9 Basic Dosimetry Calculations 77300 What’s it for? Any calculation performed that constitutes a component of the Dosimetry Record, monitor unit calcs (MU), decay calcs, off axis factors, etc. Who normally documents/bills/captures this codes? Dosimetry, Physicist or Therapists. When is this codes normally billed? This code can occur almost any time during the course of therapy What Documentation is suggested for this code? The calculation itself, signed by the physician, and Dosimetry. What are the common documentation errors identified with this code? Not having a physician’s order and, not being signed by the physician What are the common billing errors? Missing individual calculations due to not recognizing dosimetry documentation. 20/150

9. Treatment Planning CT Scan and Isodose plans 11 Isodose planning is based upon data from CT scans There is no longer any billing allowed for the treatment planning CT 77014, as this code has been retired. The CT procedure is done as part of the planning process. If a full diagnostic CT scan is done, this may be billed as a diagnostic procedure if it has been read by a diagnostic radiologist.

10. Teletherapy Isodose Plan(s) 10 77305- Simple Isodose Plan 77310 - Intermediate Isodose Plan 77315 - Complex Isodose Plan 77305 – 77315 ARE GLOBAL BILLING CODES

11. TWO FORMATS OF ISODOSE DISPLAY 15 COLOR WASH DOSE PATTERN Hot, red, colors are higher dose, with blue and green lower dose ISODOSE DOSE LINE PATTERN, each line indicates a boundary of dose, graduating out from the central highest dose

12. 16 Teletherapy isodose plans developed through the use of IMRT, or three dimensional techniques are to be reported as part of the codes 77295, or 77301 and not to be billed separately as 77315.

13. 16 Clinical Changes Clinical variations of the patient during therapy may necessitate a new plan being made and reported. The radiation oncologist must document the reasons for the rendering of an additional isodose plan.

14. 16 Documentation Requirements Documentation maintained in the patient’s medical record must include an explanation of the need for both the initial as well as any subsequent isodose plan.

15. 17 Isodose Dosimetry 77305- 77315 What’s it for? Isodose Dosimetry is a representation of dose formed by a confluence of one or more treatment beams on an area of interest. Who normally captures these codes? Dosimetry or Physicist. When are these codes normally billed? Upfront, after Simulation, and later in the course of therapy with reduced fields. What Documentation is suggested for these codes? The plan must be signed by the physician, and a Planning note is advised to more fully document the procedure. What are the common documentation errors? These are normally documented quite well with very few errors. The most common problem is the lack of a clear physician’s order for the plan. What are the common billing errors identified? Observe rules; 0nly one Isodose Plans on a given date, do not Bill this service with 3-D or IMRT.

16. Special Beam Plan 77321 18 • This code is to be utilized when a treatment decision for any special beam consideration is required, such as the use of electrons, heavy particle beams or other nuclear beams. • The use of electrons as a portion of, or as the sole modality for the treatment of a particular problem is the most common use of this code. 77321 IS A GLOBAL BILLING CODE

17. IB 21 Isodose Plan may be Needed for Electron Treatment 77315 77321

18. 22 Electron boost port 77321 Post operative Parotid tumor

19. 23 Electron boost to breast

20. 23 Typical basal cell carcinoma of the tip of the nose treated with electrons

21. Coding Guidelines Electrons 77321 24 • This special beam consideration code is to be billed only one time for the course of treatment. • We recommend that it be billed on the first day of clinical use to treat the patient. • This special beam is billed as daily treatment delivery with the code based on the maximum energy of the treatment machine, not related the electron energy utilized for treatment

22. 24 A specific report is not required by Medicare, however it will help in the documentation and justification of electron usage (RAC 2011) ONCOCHART

23. 24 Special Beam 77321 What’s it for? The use of a particulate beam in the treatment of a patient, such as electrons, protons, or neutrons. Who normally captures this code? Dosimetry, Physics or the Treating Therapist. When is this code normally billed? The first day of particulate beam therapy being delivered. What Documentation is suggested for this code? The use of electrons, protons, or neutrons in treatment. What are the common documentation errors with this code? Not following your LMRP/LCD rules on this code. What are the common billing errors identified? Not knowing the CCI rules, billing with edited 773xx codes. Not recognizing that the particulate beam was used.

24. 25 SPECIAL DOSIMETRY 77331 - Special/Microdosimetry Special/microdosimetry consists of the use of special radiation measuring and monitoring devices for determining the specific dosage of radiation at a given point. 77331 IS A GLOBAL BILLING CODE

25. 25 • This code covers the use of thermoluminescent dosimeters, solid state diode probes, special dosimetry probes, film dosimetry, or other methods for measuring the specific dosage at a given point. • These procedures must be done at the direct request of the radiation oncologist. • Medical necessity must be documented in the chart. This code may be reported for each specific location of measurement.

26. Narrative Microdosimetry report 77331 28

27. 29 Special Dosimetry 77331 What’s it for? The use of Diodes, TLDs, and other beam measuring devices Who normally captures this code? Treatment Therapist and/or Physicist. When is this code normally billed? Within the first few fractions of any new field being treated. What Documentation is suggested for this code? A Physics/Physician report documenting the measurement, and any actions to be taken as a result of the readings. What are the common documentation errors identified with this code? Not being signed by the physician or physics. Not having a specific physician’s order for the procedure. Failure to establish medical necessity for the procedure What are the common billing errors? Not understanding what a diode is, how it is performed, and where it is documented. Failure to observe CCI edits with other 773XX codes.

28. 30 TREATMENT DEVICES

29. 30 CPT Codes 77332 - Treatment Devices; Simple 77333 - Treatment Devices; Intermediate 77334 - Treatment Devices; Complex 77338 – IMRT Single Block Charge 77332 -77334, 77338 ARE GLOBAL BILLING CODES

30. 30 Occurrence Rate, Blocks 2014 • 77332 is <2% occurrence rate • 77333 is <1% occurrence rate • 77334 is 98% occurrence rate • Immobilization devices account for 27% of 77334, about 1.64 per case.

31. 36 77332Simple Treatment Devices Treatment Devices, design, construction or selection; Simple (single block, single bolus) Usually no special fabrication is necessary for these blocks; pre-made blocks may be used.

32. 36 Simple Treatment Block 80/150

33. Bolus 37 • The use of bolus usually constitutes a simple device. • It is a rare situation where a simple bolus is the only treatment device used. • If some other treatment device is used, the most complex of these will drive the level of complexity for that port. • A simple bolus used with a complex device will cause the charge to be driven to the higher level of complexity 77334. You may not charge for the bolus. 85/150

34. 39 77333Intermediate Treatment Devices Treatment Devices, design, construction or selection; Intermediate (more than one area of port blocked - blocks, stints, bite blocks, special bolus)

35. 39 • The most common intermediate treatment device will be simple blocking, but covering multiple areas of the port. • Simple blocking covering two different areas, such as multiple bone metastasis is considered intermediate

36. 40 Stints A pre-fabricated stint used to modify a patient’s anatomy for the proper delivery of a radiation dose is billed as an intermediate treatment device. A custom stint is a complex device (ACR, 2001)

37. 40 Custom Stint 77334

38. 40 BILL AS 77334 A custom stint is being used to distance the electron treatment port away from the underlying gum

39. 41 MULTIPLE SIMPLE SKIN LESIONS 1= Simple 2= Intermediate 3+= Complex This case has 3 or more sites; Treatment planning is complex 77263 Simulation (clinical simulation) is complex 77290 Blocks, treatment devices, are each simple, 77332 X 3 Dosimetry is done for each port, 77300 X 3

40. 41 77334Complex Treatment Devices

41. Complex treatment device 42

42. 42 Multi-leaf or Dynamic Collimation (MLC) This procedure must be planned in the same comprehensive and complex fashion as custom field blocking and is reported as 77334.

43. 42 Blocking for IMRT 77338 In the case of IMRTtreatment, each portal may use MLC custom shaped blocking, For Medicare, all government insurance, and most private insurance, MLC must be reported as IMRT beam modifier, 77338. Compensator IMRT is still 77334

44. Eye Shields 77334 An eye shield is a complex multi-use device. 43

45. Its application is highly complex and precise. The radiation Oncologist must clinically place this eye shield with each treatment. 43

46. 47 Immobilization Devices Treatment devices may be used for patient immobilization to accurately reproduce the set up on a daily basis. These devices are fabricated under the direct supervision of a physician and are specifically designed for an individual patient’s treatment course. (ACR, 2001)

47. Vacuum Bags 77334 47 Bead filled vacuum bags are complex multi-use devices. Each vacuum bag is utilized only for a single patient throughout the entire course of therapy.

48. Breast Board 47 BILL AS 77332

49. 47 According to the ACR/ASTRO Code Utilization & Application Subcommittee, the multiple setting breast board is now considered as a simple treatment device. This opinion represents a consensus of coding practices from around the country, but does not constitute permission or prohibition for a given billing practice.

50. 49 COMPENSATOR • A compensator is a device that will shape the profile of the beam to compensate for uneven patient contours across the flat face of the treatment port to even out the dosage to the treatment area. • The most common use of a compensator will be to compensate for the steep slope of the chest wall. • A compensator, if custom designed for a particular situation, may be billed individually and in addition to other complex treatment devices.