How to bill for radiation treatment planning

Our clinic is doing some research on CyberKnife Radiation Therapy treatment planning for one of our urologists. We have had difficulty for some time now obtaining reimbursement from our Medicare provider, WPS. Our urologist places the fiducial seeds and then helps the radiation oncologist with the CyberKnife Therapy treatment planning. We know that we have to use the unlisted procedure code 55899 for the urologist’s portion of the treatment planning, since the radiation oncologist bills the 77263 code. We provide a description of the service in box 19 of the claim as they request. We provide the documentation of the treatment plan from the radiation oncologist’s office and our physician dictates a brief note. Are you aware of any best practice documentation guidelines for the urologist’s portion of his services? We have been unable to find anything thus far.

This issue has been explored by a number of specialties. The short answer is, you are correctly reporting the services provided from a coding standpoint.

From a best practice standpoint, we will provide you a bit of background on the issues you are up against for this service.

The radiation oncologist’s CPT code 77263 (Therapeutic radiology treatment planning; complex) is the correct choice for treatment planning related to CyberKnife. If you analyze the documentation in CPT, you will note that the introduction to that section of CPT codes includes the following:

“The clinical treatment planning process is a complex service including interpretation of special testing, tumor localization, treatment volume determination, treatment time/dosage determination, choice of treatment modality, determination of number and size of treatment ports, selection of appropriate treatment devices, and other procedures.

Three codes for therapeutic radiation treatment planning are available (see, “Radiation treatment planning: Definitions,” below).

In considering the expanded definition from CPT, it appears that any payment for treatment planning would be covered in the payment for code 77263. However, a group of specialty societies agreed that the planning done by the radiation oncologists must be critically reviewed by the specialist to make certain the correct areas are targeted for proper treatment.

One option the societies explored was the potential of using modifiers to either split payment or add payment to the reimbursement of the 77263 to allow the specialist (urologist) to be paid for the service of assisting in the treatment planning. In the existing database, neither –62 nor –66 are allowed with code 77263. Further, radiation oncologists were understandably reluctant to have the payment split as the workload of initial treatment planning did not change and in fact may be increased when the planning is reviewed and changes are recommended. As such, the co-surgeon or team surgeon option is not viable.

If you review AUA Coding Today (www.auacodingtoday.com), you will note that modifiers –80, –81, –82, and –AS are allowed; however, documentation is required to support the use of the modifier, meaning that a first submission will be denied with a request for supporting documentation, but payment could be allowed if your submitted documentation supports the use of the modifier. As you know, modifiers –80, –81, –82, and –AS are used to report varying levels of assistant at surgery.

The indicator tagging assistant at surgery modifiers as payable with documentation for a radiology code of this type is curious. We have confirmed that many private payers have a system block that does not allow any assistant at surgery modifier with any pathology or radiology code. Based on the definition of the modifiers and the treatment of the modifiers by private payers, we do not recommend the use of modifier –80.

The other option considered was the creation of a new code. The argument was made that this specialist review did indeed represent an extra work effort by a separate provider in addition to the work effort of the radiation oncologist. A proposal was brought forth to create a code for specialist review of the treatment planning, addressing the review regardless of specialty. This proposal was rejected, and it was recommended that each specialty develop a code for review specific to the treatment to be included in the appropriate anatomic code group within CPT. The specialty of thoracic surgery took this step, resulting in code 32701 (Thoracic target[s] delineation for stereotactic body radiation therapy [SRS/SBRT], [photon or particle beam], entire course of treatment).

Again, checking AUA Coding Today, you can see an adjusted value of 6.55 has been assigned for payment of this code. Urology has not yet pursued a CPT code for treatment planning review for use of the CyberKnife in the genitourinary system for many reasons.

With that background, we would recommend for best practices that the urologist reviewing treatment planning for CyberKnife include in the patient record a clear indication that the radiation oncologist’s treatment plan was reviewed in detail. You should also note target and dose amount with any change recommendations or that the urologist concurs with the plan as is. For reporting, use the unlisted code 55899. For documentation support, include the note and reference to code 32701 as justification for charge and support of the service type as a separately identifiable work effort paid for by Medicare. Perhaps the reference to code 32701 will help tip the scales.UT

Radiation treatment planning: Definitions

Simple planning requires a single treatment area of interest encompassed in a single port or simple parallel opposed ports with simple or no blocking.

Intermediate planning requires three or more converging ports, two separate treatment areas, multiple blocks, or special time dose constraints.

Complex planning requires highly complex blocking, custom shielding blocks, tangential ports, special wedges or compensators, three or more separate treatment areas, rotational or special beam considerations, and combination of therapeutic modalities.