Process of Care

The process of care in radiation oncology is a series of complex steps that can be broken down into six phases:

1. Patient consultation;
2. Preparing for treatment;
3. Medical radiation physics, dosimetry, treatment devices and special services;
4. Radiation treatment delivery;
5. Radiation treatment management; and
6. Follow-up care management.

This coding article addresses the second step in the process of care: Preparing for treatment, which consists of two steps:

• Clinical treatment planning
• Simulation

Each of these three steps is described in detail below. Depending on the modality of radiation therapy used, the process of care within treatment preparation may vary. This article discusses the differences in the processes of care within treatment preparation for a 3-D conformal plan and an IMRT plan. Note that isodose planning (CPT code 77295) was moved out of the simulation family to the Medical Radiation Physics, Dosimetry, Treatment Devices and Special Services (CPT codes 77300-73370) phase of the process of care.

1. Clinical treatment planning (CPT^® codes 77261-77263)
   The decision to administer radiation therapy is made by the radiation oncologist following evaluation of the patient at the initial consultation. Integrating the patient’s overall medical condition and extent of disease with a plan for therapy triggers the clinical treatment planning process. Clinical treatment planning codes (CPT codes 77261-77263) are the professional charges for the physician to integrate the patient’s overall medical condition and extent of disease and to formulate a plan of therapy for the patient. The term “clinical treatment planning” should not be confused with CPT codes that describe dosimetry isodose plans, which occur later in the process of care [e.g., teletherapy isodose plan (CPT codes 77306-77307), 3-D radiotherapy plan (77295), IMRT plan (77301) and brachytherapy isodose plan (77316-77318)].
   
   Furthermore, Clinical treatment planning is a separate and discrete step in the process of care that represents services that are unique and distinct from those provided within other planning codes. Within clinical treatment planning, the radiation oncologist develops the specific parameters of the therapeutic management plan, including the overall clinical, physical and technical aspects of radiation treatment required for safe and effective therapy for each patient. This includes determining the treatment modality, total dose, fractionation and the need for planned field changes. The physician must select from the various radiation modalities (e.g., IMRT, 3-D conformal, brachytherapy, etc.), and decide whether to combine chemotherapy with radiation therapy. A clinical treatment planning code may be reported regardless of which modality is ultimately chosen to treat the patient. Once the documentation for clinical treatment planning, which includes a written prescription or intent along with a note documenting the thought process and work, is complete the patient proceeds to the next step in treatment preparation: simulation.
    
2. Simulation (CPT^® codes 77280-77290, +77293)
   After the physician has determined the appropriate treatment parameters within the clinical treatment plan, the next step is the physical targeting of the tumor or treatment volume to ensure accurate treatment delivery. Simulation is the process of defining relevant normal and abnormal target anatomy and acquiring the images and data necessary to develop the optimal radiation treatment process, without actually delivering a treatment. During simulation, the radiation oncologist, with the assistance of the radiation therapist, utilizes simulation equipment to define the exact treatment position for the patient. Simulation may be repeated during the treatment course as medically indicated depending on the type of cancer, radiation therapy utilized and the clinical response to the treatment. The simulation codes describe the work and complexity of establishing the proper patient positioning and obtaining adequate imaging with the patient in the treatment position.
   
   Simulation followed by a 3-D conformal plan
   Traditional preparation for radiation therapy consists of a distinct simulation procedure followed by the development of a computer-generated treatment plan that is the basis for the treatment course. A simulation is defined as complex (77290) if any of these Criteria are met: particle therapy, rotation or arc therapy, tangential therapy, complex or custom blocking, brachytherapy simulation, hyperthermia probe verification or any use of contrast material. If simulation does not meet any of the criteria, the complexity is defined by the number treatment areas: one treatment area is simple (77280), two treatment areas are intermediate (77285) and three or more treatment areas are complex. Prior to starting treatment, the patient may undergo verification simulation confirming the isocenter placement, compatibility with treatment machine constraints, and multileaf collimation design, utilizing CPT code 77280.
   
   Simulation followed by an IMRT plan
   CPT code 77301 IMRT treatment planning includes all simulation services. The practice expense relative value units (PE RVUs) associated with CPT code 77290 are included in the valuation of CPT code 77301, so 77290 cannot be reported separately. Additionally, the National Correct Coding Initiative (NCCI) Policy Manual includes same date of service procedure-to-procedure edits between CPT code 77301 and all pre-IMRT simulation activities associated with the development of the IMRT plan whether these procedures are reported on the same or different dates of service. This became effective January 1, 2014. ASTRO notes that prior and conflicting guidance — from CMS transmittals and other sources — on the co-reporting of CPT code 77301 and simulation services may still be available online and in other formats. ASTRO urges facilities and providers to amend their billing policies to align with the above NCCI directive as necessary.
   
   Therefore, if IMRT is the chosen modality for treating the patient, a simulation code cannot be reported separately prior to completion of the IMRT treatment plan, even if the two services are performed on separate days. To reflect this change, ASTRO has revised its guidance as follows: If a simulation charge(s) was already reported prior to reporting an IMRT treatment plan, the charge(s) must be voided on a subsequent claim.
   
   Respiratory Motion Management Simulation (CPT +77293)
   With the creation of CPT code +77293, the concept of an add-on code has been introduced into the radiation oncology code set. An add-on code is a code that can only be billed in addition to the primary code; it cannot be billed as a stand-alone code. It is designated by a plus (+) symbol, which is found in front of the code. +77293 describes the physician work and practice expense involved in simulating a patient using motion (respiratory) tracking of a mobile target volume. Respiratory motion management simulation is typically performed when there is a need to account for the breathing-related motion of pulmonary or abdominal tumors that will be targeted with radiation therapy. The work involves acquisition and review of multiple additional CT images that allow for a full accounting of breathing-related tumor motion. The work represented by respiratory motion management simulation is also distinct from the work of the treatment planning process and is identical the work for 3-D conformal and IMRT patients, therefore it can be billed in conjunction with either CPT code 77295 or 77301 on the same date of service even though simulation preformed on a prior day. In the hospital setting under the Hospital Outpatient Prospective Payment System (HOPPS), +77293 is not separately reimbursable. However, it is extremely important to still report +77293 (when performed) separately for tracking purposes and for non-governmental payers that may not conform to HOPPS guidelines.

Coding Question: For patients being treated with IMRT, can CPT code 77280 be charged for the work of performing a verification simulation of the treatment field, after charging 77301 for all simulation services performed related to the IMRT plan?

Coding Answer: CMS has updated previous guidance on the CPT codes that may be reported with 77301 for developing an IMRT treatment plan. Effective January 1, 2017, the following guidance will apply to CPT code 77301 in both the hospital and the freestanding setting.

Payment for the services identified by CPT codes 77014, 77280, 77285, 77290, 77295, 77306, 77307, 77321 and 77331, are included in the payment for CPT code 77301 (IMRT planning). These codes should not be reported in addition to CPT code 77301 when provided prior to or as part of the development of the IMRT plan. Since January 2017, CPT code 77280 (simulation aided field setting) should not be reported for verification of the treatment field during the course of IMRT.

Disclaimer: The opinions referenced are those of members of the ASTRO Code Utilization and Application Subcommittee based on their coding experience and they are provided, without charge, as a service to the profession. They are based on the commonly used codes in radiation oncology, which are not all inclusive. Always check with your local insurance carriers, as policies vary by region. The final decision for coding for any procedure must be made by the physician, considering regulations of insurance carriers and any local, state or federal laws that apply to the physicians practice. ASTRO nor any of its officers, directors, agents, employees, committee members or other representatives shall have any liability for any claim, whether founded or unfounded, of any kind whatsoever, including but not limited to any claim for costs and legal fees, arising from the use of these opinions.  

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