Respiration Motion Management (+77293)

As of January 1, 2014, CPT code +77293 will be used to report respiratory management at simulation.

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 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.

This new code describes the physician work and resources involved in acquiring a respiratory correlated or ‘4-D’ CT simulation study for conformal planning. The plus (+) symbol in front of the code number indicates that this is an add-on code. Add-on codes are never performed independently and must be reported in addition to the primary procedure. In the case of +77293, it must always be billed with either CPT code 77295 or 77301 on the same date of service, even though the work may take place over many days.

* CPT code 77295 has been moved to the Medical Radiation, Physics, Dosimetry, Treatment Devices and Special Services subsection of the CPT book (CPT codes 77300-77370) to represent the work of physics and dosimetry planning rather than the work performed in the simulation.. The descriptor has been revised to reflect this change.

The work involved in +77293 includes physicians, therapists, dosimetrists and physicists and has both a professional and a technical component. The work is performed both in the simulator and in dosimetry. The add-on code +77293 is part of the simulation and isodose planning process, not part of treatment delivery.

Respiratory motion management simulation

Respiratory motion management simulation describes the physician work involved in simulating a patient using motion (respiratory) tracking of a mobile target volume. Simulation CPT^® codes 77280-77290 assume a static target and acquisition of a single data set. Increasingly, simulation is performed with motion management to inform field and portal design with precise knowledge about respiratory movement of target tissues and organs at risk. Motion management requires multiple scans and fusion of those scans with motion (respiratory) tracking and is performed along with base simulation and a chosen computer planning process.

Respiratory motion management simulation is typically performed when there is a need to account for the breathing-related motion of thoracic 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. Therefore, the service is performed in addition to the simulation code. The work represented by respiratory motion management simulation is also distinct from the work of the treatment planning process.

Since the work of motion management is identical for 3-D conformal and IMRT patients, it can be billed in conjunction with either CPT code 77295 or 77301. CPT code +77293 is an add-on code therefore, cannot be billed on its own and must always be billed with either CPT code 77295 or 77301.

The add-on code +77293 can only be billed once. If the patient is receiving treatment with gating or other respiratory motion tracking during the treatment, 0197T should be used.

Performing respiratory motion management simulation

Motion management is performed after CT simulation. Proper breathing is required by the patient in order to acquire appropriate images. The patient is coached on achieving a reproducible breathing pattern, typically using a respiratory sensor as a guide. Respiratory excursion inhibiting devices (abdominal compression, etc.) may also be used to minimize respiratory motion or enhance breathing pattern regularity. External fiducial markers may be used and oriented on the patient by the physician. The respiratory monitoring system is then adjusted for the optimum anatomic position to yield the most appropriate signal strength and the best correlation with the anticipated tumor motion. Internal fiducial markers may have been previously placed but are not considered a necessary part of the process. CT scout images and adjustments are made to achieve the desired alignment. Upper and lower borders for scanning are selected based on the location of the primary lesion and the involved lymph nodes. Field of view is reviewed to ensure inclusion of all relevant tissues and skin markers on the image set.

Four-dimensional CT images are then obtained with the real-time recording of a respiratory signal simultaneously with multiple CT images acquired at each axial position in the patient to capture the entire respiratory cycle at each CT slice position. Simultaneously, a measure of the patient’s respiratory motion is acquired using a respiratory sensor, correlated with each CT slice acquisition phase and stored for later use in the 4-D reconstruction. This multi-image technique, which is known as over-sampling, is performed to obtain a sufficient number of CT slices over superior/inferior extent of the patient anatomy, so that there are enough images to achieve respiratory sorting with acceptable spatial and temporal accuracy. Over- sampled images from the CT dataset are sorted into several phases, or bins, based on the information obtained from the respiratory signal, such as peak exhale, mid exhale, peak inhale and mid inhale. Generally up to 10 respiratory-binned CT slices are reconstructed at each CT slice position. A complete set of image bins acquired over a respiratory cycle constitutes the 4-D CT dataset.

The multiple data sets are then processed and reconstructed before being transferred to a physician workstation for review. The binned images are reviewed by the physician for consistency and absence of data gaps and respiratory motion consistency. If the patient’s respiration pattern was suboptimal, the acquisition process will be repeated. These binned images are then further processed into maximum intensity projection and/or minimum intensity projections. The complete set of 4-D images to modify GTVs over the full range of the previously acquired 3-D dataset is used to create the motion compensated treatment volume(s).

Clinical circumstances must warrant the use of this service. The following examples are illustrative of when it would be appropriate to report motion management. Examples include lung cancers or upper abdominal tumors (for example, hepatic or pancreatic cancers) in which the motion from respiration may cause significant movement of the intended target volume during different phases of the respiratory cycle.

Documentation

Complete documentation is essential when reporting an add-on code. Documentation should include both the medical necessity of reporting CPT^® code +77293 as well as that the work the code describes was done. The documentation needs to be more extensive than just part of the simulation note since it is part of the isodose planning process. Physicians should work with their staff to ensure that proper documentation has been completed.

Since the work that is included in +77293 occurs over several days, and it involves the therapists, the dosimetrist, the physicist, and the physician, the information that could support the code would appear in several documents. The simulation note would also document physician review of respiratory motion management set-up and use at the time of simulation. The treatment plan document would indicate that the physician created an ITV that covered the target volume in all phases of respiratory motion.

Add-on codes are to be reflected as a separate claim line on electronic claim submission. Add-on codes should be listed separately in addition to the primary procedure code. This code is only charged once per 3-D or IMRT plan and should be reported on the same day as the primary planning code (77295 or 77301).

Note: This new code describes the work involved in simulating a patient using motion (respiratory) tracking of a mobile target volume. Similar to imaging services, CMS will not provide separate technical payment for the new respiratory management service (+77293) in the hospital outpatient environment.

References

ASTRO/ACR Guide to Radiation Oncology Coding 2010 (including 2014, 2013, 2012 and 2011 updates). Fairfax, VA and Reston, VA: American Society for Radiation Oncology and the American College of Radiology; 2010.

American Medical Association Code Manager^® 2014

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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