Practice Management Resources

ASTRO Practice Management Resources are developed to provide information to the membership on topics of interest related to coding, reimbursement, coverage and practice management. New articles in this series will be published on a regular basis to inform members of various practice management matters.

April 5 Supervision Town Hall and FAQs

View the recording of the April 5 Supervision Town Hall meeting.
View the FAQs created in preparation for the April 5, Supervision Town Hall meeting.

The Basics of Radiation Oncology Coding

Radiation Oncology Coding

(Includes changes for CY 2016)

Objective: An introduction to physician coding for radiation oncology services.

A course of radiation therapy treatment is comprised of a series of distinct activities of varying complexity and is a function of the individual patient situation. The “process of care” in radiation oncology provides a conceptual framework for coding and documenting care throughout the course of treatment.

The radiation oncology process of care can be separated into the following six categories:

Consultation
Preparing for treatment
Medical radiation physics, dosimetry, treatment devices and special services
Radiation treatment delivery
Radiation treatment management
Follow-up care management

A high-level overview of radiation oncology coding is provided as an introduction to physician coding for radiation oncology services. Individuals should always verify correct code usage with the appropriate health care provider and/or contractor.

Consultation

What is it? A consultation is a type of evaluation and management service provided by a physician at the request of another physician or appropriate source. The outcome of the consultation will be to either recommend care for a specific condition or problem, or determine whether to accept responsibility for ongoing management of the patient’s entire care or for the care of a specific condition or problem.

Tasks performed. The clinical team, led by the radiation oncologist, provides the medical services associated with the process of care. The physician, as part of this process, will review the pertinent radiographs, pathology reports, patient complaints and physical findings.

CPT codes. The consultation E/M services are reported using the 99xxx series in the CPT^® codes. Note that as of January 1, 2010, CMS has eliminated payment for office and inpatient consultation codes and providers are directed to report other appropriate E/M CPT codes.

Preparing for treatment

This phase in the process of care includes clinical treatment planning and simulation services.

Clinical Treatment Planning
What is it? Clinical treatment planning is the initial step in preparing for radiation oncology treatment. The planning stage is a very important phase in the process of care. The radiation oncologist may use information obtained from the patient’s clinical evaluation at the time of the initial consultation, as well as request additional tests, studies and procedures that may be required to complete the treatment plan.

Tasks performed. Clinical treatment planning includes the following components: determining the disease-bearing areas, identifying type and method of radiation treatment delivery, specifying areas to be treated, selecting radiation treatment technique and specifying dose and duration of therapy.

CPT codes. Clinical treatment planning services are reported using CPT codes 77261-77263.

Simulation
What is it? 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.

Tasks performed. Utilizing simulation equipment, the exact treatment position for the patient is defined. This may include marking the area to be treated on the patient’s skin, aligning the patient with localization lasers, and/or designing immobilization devices to ensure precise patient positioning. Each port or field is visualized in reference to the proper landmarks. Documentation of the size, angle, distance and other working parameters are recorded during simulation. Simulation may be performed more than once during a course of treatment—e.g., in some brachytherapy circumstances, it can be twice per day.

CPT codes. Simulation services are reported using CPT codes 77280-77290.

Respiratory Motion Management Simulation
What is it? In current clinical practice, simulation is performed with motion management to inform field and portal design with precise knowledge about the respiratory movement of target tissue and organs at risk.

Tasks performed. This new code describes the physician work involved in simulating a patient using motion (respiratory) tracking of a mobile target volume. The work involves acquisition and review of multiple additional CT images that allow for a full accounting of breathing-related tumor motion.

CPT codes. Respiratory management simulation is reported using CPT code +77293.

Medical radiation physics, dosimetry, planning, treatment devices and special services

What is it? During this phase, a mathematical computation of the specific radiation dose at a particular point is developed. The radiation oncology team develops the appropriate dosimetry calculations and isodose plan, builds treatment devices to refine treatment delivery, and performs any other special services required for the precision of dose delivery.

Tasks performed. The physician, with the assistance of a qualified medical physicist, prescribes, supervises, designs, reviews and clinically confirms all aspects of each activity in this phase of care.

CPT codes. Medical radiation physics, planning, dosimetry, treatment devices, and special services are reported using: 77295, 77300, 77331, 77301, 77338, 77306-77307, 77316-77318, 77321, 77332-77334, 77336 and 77370.

Radiation treatment delivery

What is it? Radiation treatment is delivered using either a type of external beam radiation or brachytherapy, and includes various methods, modalities and complexities. Delivery codes are normally used each day of treatment, in some instances twice a day. Energy level and complexity of treatment determine the appropriate treatment delivery CPT code to report.

Tasks performed. The physician is responsible for verification and documentation of the accuracy of treatment delivery as related to the initial treatment planning and setup procedure.

CPT codes. Treatment delivery is reported using the following CPT codes:

Brachytherapy: 77761-77763, 77767-77768, 77770-77772, 77778, 0394T-0395T, 77789, 77750 and 77790
Conventional external beam radiation treatment delivery: 77401-77416 and G6003-G6014
Intensity Modulated Radiation Therapy: (IMRT) 77385-77386, G6015-G6016
Intraoperative Radiation Therapy: (IORT) 77424 and 77425
Neutron beam treatment delivery: 77422-77423
Proton beam treatment delivery: 77520-77525
SRS treatment delivery: 77371-77372
SBRT treatment delivery: 77373

CPT codes. Image guided Radiation therapy (IGRT) is reported using the following CPT codes:

Image-guided radiation therapy (IGRT): 77387, G6001, G6002, G6017 and 77014

Note that brachytherapy may have a different process of care that is not fully addressed within this document.

Radiation treatment management

What is it? Radiation treatment management represents the radiation oncologist’s professional contribution to patient management during the course of treatment.

Tasks performed. For the radiation oncologist, radiation treatment management requires and includes a minimum of one examination of the patient by the physician for medical evaluation and management. The professional services performed during the treatment management phase typically include: review of port films; review and changes to dosimetry, dose delivery, and treatment parameters; review of the patient’s setup; and patient examination.

Not all of these parameters of treatment management are completed each week (except for the patient examination) because the clinical course of care may differ due to variation in treatment modality and individual patient requirements.

CPT codes. Radiation treatment management is reported using the following CPT codes: 77427, 77431, 77432, 77435, 77469 and 77470.

Follow-up care management

Follow-up care is the last phase in the process of care for a radiation therapy patient. Continued care is appropriately provided by the radiation oncologist to monitor the patient for tumor recurrences. Medicare will not pay for routine follow-up care during the three months after completion of external beam therapy, since this is considered part of the treatment management.

Supervision

**CMS REVISED SUPERVISION POLICIES APPLY DURING COVID-19 PHE. SEE ASTRO SUMMARY.**

The Medicare physician supervision requirements for radiation therapy services is an area of great importance to our membership.

View the recording of the April 5 Supervision Town Hall meeting.

ASTRO has received countless inquiries from members regarding the requirements related to physician supervision of radiation therapy and other services provided to Medicare patients over the years. The recent discussions of physician supervision requirements in the outpatient hospital setting in the Hospital Outpatient Perspective Payment System (HOPPS) Proposed and Final Rules for 2011 have raised even more questions. It is clear that our members want to ensure compliance with all Centers for Medicare and Medicaid Services (CMS) supervision requirements, regardless of practice setting; however the answers to these questions are not simple. ASTRO strongly encourages all radiation oncologists to work closely with their compliance officers and/or hospital administrators to ensure compliance with all Medicare supervision requirements.

CMS is responsible for administering the Medicare program. Over the years, Medicare’s policies related to physician supervision requirements have been issued through regulations or through instructions to Medicare carriers in various manuals. The policies on physician supervision requirements that are pertinent to radiation oncologists relate to five specific benefits to which Medicare beneficiaries are entitled by law (Title XVIII of the Social Security Act). ASTRO’s “Medicare’s Physician Supervision Requirements” paper attempts to simplify the physician supervision requirements related to the following five categories:

“Incident to” services in an outpatient hospital setting.
Radiation therapy in an office or free-standing radiation therapy center.
Diagnostic tests in an office or free-standing radiation therapy center.
Diagnostic tests in an outpatient hospital setting.
“Incident to” services in an office or free-standing radiation therapy center.

The paper does not address issues related to credentialing or privileging.

ASTRO White Paper on Physician Supervision Requirements.

ASTRO's "Guidance on Shared and Incident To Billing of Evaluation and Management Services in Radiation Oncology" addresses how radiation oncologists share Evaluation and Management Services with residents, nurse practitioners and physician assistants related to the following categories:

Shared E/M Services in a Hospital or Facility Setting.
“Incident To” E/M Services in a Physician Office Setting.
Additional Considerations for E/M Services Involving Teaching Physicians, Residents and Medical Students.

ASTRO Guidance on Shared and Incident To Billing of Evaluation and Management Services in Radiation Oncology.

Resources to Address Payer Denials

OIG Audits Letter

CT Image Guidance Payer Notice

CT Image Guidance and IMRT Delivery

Coding Guidance for Use of CT Image Guidance Related to IMRT Planning and Treatment Delivery

ASTRO Update on Aetna Image Guidance Decision

ASTRO/ACR letter to NGS on prostate rectal spacers and reference document

Rectal Spacers Payer Notice

When submitting appeal letters, please copy ASTRO by emailing our Health Policy team.

Letters to Payers

eviCore Oligometastases Policy Comments

Washington State HCA SBRT Policy Comments

BCBS Mississippi SBRT Policy Comments

MAC 3-D CRT Denials Letter to CMS