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

Basic Dosimetry Calculations 77300 IS A GLOBAL BILLING CODE 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, and as many times as necessary. 77300 IS A GLOBAL BILLING CODE

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.

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

Computer calculations (Varis/Aria) NIB Computer calculations (Varis/Aria)

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

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

Basic Dosimetry Calculations 77300 9 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

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.

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

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

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.

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.

Documentation Requirements 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.

Isodose Dosimetry 77305- 77315 17 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.

77321 IS A GLOBAL BILLING CODE 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

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

22 Electron boost port 77321 Post operative Parotid tumor

Electron boost to breast 23 Electron boost to breast

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

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

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

Special Beam 77321 24 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.

77331 IS A GLOBAL BILLING CODE 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 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.

Narrative Microdosimetry report 77331 28

Special Dosimetry 77331 29 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.

30 TREATMENT DEVICES

77332 -77334, 77338 ARE GLOBAL BILLING CODES 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

Occurrence Rate, Blocks 2014 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.

77332 Simple Treatment Devices 36 77332 Simple 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.

Simple Treatment Block 36 Simple Treatment Block 80/150

Bolus The use of bolus usually constitutes a simple device. 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

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

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

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)

40 Custom Stint 77334

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

MULTIPLE SIMPLE SKIN LESIONS 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

77334 Complex Treatment Devices 41 77334 Complex Treatment Devices

Complex treatment device 42

Multi-leaf or Dynamic Collimation (MLC) 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.

Compensator IMRT is still 77334 42 Blocking for IMRT 77338 In the case of IMRT treatment, 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

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

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

Immobilization Devices 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)

Bead filled vacuum bags are complex multi-use devices. 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.

Breast Board 47 BILL AS 77332

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.

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.

49 REGARDLESS OF COMPLEXITY OF DESIGN OR USE, ALL COMPENSATORS WILL BE BILLED AS 77334

FOR TOTAL BODY TREATMENT 77334 CUSTOM COMPENSATOR FOR TOTAL BODY TREATMENT 77334 50

Proton Tissue compensator 50 Proton Tissue compensator 77334

Milled brass proton beam shaping compensator NIB Milled brass proton beam shaping compensator 77334

IMRT COMPENSATOR 77334 NIB

50 Rice bolus Square tissue compensator to evenly distribute the dose over the tumor volume. Complex compensator, 77334, in addition to the mask, 77334 Tumor volume

50 This is the patient 6 months after completion of radiation therapy to the scalp lesion.

IMRT Compensator Blocking Each block or fluence is billed as 77334 51 When cast compensators are utilized for IMRT blocking. Each block or fluence is billed as 77334 Note; this is still the same as in previous years, do not use the single 77338 code for compensator blocking

52 Regardless of the complexity or design of the conventional therapy treatment device, some form of narrative may be required

52 Device report for two immobilization devices, each of these will be billed as 77334, complex device.

WHEN TO BILL TREATMENT DEVICES 53 WHEN TO BILL TREATMENT DEVICES Date of DESIGN of device Date of CREATION of device Date of USE of device

Treatment Devices 53 SP134/150 What are they for? Blocking (cast or MLC) wedges, compensators, Brachytherapy devices. Who normally documents/bills/captures these codes? Dosimetry, Treatment or Simulator Therapist, physics or physician. When are these codes normally billed? They can occur anytime in the course of therapy. What Documentation is suggested for these codes? The design on DRRs for a block. A written report may be generated if required by your insurance carriers. Photographs are useful. What are the common documentation errors with these codes? Insufficient documentation to support the use of the device. Lack of Physician statement of medical necessity. What are the common billing errors identified? Not understanding the specific rules of CCI and MUE edits Not understanding which device is immobilization and which is blocking. Not knowing that professional and technical rules are different. Not recognizing that the procedure was performed. SP134/150

Special Physics CPT Codes 55 Special Physics CPT Codes 77336 - Continuing Medical Physics Services 77370 - Special Medical Physics Consult

55 Special Physics Codes The two special physics codes 77336 and 77370 are considered as technical services only. The physician may not bill for these procedures, however the physician is legally responsible for all physics procedures performed in his department.

77336 Continuing Medical Radiation Physics 55 77336 Continuing Medical Radiation Physics The safe use of radiation requires the continuing medical physics services to ensure that the treatment being delivered conforms precisely to the physician’s intent and prescription from a technical (medical physics) point of view. These services are typically described using 77336 and are distinctly provided by the medical physicist for each patient. These services are provided by or under the supervision of a qualified medical physicist.

55 77336 77336 was devised many years ago to account for a general, single reimbursement value per week covering a multitude of relatively small physics services that are performed for each patient undergoing treatment These are not to be considered as quality control features but, are essential to assure the accuracy and safety of the radiation treatment as it is being delivered in an ongoing fashion hence, the name Continuing Medical Radiation Physics in support of the therapeutic radiologist.

Patient Services covered by the radiological physics code 77336 56 Weekly checking of the patient’s treatment record Confirmation of the proper mathematics related to daily chart entry Verification of the accuracy of the dose calculations Accuracy of daily entry in the treatment log relative to the physician’s prescription Proper utilization of the various treatment aids Assurance of the accuracy of treatment device design Translation of computer generated data to the daily treatment log pages Assurance that the physician’s prescription is being followed exactly

77336 56 The tasks provided by the physicist are essential in ensuring that the physician’s prescription is being followed accurately during the course of radiation therapy. Documentation of physics services performed is essential. These services (77336) are not considered as special physics calculations (77370) and are not to be billed as such. (ACR, 2001)

IMRT weekly physics report 77336 57 IMRT weekly physics report 77336

CONTINUING PHYSICS WITH BRACHYTHERAPY 58 Multiple procedures may be performed and billed by the physicist for his work related to a course of Brachytherapy. Most of these procedures are covered under the continuing physics code 77336 or a special physics consultation 77370. See the list on page 60.

Continuing physics report, 77336, for Brachytherapy 59 Continuing physics report, 77336, for Brachytherapy

Continuing Medical Physics 77336 59 What’s it for? The Medical Physicist weekly involvement in insuring proper patient treatment. Who normally documents this code? The Physicist. When is this code normally billed? Weekly (every 5 fractions) during a course of therapy. What Documentation is suggested for this code? A worksheet or electronic document showing that the Medical Physicist has reviewed the week’s treatment. What are the common documentation errors with this code? Inadequately documenting services rendered. What are the common billing errors identified? This code can be billed any time during the course of the five fractions. Know the many CCI edits against this code . This is a technical only code, never bill a professional component.

60 77370 Special Medical Radiation Physics Consultation This code is used in a consultative situation describing a very specific procedure that is carried out by the medical radiological physicist at the direct request of the radiation oncologist. This code describes a special situations requiring the expertise of the medical radiological physicist to completely analyze a problem and develop a summary for the radiation oncologist. The physicist must render a special written report to the radiation oncologist.

A direct request by the physician for this procedure is required. Computerized physician order [CPO] requesting a physics consultation. This consultation will ultimately be billed as a 77370 special physics consult. A direct request by the physician for this procedure is required. 60

60 77370 This procedure is performed to directly benefit an individual patient, and is patient specific and distinctly different from the broader multi-patient issues addressed by the Code 77336. The radiation oncologist will be expected to analyze and sign off on the report. The findings may be used to design or modify the treatment situation under analysis.

Special Physics Consult The Right Doctors – The Right Technology 61 Special Physics Consult A review of the previous port films from Baptist Hospital show the port extended to the mid-portion of the body of C-7. Recommendation: A central axis beam splitting upper edge of the treatment port will allow close abutment of the port covering T-1 with the previous field at C-7. Calculations of the gap will require 1.3cm on the skin resulting in beam crossing below the level of the spinal cord. NSD decay of the 3000 rads delivered to the previous field would indicate, at maximum, a 10% reduction in equivalent dosage however, if the ports are properly set, there should be no additive effect between the two portals. Physicist Physician The Right Doctors – The Right Technology 230 North Midwest Boulevard – Midwest City, OK 73110 – (405) 737-8455

62 Some of the recent edits of Medicare will not allow any other 77300 series code to be billed on the same date as 77336 or 77370. These codes should be reported on separate dates, and cannot be billed together. 77336 can be reported any time within the 5-day period of a week of therapy. Check your LCD

63 The technical component of 77336 and 77370 codes recognizes the efforts of the physicist, dosimetrist, and auxiliary personnel. No professional charges will be made for these services by the Physician, medical radiation physicist or dosimetrist.

Medicare assumes that a physics assessment (77336) is reported once for every week (five fractions) of external beam treatment. For other forms of radiation therapy that do not adhere to the five-fraction/week rule (e.g. brachytherapy, stereotactic), code 77336 may be reported as medically necessary and supported by documentation. A special physics consult (77370) is typically required only once per course of radiation therapy. 63

Special Medical Physics Consultations 77370 64 Special Medical Physics Consultations 77370 What’s it for? This is a requested consultation, and it should be documented as answering a difficult question on a specific patient. Who normally captures this code? Medical Physicist. When is this codes normally billed? Once per treatment course at any time What Documentation is suggested for this code? A narrative type document by the physicist explaining the physics problem being requested by the physician. What are the common documentation errors identified with this code? A Special Physics Consult must be performed, and must be documented in the medical record to bill the service. Medical necessity must be evident. What are the common billing errors identified? Multiple CCI edits exist against 77370, almost all 773xx codes are edited against it. 150/150

PRINCIPLES OF BILLING, CODING AND COMPLIANCE IN RADIATION ONCOLOGY BMSi 2014 End sect 8

END OF SECTION 8 8

NEW PROGRAM FORMAT Dr. Bogardus will not be here in person, but he will be available and participating using a live video simulcast from the BMSi office in Oklahoma City. This is a live two way communication, and the audience is encouraged to interact as we have always done in the past.

Bolus Buildup Simple device 40 Bolus Buildup Simple device

77332 SIMPLE GENERIC DEVICES PRE MADE CAST ELECTRON BLOCKS NIB 77332 SIMPLE GENERIC DEVICES PRE MADE CAST ELECTRON BLOCKS

26 DIODE PROBE

MOSFET SOLID STATE DOSIMETER 27 MOSFET SOLID STATE DOSIMETER SINGLE USE DEVICE 77331

IMPLANTABLE TRANSPONDER MOSFET DOSIMETER 27 IMPLANTABLE TRANSPONDER MOSFET DOSIMETER Single use implantable dosimeter coupled with a telemetric passive transponder Capable of recording cumulative daily dose Approved for use in prostate Generally two are implanted Urology code 55876 for implantation Medicare professional $108.77 (2008) Hospital code A4649 Medicare technical ~ $1,200.00

27 Hand held wand Reader circuit Antenna Passive solid State circuit Mosfet

77421 Stereoscopic localization, report daily for IGRT 77331 27 77421 Stereoscopic localization, report daily for IGRT 77331 Special Dosimetry, can report cumulative dose, per dosimeter EACH OF THESE PROCEDURES REQUIRES A SEPARATE REPORT

Mosfet implanted dosimeter/marker report for micro dosimetry 28 Mosfet implanted dosimeter/marker report for micro dosimetry Two versions of report, narrative and brief

Record and Verify Systems are not reportable as 77331. 29 77331 is not appropriate, and could not be reasonably defended, for a room survey following Brachytherapy. Record and Verify Systems are not reportable as 77331. Record and verify is part of standard quality assurance and carries no reimbursable component. 60/150

19 Electrons The characteristics of electrons are such that a higher level of care of the patient, special attention by the treatment machine personnel, and an extensive knowledge of the physics and interaction of electrons with tissue, is required of all personnel. 35/150

The use of Electrons 22 Electrons may enable the radiation oncologist to re-treat an area that has previously been heavily irradiated. Electrons are most often used as a boost to an area that is either receiving or has received a separate photon beam in addition to the electrons. If the center does not have a KV unit, then Electrons may be the best modality for treating small primary skin malignancies or skin metastasis.

Standard Machine Wedge 45 77334 A wedge is a device that shapes the profile of the treatment beam to compensate for an angular plane of entry Standard Machine Wedge

The most common immobilization device in 1970 was 3-M masking tape NIB The most common immobilization device in 1970 was 3-M masking tape

Can I bill for the tape as a complex treatment device?

Rectal balloon prostate immobilization device NIB Inflation device Inflatable balloon Adjustable depth stop Vent Rectal balloon prostate immobilization device Depth gauge This is a customizable complex immobilization device, but it cannot be billed daily by the physician for each new device used. Hospitals may be able to bill a supply code daily for the device. Some physicians are generating a comprehensive 5 day report and billing the use of these devices (77334) on a weekly basis

NIB Typical narrative report for the daily use of rectal balloon prostate immobilization devices, bill as 77334 one time every 5 uses, documentation required, may not be paid by Medicare, CHECK YOUR LCD

Aquaplast Face Mask 50 77334 119/150

ACCUFORM IMMOBILIZATION DEVICE 51 BILL AS 77334 in addition to the Aquaplast face mask

43 For private pay or commercial insurance plans, the code 77334 per fluence may still be valid. Basic Dosimetry 77300 may still be billed one per fluence. CHECK YOUR LCD

52 Conventional Treatment Compensator 77334 documented by a physics report

44 For Medicare and most insurance, you must report IMRT blocking as 77338, one time per IMRT treatment plan, the basic Dosimetry 77300 may still be billed per fluence

49 Alpha Cradle 77334 CCN Page 211 – Figure 12.33A 2002

Multiple complex treatment devices 47 Multiple complex treatment devices 107/150

Custom Immobilization Device NIB Custom Immobilization Device 77334 Tumor volume Device Tongue Fixation/Immobilization device fabricated to separate the tongue from a lesion in the palate

Continuing Quality Assurance 58 Continuing Quality Assurance Machine calibration (usually done monthly) Interlock checks (usually done monthly) Source verification (usually done weekly or monthly) General radiation safety issues

This report may be billed as a special physics consultation 77370 64 This report may be billed as a special physics consultation 77370