1. Section 6 Clinical Treatment Planning For External Beam, Brachytherapy & Hyperthermia Modified for Modified for 04-10-14 40 031314 1:30 to 2:00 PM Carl R Bogardus, Jr MD

2. The Physician’s Clinical Treatment Plan is the single most important document in the clinical record 1

3. THE CLINICAL TREATMENT PLAN u It is here that the Physician describes in detail the plan of therapy. u The plan lays out the initial logic of the proposed course of treatment. 1

4. Description The clinical treatment planning process is a comprehensive cognitive effort performed by the radiation oncologist for every patient. The clinical treatment planning process is a comprehensive cognitive effort performed by the radiation oncologist for every patient. This is a professional service of the physician performed at the beginning of a course of radiation therapy. This is a professional service of the physician performed at the beginning of a course of radiation therapy. 1

5. The course of therapy should be planned as completely as possible before the first treatment is delivered. 2

6. Multiple types of clinical treatment plan formats are available depending upon the proposed mode of therapy to be planned NIB Each of these has an entirely different set of questions to be answered

7. It must be understood that treatment planning is usually a one-time charge per course of therapy. CPT does not allow the flexibility of reporting multiple treatment plans for a single course of treatment unless a major change in the course of therapy has occurred. If the patient develops a new problem, AND A NEW ICD-9 CODE IS NEEDED, then, a new or modified course of radiation therapy will be required, and a new treatment planning code may be reported at that time. 3

8. Second Clinical Treatment Plan Warning

9. The original plan may be modified as the course of therapy progresses and the patient’s condition changes 4

10. Occasionally the clinical treatment plan will be modified more than one time. Each modification may change the intent of the plan but is not a billable event.4

11. Occasionally the entire intent of the plan must be changed, still use the addendum format.4

12. . If a change is made in the physicians clinical treatment plan is often a very good idea to also include a note in the weekly progress note outlining that these changes have occurred. 4

13. Additional clinical Treatment Plans u Absolute CCI edits will prohibit payment for additional plans. u Multiple plans may be required if different modalities are being utilized such as a mixture of photons and electrons. u The physician must establish medical necessity for any additional plans. u Payment may still be denied. 4

14. Documentation Requirements  Definition of the field of treatment  Selection of the beam energy to be used  Selection, or combination, of treatment modalities  Identification of the tumor volume  Identification of critical structures  An indication of the time/dose plan of therapy  An indication of the estimated final target dosage  An indication of any limiting dosages or dose points Documentation must be maintained in the patient’s medical record to include evidence of the planning process covering, but not limited to: Documentation must be maintained in the patient’s medical record to include evidence of the planning process covering, but not limited to: 4-5

15. RATE OF OCCURRENCE u 77261 Simple 3% u 77262 Intermediate 1% u 77263 Complex 96% 6

16. CPT Codes 77261 - Therapeutic Radiology Treatment Planning; Simple 77262 - Therapeutic Radiology Treatment Planning; Intermediate 77263 - Therapeutic Radiology Treatment Planning; Complex 5 CODES 77261 – 77263 ARE PROFESSIONAL CODES ONLY

17. Basic Definitions as Published in CPT 2009 77261Simple Treatment Planning A few advanced disease treatment situations will fall within the category of simple treatment planning: Small, single ports with simple or no blocking on a patient with a relatively uncomplicated history Many benign disease treatments. 6

18. - Clinical Case - Carcinoma of the breast with bone metastasis. This patient was initially diagnosed four years ago with a carcinoma of the breast. The patient underwent a radical mastectomy followed by multi-drug chemotherapy. A bone scan showed metastatic disease in the T1-T2 area. She was treated with radiation therapy and had a good response. She now returns with a painful lumbar spine with a positive MRI scan. 7

19. Metastatic disease to the lumbar spine 7

20. NIB

21. CCN Page 121 – Figure 10.01B 2002 Simple treatment planning case NIB

22. Simple Plan 77261 7

23. Basic Definitions as Published in CPT 2009 77262Intermediate Treatment Planning Two separate treatment areas Patients with bone metastasis in two different sites, bone and brain metastasis Uncomplicated lung cancer, whole pelvis irradiation or other uncomplicated situations Simple parallel opposed portals 8

24. - Clinical Case - 62-year-old female, twenty years post-menopausal. Patient recently had a D & C, which showed adenocarcinoma of the endometrium with involvement of 2/3 of the wall of the uterus. She is now post-hysterectomy and is being planned for radiation therapy to the whole pelvis. 8

25. The treatment planning will be at the intermediate level. There are two sets of intermediate blocks, the AP/PA and laterals. 77262 8

26. Basic Definitions 77263Complex Treatment Planning The patient may have early or advanced disease, which is complex in its distribution. The treatment volume may contain multiple critical structures that may require planning of special protection. Brachytherapy hyperthermia, chemotherapy, or surgery, may be planned. Three or more areas may require treatment. 9 20/40

27. - Clinical Case - 53-year-old male with a diagnosis of a primary brain tumor, a Glioblastoma multiforme. Recently operated by the neurosurgeon with subtotal removal of the primary tumor. The patient is now being seen in Radiation Oncology to be treated postoperatively with IMRT to the high risk area in an attempt to prevent recurrence. 9

28. The location in the brain, and the use of complex IMRT treatment makes this a very complex treatment plan. 9

29. - Clinical Case - 53-year-old female with Stage IV carcinoma of the breast, post chemotherapy. Collapse of T5 due to metastatic disease. Patient now being treated with Taxol. Patient cautioned regarding cross toxicity of treatment with concurrent chemotherapy. 10

30. Complex treatment planning case CCN Page 125 – Figure 10.05 2002 There may be special circumstances where relatively simple treatment may become complex due to the proximity of critical structures, previous treatment fields, chemotherapy, or other situations. These cases require very thorough documentation as to reason and benefit. 10 The concurrent use of chemotherapy drives the treatment planning to the complex level.

31. Historical Background The definitions for simple, intermediate, and complex treatment planning, dosimetry, simulation, and treatment delivery slowly evolved over the years from the first mention in AMA/CPT for radiation therapy in the early 1970's. The ACR/ASTRO User's Guide for 2007 continued to expand and change the definitions of simple, intermediate, and complex until today the literal interpretation of these definitions can place over 95% of all radiation therapy procedures at the complex level. 12 25/40

32. Assignment of the level of treatment planning should not be done until the physician has fully described all of the parameters of the case. The treatment plan complexity level must be set, dated, and billed prior to the first day of treatment. 12

33. Definitions The assignment of the correct CPT Code for all radiation oncology procedures depends not only upon the primary factors relating to that procedure, but the complex interrelationship with other procedures performed before, during, or afterwards. This protocol will allow you to weigh all of these factors and arrive at the correct level of complexity assignment. ONCOCHART performs this function automatically. 13

34. Scoring Treatment Planning These factors form the foundation of a simple plan. An intermediate group of factors have a higher level of intensity and may require more than one to allow the appropriate elevation of complexity to the intermediate level. There are other factors that carry enough time and work requirements to bring planning into the complex realm. There are basic factors that must always be present in treatment planning: 13-14

35. Start the scoring process at the complex level. If any of these items are found, then the score is complex. If none are found, then look in the intermediate group. If none found here, the score will be simple by default as there will always be one or more of the simple items needed for treatment. 13

36. Scoring Clinical Treatment Planning Complex Factors; If any of these factors are found, Clinical, treatment planning will be scored as 77263 Intermediate Factors; If any of these factors are found, clinical treatment planning will be scored as intermediate, 77262. Minor or Simple Factors; If any or all of these factors are found, clinical treatment planning will be scored as simple 77261 13-14

37. This is a typical radiation oncology prescription form developed by a NCI panel in 1970 and still used today in some Centers and hospitals. For clinical conventional treatment planning, the basic questions don’t change 15

38. ARIA-VARIANPHYSICIAN’STREATMENTPLANNINGDOCUMENT NOTE THE SAME SET OF QUESTIONS BEING ASKED 17

39. ONCOCHART Treatment Planning SAME QUESTIONS, DIFFERENT FORMAT 17

40. A Treatment Planning Narrative Should be created To Complement the fill-out Document for completeness. Note the use of Chemotherapy as well as IMRT. 19 77263

41. Clinical Treatment Planning What’s it for? The process utilized by the physician while developing a plan of care. Who normally documents these codes? The Physician must produce a written document When are these codes normally billed? When the prescription for treatment is written prior to the start of treatment. What Documentation is suggested for this code? A written plan or filled out prescription form What are the common errors identified with these codes? Inadequate documentation, Wrong level of complexity for the service documented, Incorrect date of service, Multiple billing of this one time per course of therapy code. 19 40/40

42. PRINCIPLES OF BILLING, CODING AND COMPLIANCE IN RADIATION ONCOLOGY BMSi 2014 END SECT 6

43. End Section 6

45. CCN Page 122 – Figure 10.02 2002 The treatment planning will be at the intermediate level. There are two sets of intermediate blocks, the AP/PA and laterals. Four-port whole pelvis 7

46. Complex Factors Planning for IMRT, 3-D, or mixed beams. Need for PET, MRI, or angiography for planning. Three or more volumes to be planned Moving portals, arcs. Conformal collimation planned Conformal shaped treatment blocks may be planned to more than four ports Conformal MLC blocking Five or more ports planned for a single volume Custom blocked, primary treatment with electrons One or more complex isodose curves required to plan the course of treatment Use of brachytherapy is planned Chemotherapy administered within the three months prior to starting treatment Concurrent chemotherapy planned with the course of treatment Re-treatment of a previous radiation therapy field must be considered 14

47. Intermediate Factors Two separate areas or volumes to be planned for treatment Custom blocking for relatively simple treatment Intermediate MLC blocking Four or fewer ports per single volume of treatment to be planned The physician must consider the consequences of treating sensitive structures Simple immobilization devices may be required Simple isodose curve to be planned The patient may be preoperative or postoperative Microdosimetry, TLD, diode, etc., planned Wedge or compensator to be planned for relatively simple treatment Custom designed bolus to be planned for relatively simple treatment Use of electrons planned as part of course of treatment 15

48. Minor or Simple Factors Single area or volume to be planned for treatment Simple or no blocking or bolus to be planned Simple MLC Blocking No special testing required. Use of a single port or simple parallel opposed ports Simple, unblocked electron port for small skin lesion X-ray photons, any energy, cobalt 60 teletherapy, kilovoltage, any energy A single central axis dose point is all that is required 15

49. This will be afternoon session covering section 6, 5, and 9 Dr Bogardus Scott Simmons Susan Vannoni THIS SCHEDULE MAY BE MODIFIED DEPENDING UPON SPEAKER AVAILABILITY

50. PRINCIPLES OF BILLING, CODING AND COMPLIANCE IN RADIATION ONCOLOGY BMSi 2013 END SECT 6 Next Session at 1:30 to 3:00 Section #5 E/M Codes Section #5 E/M Codes