Radiation oncology is a branch of clinical medicine devoted to the treatment of both malignant and benign disease with ionizing radiation. The radiation oncologist with his team is involved in the evaluation, planning, delivery and follow-up of patients treated with radiation. Radiation oncologists also may use computed tomography (CT) scans, magnetic resonance imaging (MRI), ultrasound, and hyperthermia (heat) as additional interventions to aid in treatment planning and delivery. Are you a Radiation Oncologist and facing issues in billing and coding? Here is the Radiation oncology Billing and Coding Guideline.
Radiation oncology: Reasons for claim denials
Policy Coverage
Performed services for diagnoses are not listed as covered in this policy or for excessive frequency will be denied as not medically necessary. When reason for additional services not justifiable by documentation and excessive frequency when services rendered more frequently than generally accepted by peers.
Freestanding Facility
If a hospital inpatient is transported to a freestanding facility for therapy then the technical component of the radiation oncology services cannot be paid to the freestanding facility. Patient is discharged from the hospital and treated at the freestanding facility as an outpatient then this payment will not be available for reimbursement.
Coverage Indication
Indications are need to be listed as covered under the coverage indications, limitations, and/or medical necessity section otherwise claims will be denied as not medically necessary.
Appeals for Denials
Appeals for denied claims must be supported by that portion of the patient’s medical record that documents the reason for the service. It is not mandatory to provide the complete medical record. Keep a note that all documentation should be specific to the patient being treated or the claim will be denied.
Radiation oncology billing and coding
Course Therapy
In course therapy, treatment planning is a one-time charge. If you are billing for multiple treatment plans for a single course of treatment is not allowed. Physicians hold responsibility for all the technical aspects of the treatment planning process.
CPT code 77261
CPT code 77261 is used when the volume of interest to be treated is clearly defined and easily encompasses the tumor while excluding normal tissue and structures. Simple planning requires a single treatment area of interest encompassed in a single port or simple parallel opposed ports with simple or no blocking.
CPT code 77262
CPT code 77262 is used when there is a moderate level of planning difficulty involved. It requires three (3) or more converging ports, two (2) separate treatment areas, multiple blocks, or special time dose constraints.
CPT code 77263
CPT code 77263 is used when complex treatment planning is involved. Complex planning requires highly complex blocking, custom shielding blocks, tangential ports, special wedges or compensators, three (3) or more separate treatment areas, rotational or special beam considerations, or combination of therapeutic modalities. Complex planning includes interpretation of special testing, tumor localization, treatment volume determination, treatment time/dosage determination, choice of treatment modality, determination of number and size of treatment ports, selection of appropriate treatment devices, and other procedures.
Simulation
Treatment planning which involves simulation is used to actually direct the treatment beams to the specific volume of interest. Simulation may be carried out on a dedicated conventional stimulator or CT scanner, radiation therapy treatment unit or using diagnostic imaging equipment. The difficulty of the simulation is based on number of ports, volumes of interest, and the inclusion and type of treatment devices. The number of films taken per treatment, the modality from which the images for simulation are obtained, and the use of fluoroscopy are not determinants of complexity. Portal changes based on unsatisfactory initial simulation(s) are not reported as additional simulations.
The typical course of radiation therapy will need between one and three simulations. However, you must report a single simulation on any given day. Frequency of excessive of three simulations should be supported by documentation in the medical record.
CPT code 77280
Use CPT code 77280 to report simple simulation of a single treatment area. A treatment area is a contiguous anatomic location that will be treated with radiation therapy. Generally, this includes the primary tumor organ or the resection bed and the draining lymph node chains.
CPT code 77285
Use CPT code 77285 to report intermediate simulation for two (2) separate treatment areas.
CPT code 77290
Use CPT code 77290 to report complex simulation for three (3) or more treatment areas, or any number of treatment areas if any of the following are involved: particle, rotation or arc therapy; complex blocking; custom shielding blocks; brachytherapy simulation; hyperthermia probe, verification; any use of contrast materials.
CPT code 77293
Use CPT code 77293 as an add-on code for respiratory motion management simulation. It describes the physician work and resources involved in acquiring a respiratory correlated or 4-D Ct simulation study for conformal planning. Add-on codes are never performed independently and must be reported in addition to the primary procedure. This code must be reported with the primary procedure of either 77295 or 77301 for the same date of service, even though the work may take place over many days.
Clear and precise understanding of oncology billing and coding is important to get a good reimbursement from the payer. If you need any help for oncology medical billing and coding, you can contact us.
