Transcript SECTION 08 DOSI BLOCKS ISODOSE 03-22-13

Section 8
Radiation Oncology Dosimetry
CPT Codes 77300 - 77370
Susan Vannoni
3:15 to 4:00 PM Section #8
031314
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Modified For 04-10-14
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
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Occurrence Rate 2013
 77300
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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
Only one 77300 may be charged
for the required two
independent means of
calculating the basic dosimetry.
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NIB
Computer calculations (Varis/Aria)
5
MU CHECK IS COMPUTER GENERATED, BUT IS
CONSIDERED A SECOND (HAND) DOSE
CALCULATION
Documentation Requirements
•
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
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Basic Dosimetry Calculations 77300
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
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Treatment Planning CT Scan
and Isodose plans
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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.
Teletherapy Isodose Plan(s)
77305 - Simple Isodose Plan
77310 - Intermediate Isodose Plan
77315 - Complex Isodose Plan
77305 – 77315 ARE GLOBAL BILLING CODES
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TWO FORMATS OF ISODOSE DISPLAY
COLOR WASH DOSE PATTERN
Hot, red, colors are higher dose,
with blue and green lower dose
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ISODOSE DOSE LINE PATTERN,
each line indicates a boundary
of dose, graduating out from the
central highest dose
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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.
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.
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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
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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.
Special Beam Plan 77321
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• 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
IB
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Isodose Plan may be Needed for Electron Treatment
77315
77321
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Electron
boost port
77321
Post operative
Parotid tumor
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Electron boost to breast
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Typical
basal cell
carcinoma
of the tip of
the nose
treated
with
electrons
Coding Guidelines Electrons 77321
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• 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
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A specific report is not required by Medicare, however it
will help in the documentation and justification of
ONCOCHART
electron usage (RAC 2011)
Special Beam 77321
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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.
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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
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• 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
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Special Dosimetry 77331
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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.
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TREATMENT
DEVICES
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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
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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.
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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
80/150
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Bolus
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• 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
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77333 Intermediate Treatment Devices
Treatment Devices, design,
construction or selection;
Intermediate (more than one area
of port blocked - blocks, stints,
bite blocks, special bolus)
•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
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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)
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Custom Stint 77334
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BILL AS
77334
A custom stint is being used to distance the electron
treatment port away from the underlying gum
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MULTIPLE
SIMPLE
SKIN
LESIONS
This case has 3 or more sites;
1= Simple
2= Intermediate
3+= Complex
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
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77334 Complex Treatment Devices
Complex treatment device
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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.
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
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Eye Shields 77334
An eye shield is a complex
multi-use device.
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Its application is highly
complex and precise.
The radiation Oncologist
must clinically place this
eye shield with
each treatment.
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)
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Vacuum Bags 77334
Bead filled vacuum
bags are complex
multi-use devices.
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Each vacuum bag is utilized only for a single
patient throughout the entire course of therapy.
Breast Board
BILL AS
77332
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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.
COMPENSATOR
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• 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.
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REGARDLESS OF
COMPLEXITY OF DESIGN
OR USE, ALL
COMPENSATORS
WILL BE BILLED AS 77334
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CUSTOM COMPENSATOR
FOR TOTAL BODY TREATMENT 77334
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Proton Tissue compensator
77334
NIB
Milled brass proton beam shaping compensator
77334
IMRT COMPENSATOR
77334
NIB
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Rice bolus
Tumor volume
Square tissue compensator to
evenly distribute the dose
over the tumor volume.
Complex compensator, 77334,
in addition to the mask, 77334
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This is the patient 6 months after completion of
radiation therapy to the scalp lesion.
IMRT Compensator Blocking
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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
Regardless of the complexity or design of the
conventional therapy treatment device,
some form of narrative may be required
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Device report for two immobilization
devices, each of these will be billed as
77334, complex device.
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WHEN TO BILL TREATMENT DEVICES
Date
of DESIGN of device
Date of CREATION of device
Date of USE of device
Treatment Devices
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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
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Special Physics CPT Codes
77336 - Continuing Medical Physics Services
77370 - Special Medical Physics Consult
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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.
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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.
77336
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•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
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•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
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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)
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IMRT weekly physics report 77336
CONTINUING PHYSICS WITH
BRACHYTHERAPY
 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.
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Continuing physics report, 77336, for Brachytherapy
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Continuing Medical Physics 77336
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.
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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.
Computerized physician order [CPO]
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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.
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.
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Special Physics Consult
A review of the previous port films from Baptist Hospital show the port extended to the midportion 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
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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 63
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.
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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.
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Bolus Buildup Simple device
NIB
77332 SIMPLE GENERIC DEVICES
PRE MADE CAST ELECTRON BLOCKS
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DIODE
PROBE
MOSFET SOLID
STATE
DOSIMETER
SINGLE USE DEVICE
77331
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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
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Hand held
wand
Reader
circuit
Antenna
Passive solid
State circuit
Mosfet
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77421
Stereoscopic
localization,
report daily for
IGRT
77331
Special
Dosimetry, can
report cumulative
dose, per
dosimeter
EACH OF THESE PROCEDURES REQUIRES A SEPARATE REPORT
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Mosfet implanted
dosimeter/marker
report for micro
dosimetry
Two versions
of report,
narrative
and brief
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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.
60/150
Record and verify is part of standard
quality assurance and carries no
reimbursable component.
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 retreat 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.
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
45
NIB
The most common immobilization device in
1970 was 3-M masking tape
NIB
Can I bill for the tape as a complex treatment device?
NIB
Inflation device
Inflatable balloon
Depth gauge
Adjustable depth stop
Vent
Rectal balloon prostate
immobilization device
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
77334
119/150
50
ACCUFORM IMMOBILIZATION DEVICE
BILL AS 77334
in addition to
the Aquaplast
face mask
51
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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
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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
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Alpha Cradle
77334
CCN
Page 211 – Figure 12.33A
2002
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Multiple complex treatment devices
107/150
77334
Custom Immobilization Device NIB
Tumor volume
Device
Tongue
Fixation/Immobilization device
fabricated to separate the tongue from a
lesion in the palate
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
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This report may be billed as a special physics consultation 77370