HEALTH POLICY & ECONOMIC ISSUES Blake Dirksen, MS, Coralville, IA

Properly coding the work performed in radiation oncology is very complicated. It is impossible to cover every clinical scenario or treatment approach in a series of CPT procedure codes. However, it is important that we endeavor to comply with coding rules to ensure fair and stable reimbursement of our services. AAPM works with ACR and ASTRO to manage the CPT code descriptors and assist members on coding issues, including fielding member questions. AAPM Professional Economics Committee felt it would be beneficial to share some of the frequently asked coding questions and our answers.

Often, clinical situations present themselves that are not perfectly described by the existing CPT code set or are subject to payment policies of regional and local payers. In these gray areas, department leadership should evaluate their individual situation to determine department policy.

1. What date should an isodose plan charge be reported?
   The work of developing a treatment plan includes multiple steps and multiple individuals and is typically performed over multiple days. It is not practical or required that the work be performed and documented on the same day.
   It is common within many practices that there will be one date on the document, the medical physicist will sign on another date, and the physician will potentially sign on a third date. It is ASTRO's recommendation (not a requirement) that the charge should be submitted on the date the plan is signed by the physician but what is most important is that the department leadership determine a policy and consistently follow it. For example, medical physics plan review or patient specific IMRT quality assurance (QA), do not have to fall on the day the planning charges are billed. Also, physics plan review and patient specific IMRT QA do not require the direct supervision of a physician.
   It is important that you have a consistent policy developed by your leadership team that puts patient safety first when developing workflows. If you encounter issues with this topic please reach out to AAPM Professional Economics Committee and we will try to assist.
2. We perform diode checks or EPID in vivo dosimetry on the first day of treatment to verify the treatment delivery and machine output. For the calculation associated with this check can we bill a basic radiation dosimetry calculation (CPT 77300) or special dosimetry (77331)? If not, what code would be recommended for this check?
   Measurements obtained for quality assurance purposes are not separately reportable. A special dosimetry charge (CPT 77331) can be used if there is a specific clinical reason other than routine quality assurance for a particular patient case.
3. What day should we bill the weekly chart check? The day of the 5^th fraction or the date we complete the chart check? Do we have to perform the chart check during clinical hours?
   Billing the chart check either weekly or every fifth fraction is acceptable, but it is important to be consistent. For the continuing medical physics consultation (CPT 77336) it is important to note that the work involved covers much more than the weekly chart review. This means that the work performed occurs throughout the week. Therefore, the billing of CPT 77336 is not required to occur on the day of the chart review but can be if that is your department policy. The continuing medical physics consultation charge covers a series of up to five fractions and at least three fractions are required to bill one CPT 77336 code. For example, if a patient has a total of 18 fractions, a maximum of four CPT 77336 codes may be reported. If a patient has 16 fractions, a maximum of three CPT 77336 codes may be reported because the fourth series of treatments includes only one fraction.
   The work of CPT 77336 includes consultation with the physician and communication with the clinical team. The medical physicist should have significant physical presence in the department during the week and ideally when performing the chart review to facilitate communication of issues found or to follow up with questions. It is important that you have a consistent policy developed by your leadership team that puts patient safety first when developing chart review workflows.
4. Can you bill for complex simulation if the patient is getting IMRT treatment? The same question applies to SRS/SBRT.
   You cannot bill a complex simulation code (CPT 77290) as part of the simulation and planning for a course of IMRT treatment. The work of a complex simulation (CPT 77290) is included in the work of the IMRT planning code (CPT 77301).
   You may bill a complex simulation (CPT 77290) for SRS or SBRT if it meets all the criteria of a complex simulation and IMRT planning is not utilized.
5. Can you bill for image fusion?
   Yes, if a medical physicist is directly involved with the image fusion and generates a custom report for each patient case then you may report a special medical radiation physics consultation (CPT 77370).An article outlining what is required to bill a special medical physics consultation code for image fusion was published in the Nov/Dec 2008 AAPM newsletter.
6. Is a medical physicist required to be present at the treatment console during an SBRT or SRS procedure?
   Yes, there are direct practice expense (PE) inputs for medical physics time in the CPT codes for SBRT and SRS treatments, which means the payment rates for SBRT and SRS in the Medicare Physician Fee Schedule include dedicated time from the medical physicist during the procedure.
7. Can you use IMRT for SRS or SBRT planning?
   Yes, the treatment planning codes reported are independent of the treatment delivery codes reported. The treatment planning code that best describes the work performed should be utilized. The same rules for determining if a treatment plan is IMRT or 3D apply regardless of if the technique is SRS, SBRT, or traditional fractionation.

The opinions referenced are those of members of AAPM Professional Economics Committee based on their coding experience and they are provided, without charge, as a service to the profession. They are based on the commonly used codes in radiation oncology, which are not all inclusive. Always check with your local insurance carriers, as policies vary by region. The final decision for coding of any procedure must be made by the physician and/or facility, considering regulations of insurance carriers and any local, state or federal laws that apply to the facility and physicians' practice. Neither AAPM nor any of its officers, directors, agents, employees, committee members or other representatives shall have any liability for any claim, whether founded or unfounded, of any kind whatsoever, including but not limited to any claim for costs and legal fees, arising from the use of these opinions.

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