Complex 2015 Changes to Radiation Oncology Coding

Complex 2015 Changes to Radiation Oncology Coding

The Centers for Medicare & Medicaid Services (CMS) issued its Final Rule on October 31 outlining the codes it would recognize in calendar year (CY) 2015. The radiation treatment delivery services were among the changes and were revised to include the addition and deletion of several codes. Given the large scale of the changes in the context of CMS’ upcoming revised process for valuing new, revised, and potentially misvalued codes, CMS decided it would hold off on valuation of the new treatment delivery codes until 2016. Therefore, CMS established HCPCS Level II “G” codes for use in 2015 to describe these procedures. It remains unclear whether or not private payers will accept the new G codes put forth by CMS. Therefore, each payer should be contacted prior to implementation to confirm that their system will accept the new G codes.

Confusion may arise from the fact that the new G codes are recognized under the Medicare Physician Fee Schedule (MPFS), but they are not recognized under the Hospital Outpatient Prospective Payment System (HOPPS). Questions have been raised on which CPT codes to report in the hospital setting versus office setting in 2015. Moreover, there may be confusion about which CPT codes are used to describe the professional component (PC) for physician work in the office versus hospital.

The following provides background on the reason for changes, as well as easy-to-follow tables which detail how to code in the hospital versus office settings for 2015.

Rationale for CPT Code Changes

Several issues required CPT clarification as clinical practice has evolved. Three new codes (77385, 77386, 77387) were created to report intensity modulated radiation treatment delivery and image-guided radiation therapy services, and to clarify which codes contain the technical component, professional component or both. The fourteen current codes that describe ultrasound guidance (76950), radiation treatment delivery (77403, 77404, 77406, 77408, 77409, 77411, 77413, 77414, 77416, 77418, 77421), and Category III codes 0073T and 0197T will be deleted. Revision of the guidelines and editorial revision of the radiation treatment delivery codes 77401, 77402, 77407, 77412 also will be made.

Radiation Treatment Delivery

The treatment delivery codes recognize technical-only services (no professional component) that may only be reported once per treatment session. The levels of complexity for radiation treatment delivery with conventional X-ray or electron beams are assigned based on the number of treatment sites and complexity of the treatment fields, blocking, wedges, and physical or virtual tissue compensators. Please reference the new extensive introductory notes in the CPT® 2015 Professional Edition codebook [pp. 437-438] regarding the Radiation Treatment Delivery codes for more detailed guidance on the use of these codes.

While “G” codes G6001-G6017 will be recognized under the MPFS, the CPT codes 77402, 77407 and 77412 will be recognized under OPPS and assigned to the CY2014 ambulatory payment classification (APC) group to describe these technical only procedures in the hospital setting. As noted in the following table, the temporary HCPCS Level II G codes created by CMS are differentiated by the type of procedure performed as is currently described by the 2014 CPT codes.

Table: Reporting of Technical Only Radiation Treatment Delivery Codes Crosswalk 2014 CPT Code

for Both Hospital and Office

2015 CPT/HCPCS Code MPFS (e.g., only Office)*

2015 CPT Code

HOPPS (only Hospital)

Radiation treatment delivery, superficial and/or ortho voltage

delivery, superficial and/or ortho voltage, per day

77402 Revised Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks; up to 5 MeV

G6003

Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks: up to 5 MeV

77402

Radiation treatment delivery, >1 MeV;** Simple 77403 Deleted 6-10 MeV G6004 6-10 MeV Use 77402 77404 Deleted 11-19 MeV G6005 11-19 MeV Use 77402 77406 Deleted 20 MeV or greater G6006 20 MeV or greater Use 77402 77407 Revised Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks; up to 5 MeV

G6007

Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks:

up to 5 MeV

77407

Radiation treatment delivery, >1 MeV;** Intermediate 77408 Deleted 6-10 MeV G6008 6-10 MeV Use 77407 77409 Deleted 11-19 MeV G6009 11-19 MeV Use 77407 77411 Deleted 20 MeV or greater G6010 20 MeV or greater Use 77407 77412 Revised Radiation treatment

delivery,3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; up to 5mev G6011 Radiation treatment delivery,3 or more

separate treatment areas, custom blocking,

tangential ports, wedges, rotational beam,

compensators, electron beam;

up to 5mev

77412

Radiation treatment delivery, >1 MeV;** Complex 77413 Deleted 6-10 MeV G6012 6-10 MeV Use 77412

77414 Deleted 11-19 MeV G6013 11-19 MeV Use 77412 77416 Deleted 20 MeV or greater G6014 20 MeV or greater Use 77412

*Source: See Medicare Physician Fee Schedule Final Rule, Table 27. Radiation Therapy G-Codes Replacing CY 2015 CPT Codes

**The CPT® 2015 code book lists the “greater than” (>) symbol instead of the “greater than or equal to” (>) symbol for codes 77402, 77407, and 77412. The AMA Errata web site notes the correction of this error.

Do not report 77402, 77407, 77412 in conjunction with 77373, Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions.

Intensity-Modulated Radiation Therapy (IMRT) Delivery

(includes image guidance and tracking (IGRT))

Code 77418, IMRT, and 0073T, compensator-based IMRT, will be discontinued in 2015. While the newly created G6015 and G6016 codes are recognized for payment under the MPFS, they are not recognized under OPPS. OPPS will recognize the newly created CPT codes 77385 and 77386.

Codes 77385 and 77386 are new codes with substantial revision to the code descriptor. Codes 77385 and 77386 are assigned an interim APC. Comments will be accepted on the interim APC assignment for these new codes. Payment is made under OPPS.

Table: Intensity Modulated Radiation Treatment (IMRT) Delivery Coding 2014 CPT Codes 2015 HCPCS Codes for

Office TC (per MPFS)

2015 CPT for Hospital TC (per HOPPS)

77418 - Deleted IMRT

G6015

IMRT, single or multiple fields/arcs, via narrow spatially and temporally modulated beams, binary, dynamic MLC, per

treatment session

77385

IMRT simple (breast, prostate, compensator) (IMRT), includes

guidance and tracking, when performed; simple 77386 IMRT complex 0073T - Deleted Compensator-based IMRT G6016 Compensator-based beam modulation treatment delivery of inverse planned treatment using 3 or more high resolution (milled or cast) compensator, convergent beam modulated fields, per treatment session

77385

IMRT simple (breast, prostate, compensator) (IMRT), includes

guidance and tracking, when performed; simple

Due to the bundling of image-guided radiation therapy (IGRT) into intensity modulated radiation therapy (IMRT) in 2015, only report the technical component of IGRT for non-IMRT (i.e., do not bill the technical component with IMRT, stereotactic radiosurgery (SRS), or stereotactic body radiation therapy (SBRT)). Guidance codes 76950, 77421 and 0197T will be deleted in 2015. Physician reporting for the

professional component of IGRT is allowable when performed in conjunction with both IMRT and conventional radiation therapy. As noted in the CPT 2015 Professional Edition codebook introductory notes, p. 438, only the technical portion of IGRT is bundled into IMRT. The physician involvement in guidance or tracking may be reported separately. When guidance is required with conventional radiation treatment delivery, both the professional and technical components are reported because neither component of guidance is bundled into conventional radiation treatment delivery services. Table: Image Guidance Codes

2014 CPT code 2015 CPT/HCPCS Code Technical Component MPFS (eg Office) (NOT w/IMRT) 2015 CPT Code Technical Component HOPPS (Hospital) (NOT w/IMRT)* 2015 CPT/HCPCS Code Professional Component MPFS

(Hospital and Office) (can be billed w/IMRT) 76950 – Deleted US guidance G6001 77387-TC G6001 77421 – Deleted Stereoscopic x-ray guidance G6002 77387-TC G6002 0197T – Deleted intra-fraction guidance G6017 77387-TC G6017 77014 CT guidance NOT DELETED 77014 77387-TC 77014**

*No separate payment for IGRT technical component under HOPPS.

**Code 77014 payment is packaged into payment for other services. Therefore, there is no separate APC payment for 77014.

Note that 77014 is still used for charging for CT guidance for PC in the hospital setting and both TC and PC in the office setting. However, 77014 should not be used for TC of CT image guidance in the hospital. Therefore, a hospital will use code 77387 for TC and a physician will use code 77014 for the same CT image guidance procedure. See also the Radiation Management and Treatment Table in the CPT 2015 Professional Edition code book, p. 440, which shows when IGRT is included in the technical and

professional components.

Do not report the technical component [TC] of image guidance with IMRT, SRS or SBRT (77385, 77386, 77371, 77372, 77373). However, the TC of image guidance, when performed, should be reported with conventional delivery of radiation therapy. The professional component (PC) of image guidance may be reported for IMRT and conventional radiation therapy delivery.

Isodose Planning Codes

Teletherapy isodose planning codes 77305-77315 and brachytherapy isodose planning codes 77326-77328, which are frequently reported with the basic radiation dosimetry calculation code 77300, were identified in the codes inherently performed together 75 percent of the time or greater, as the planning codes now universally require performance of dosimetry calculation as an integral part of the procedure. Five new bundled codes (77306, 77307, 77316, 77317, 77318) will be created to reflect the current process of care for teletherapy and brachytherapy isodose planning.

As the new codes now include basic dosimetry calculation(s), code 77300 should not be reported in conjunction with these codes. The current codes77305-77315 and 77327-77328 will be deleted in 2015. The following table provides a summary of the deleted codes, as well as the newly created CPT codes to be used in both the hospital and nonhospital (e.g., office) settings for reporting of the technical component (TC) and professional component (PC).

Table: Facility (Hospital) and NonFacility (NonHospital) TC and PC Isodose Planning CPT Codes 2014 CPT Codes New 2015 CPT Codes*

77305 Deleted

Teletherapy isodose plan; simple

77306

Teletherapy isodose plan; simple (1 or 2 unmodified ports directed to a single area of interest), includes basic dosimetry calculation(s)

77310 Deleted

Teletherapy isodose plan; intermediate

See 77306, 77307

77315 Deleted

Teletherapy isodose plan; complex

77307

complex (multiple treatment areas, tangential ports, the use of wedges, blocking, rotational beam, or special beam considerations), includes basic dosimetry calculation(s)

77326 Deleted

Brachytherapy isodose plan; simple

1-4 sources

**77316

Brachytherapy isodose plan; simple (calculation[s] made from 1 to 4 sources, or remote afterloading brachytherapy, 1 channel), includes basic dosimetry calculation(s)

77327 Deleted

Brachytherapy isodose plan; intermediate

5-10 sources

**77317

intermediate (calculation[s] made from 5 to 10 sources, or remote afterloading brachytherapy, 2-12 channels), includes basic dosimetry calculation(s)

77328 Deleted

Brachytherapy isodose plan; complex

>10 sources

**77318

complex (calculation[s] made from over 10 sources, or remote afterloading brachytherapy, over 12 channels), includes basic dosimetry calculation(s)

*Do not report 77300 (basic calculation) separately for these new codes or 77321, Special teletherapy port plan, for either the TC or PC. Note code 77321 is unchanged for 2015.

** New for 2015 - complexity of a high dose rate (HDR) brachytherapy isodose plan is selected based on number of utilized channels rather than sources. This now matches the current HDR brachytherapy delivery codes.

Look for impact tables and APC assignments for the 2015 radiation oncology code changes to be posted under Advocacy in Action eNews on December 12. Also, be sure to read about the 2015 Final Rule changes and what radiation oncology codes are affected in CMS Notes Further Study Required Before 2015 Proposed Radiation Oncology Changes Made