July 21, 2021
Radiation Therapy Billing FAQ: Part Three

This is the third post in our Radiation Therapy Billing FAQ Series. Billing is an essential function in radiation therapy departments but can be challenging for any clinician. Certain codes can be interpreted in various ways and insurance companies often have different acceptance criteria. To help alleviate anxiety around the topic, we’ve answered a few frequently asked questions. The information contained in these responses can be found in greater detail through a variety of billing references, such as ASTRO and Coding Strategies.

The opinions stated here reflect those of employees at Radformation based on coding experience and available resources. These opinions are based on commonly used references, and Radformation makes no formal recommendations on how departments execute their billing. Check with your local insurance payers before deciding on the appropriateness of coding for any procedure codes. Radformation (or its employees or agents) shall bear no liability for any claims made arising from the use of the following opinions.

1. What work should go into a verification simulation?

A verification simulation is a procedure in which the patient returns to the department to verify treatment position and field blocking parameters through a “dry-run” prior to the start of treatment delivery. As of January 1, 2017, verification simulations are only billable when performed with teletherapy isodose and 3D plans and are not permitted with IMRT treatment plans (NCCI Policy Manual, Chapter 9). The verification simulation ensures the initial simulation position and treatment plan can be carried out accurately and safely before the delivery of radiation doses. A physician must specifically order this service to bill for a verification simulation, typically before or at the time of initial CT simulation.

During verification simulation, the treatment target and isocenter are localized and verified through imaging. Any imaging acquired during verification simulation is included in the verification simulation code and should not be billed separately. Regardless of the complexity or type of imaging acquired, verification simulations are coded as CPT 77280. In addition to target and isocenter verification, a verification simulation is used to ensure treatment field blocking created during planning is appropriate. There must be a QA of all beam modifying devices, typically done by imaging the treatment fields with MLC or blocks on the patient at the treatment isocenter location. If some fields cannot be imaged with beam modifying devices, physician review of the blocking on the patient may be appropriate if documented appropriately. All images and verification simulation documentation should be reviewed and approved by the radiation oncologist prior to the start of the treatment.

2. Can IGRT be charged if the patient came on a day prior to the first fraction for imaging but a verification simulation wasn’t performed?

Image-guided radiation therapy (IGRT) is the process of imaging the patient to determine if any changes or positional adjustments are needed prior to but in conjunction with radiation treatment delivery. If imaging is performed on a day prior to the start of treatment delivery and a verification simulation was not ordered and performed, IGRT is not billable.

3. Are single image x-rays considered IGRT?

Several imaging techniques may be used when performing IGRT, including stereoscopic X-ray guidance using kilovoltage (kV) or megavoltage (MV) imaging systems. X-ray pairs are acquired at the treatment machine and compared to treatment plan digitally reconstructed radiographs (DRRs) utilizing specialized software as a part of a 2D/2D match. By overlaying the captured and planned images within the software, correct patient positioning in relation to the treatment isocenter can be determined. Typically, pairs of X-ray images are acquired, preferably orthogonal as recommended by the ACR and ASTRO, in order to determine the longitudinal, lateral, and vertical treatment table shifts for isocenter placement. Obtaining a single X-ray image does not allow for a 2D/2D X-ray match and therefore does not meet the standards of IGRT. If the standards for IGRT are not met, a portal image charge CPT 77417 may be captured if previously ordered by a physician; however, portal images CPT 77417 may only be captured once per five treatments and cannot be captured on a daily basis.

4. Should CPT 77014 be used for patient simulations?

CT image acquisition for treatment planning CPT 77014 can no longer be billed separately when performed at the time of patient simulation, effective January 1, 2014. This service is now bundled in simulation codes CPT 77280-77290. However, code CPT 77014 was not deleted and continues to be a valid code for IGRT CBCT at the time of treatment delivery.

5. How should optical surface monitoring be handled when performed with IGRT?

The popularity of optical surface monitoring has been increasing in recent years. This newer technology monitors a patient’s positioning before and during treatment using special cameras to render a real-time 3D image of the patient. This rendered patient image is compared to a baseline image to ensure treatment delivery accuracy. It is common to perform optical surface monitoring in combination with other forms of IGRT, such as X-ray pairs or a cone-beam CT.

When coding for optical surface monitoring in a hospital setting, CPT 77387 should be used to reimburse the technical component to the hospital with 3D treatments only. Physicians in the hospital settings should use HCPCS G6017 with a modifier 26 for the professional component for both 3D and IMRT treatments. In the freestanding facility, only HCPCS G6017 should be used for both professional and technical components. If multiple forms of IGRT are performed during any given fraction, each form is not separately reimbursable. IGRT codes, including optical surface monitoring, should not be billed with SRS or SBRT service as they are already bundled into the treatment delivery codes.

written by Katera Smith
Radformation’s Billing Efficiency Expert Katera Smith has two decades of healthcare experience in radiation oncology and radiology. Katera began her career as a radiation therapist and a vendor application trainer, and later parlayed her clinical experience as a Billing Manager for nearly five years in Greensboro, North Carolina. She is a radiation oncology certified coder through the American Medical Accounting and Consulting group.

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