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Code This!

Scenario Week of August 16, 2010:
View Current Scenario

Day One
The patient is a 69-year-old female diagnosed with right lower-outer quadrant breast cancer, post lumpectomy. After initial consultation, the decision was made to treat via mammosite application BID for duration of 5 days and a total of 10 treatments. Due to the complexity of brachytherapy delivery, the physician will spend additional time planning treatment. The patient was brought to the CT simulator and was placed in the supine position. After appropriate set up position was determined, marks were made on the skin to define the superior and inferior border of the treatment field. Immobilization device included a breast board. The brachytherapy ribbon with dummy seeds was inserted in the catheter.

CT scan was obtained to acquire anatomic information regarding the location of the lumpectomy site, patient contour, and critical structures. The procedure was completed without complications and the patient was scheduled for treatment starting tomorrow.

Day Two
Patient presented for first treatment this morning. A simulation of mammosite treatment of the right breast was performed. Dummy seeds were inserted into the catheter and CT guidance was utilized to confirm size and balloon configuration. A complex brachytherapy isodose plan was generated and checked by physics staff. A confirmatory calculation was completed. The patient was transported to the high dose rate (HDR) brachytherapy suite. The catheter was attached and the first application was completed.

Patient presented for second treatment this afternoon, six hours after completion of morning application. A simulation of the right breast was performed. Dummy seeds were inserted into the catheter and CT guidance was utilized to confirm size and balloon configuration. A confirmatory calculation was performed. The patient was transported to the HDR suite. The catheter was attached and the second application was completed.

Day Three
Patient presented for third treatment this morning. A simulation of the right breast was performed. Dummy seeds were inserted into the catheter and CT guidance was utilized to confirm size and balloon configuration. A confirmatory calculation was completed. The patient was transported to the HDR suite. The catheter was attached and the third application was completed.

Patient presented for fourth treatment this afternoon, six hours after completion of morning application. A simulation of the right breast was performed. Dummy seeds were inserted into the catheter and CT guidance was utilized to confirm size and balloon configuration. A confirmatory calculation was performed. The patient was transported to the HDR suite. The catheter was attached and the fourth application was completed.

Day Four
Patient presented for fifth treatment this morning. A simulation of the right breast was performed. Dummy seeds were inserted into the catheter and CT guidance was utilized to confirm size and balloon configuration. A confirmatory calculation was completed. The patient was transported to the HDR suite. The catheter was attached and the fifth application was completed.

Patient presented for sixth treatment this afternoon, six hours after completion of morning application. A simulation of the right breast was performed. Dummy seeds were inserted into the catheter and CT guidance was utilized to confirm size and balloon configuration. A confirmatory calculation was performed. The patient was transported to the HDR suite. The catheter was attached and the sixth application was completed.

Day Five
Patient presented for seventh treatment this morning. A simulation of the right breast was performed. Dummy seeds were inserted into the catheter and CT guidance was utilized to confirm size and balloon configuration. A confirmatory calculation was completed. The patient was transported to the HDR suite. The catheter was attached and the seventh application was completed.

Patient presented for eighth treatment this afternoon, six hours after completion of morning application. A simulation of the right breast was performed. Dummy seeds were inserted into the catheter and CT guidance was utilized to confirm size and balloon configuration. A confirmatory calculation was performed. The patient was transported to the HDR suite. The catheter was attached and the eighth application was completed.

Day Six
Patient presented for ninth treatment this morning. A simulation of the right breast was performed. Dummy seeds were inserted into the catheter and CT guidance was utilized to confirm size and balloon configuration. A confirmatory calculation was completed. The patient was transported to the HDR suite. The catheter was attached and the ninth application was completed.

Patient presented for tenth treatment this afternoon, six hours after completion of morning application. A simulation of the right breast was performed. Dummy seeds were inserted into the catheter and CT guidance was utilized to confirm size and balloon configuration. A confirmatory calculation was performed. The patient was transported to the HDR suite. The catheter was attached and the tenth application was completed.


ANSWERS
Diagnosis Codes
174.5 Malignant neoplasm of female breast, lower-outer quadrant

CPT Codes
Day One: 77263, 77290, 77014, 77332, 77470
Day Two: Morning –77280, 77014, 77300, 77326, 77785 Afternoon – 77785/76, 77300/76
Day Three: Morning – 77280, 77014, 77300, 77785 Afternoon – 77785/76, 77300/76
Day Four: Morning – 77280, 77014, 77300, 77785, 77427 Afternoon – 77785/76, 77300/76
Day Five: Morning – 77280, 77014, 77300, 77785 Afternoon – 77785/76, 77300/76
Day Six: Morning – 77280, 77014, 77300, 77785 Afternoon – 77785/76, 77300/76, 77427

Rationale

Day One — set up
77263 Therapeutic radiology treatment planning; complex CMS instructions indicate that brachytherapy typically falls under the complex plan due to the volume design, dose levels, and detailed fractionation.

77290 Therapeutic radiology simulation-aided field setting; complex Initial simulation is utilized for planning and determining position for treatment delivery. CPT Assistant indicates brachytherapy simulation is the complex process of making position adjustments and for performing dose calculations.

77014 Computed tomography guidance for placement of radiation therapy fields A treatment planning CT scan is performed to assist with simulation and treatment planning and is reportable based on this definition.

77332 Treatment devices, design and construction; simple The breastboard qualifies as a simple treatment device because it is reusable and not custom made for the individual patient. It is utilized to immobilize the patient and assist in consistent positioning throughout the course of treatment.

77470 Special treatment procedure This is reportable when the physician documents the extra time required to plan brachytherapy treatment delivery.

Day Two through Day Six — treatment
77280 Therapeutic radiology simulation-aided field setting; simple A simple simulation is performed prior to each treatment delivery to verify catheter placement as indicated by CMS. However, most carriers will only reimburse one simple simulation per day even though documentation will indicate the service was provided twice per day with each treatment session.

77014 Computed tomography guidance for placement of radiation therapy fields CT scan is performed to assist with simulation and treatment planning and is reportable based on this definition.

77300 Basic radiation dosimetry calculation Brachytherapy requires a dosimetry calculation to establish duration of radiation implant during the course of therapy and this may very from day to day and even treatment to treatment. In order to bill multiple calculations, documentation should support medical necessity. CPT Assistant indicates this code may be reported any time during a course of radiation therapy in which a calculation is done, as many times as necessary. As mammosite is typically performed twice a day with a significant break between treatments, it is necessary to append modifier 76 Repeat procedure or service by same physician, to the second calculation.

77326 Brachytherapy isodose plan; simple CPT indicates this code is reported when calculation is made from single plan, 1 to 4 sources/ribbon application, remote afterloading brachytherapy, 1 to 8 sources.

77785 Remote afterloading high dose rate radionuclide brachytherapy; 1 channel CPT Assistant indicates this code selection is based on the number of catheters implanted in the patient for delivery of radiation and, in the case of mammosite therapy, one catheter is utilized which equates to one channel. Furthermore, this code is reportable each time treatment is delivered. While there are no global days indicated for this code, it may be necessary to append a 76 modifier to indicate repeat procedure on the same day to avoid duplicate denials, and further investigation may be required to determine how a specific carrier will accept this billing.

77427 Radiation treatment management, 5 treatments This code is reported by the physician for every fifth treatment during therapy. It encompasses the review of CT and/or port films as well as set up verifications, dose delivery, treatment field, and overall evaluation of the patient as described in CPT.

 
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