How ICD-10 Affects Radiation Oncology Presented by, Lashelle Bolton CPC, COC, CPC-I, CPMA
ICD-10 ICD-10-CM has added new challenges to the radiation oncology specialty. Approximately 220 ICD-9-CM codes in the malignancy section for radiation therapy, the new code set now renders over 1,700 malignancy code choices. The factors most utilized include location and laterality.
ICD-10 Code set C00- D49 Guidelines Not many 1:1 codes
Neoplasms Benign Malignant o Secondary In situ Uncertain behavior o o C codes (malignant) D codes (In situ, benign, uncertain behavior)
Coding ICD-10 Manual Consultation Report Pathology
Guidelines Anemia associated with malignancy When admission/encounter is for management of an anemia associated with the malignancy, and the treatment is only for anemia, the appropriate code for the malignancy is sequenced as the principal or first-listed diagnosis followed by the appropriate code for the anemia (such as code D63.0, Anemia in neoplastic disease).
Guidelines Management of dehydration due to the malignancy When the admission/encounter is for management of dehydration due to the malignancy and only the dehydration is being treated (intravenous rehydration), the dehydration is sequenced first, followed by the code(s) for the malignancy.
Guidelines Disseminated malignant neoplasm, unspecified Code C80.0, Disseminated malignant neoplasm, unspecified, is for use only in those cases where the patient has advanced metastatic disease and no known primary or secondary sites are specified. It should not be used in place of assigning codes for the primary site and all known secondary sites.
Guidelines Malignant neoplasm without specification of site Code C80.1, Malignant (primary) neoplasm, unspecified, equates to Cancer, unspecified. This code should only be used when no determination can be made as to the primary site of a malignancy. This code should rarely be used in the inpatient setting.
ICD-10 An example of the exploding code choices is found in malignant neoplasm, female breast. In ICD-9-CM, this sub-section had six codes. ICD-10- CM, there are 18 codes to choose from.
ICD-10 Anatomical Location ICD-9 ICD-10 Nipple Right 174.0 C50.011 Nipple Left 174.0 C50.012 Nipple Unspecified 174.0 C50.019 Central Right 174.1 C50.111 Central Left 174.1 C50.112 Central Unspecified 174.1 C50.119 Upper Inner Right Quadrant 174.2 C50.211 Upper Inner Left Quadrant 174.2 C50.212 Upper Inner Unspecified 174.2 C50.219 Quadrant Lower Inner Right Quadrant 174.3 C50.311 Lower Inner Left Quadrant 174.3 C50.312 Lower Inner Unspecified 174.3 C50.319 Quadrant Upper Outer Right Quadrant 174.4 C50.411 Upper Outer Left Quadrant 174.4 C50.412 Upper Outer Unspecified 174.4 C50.419 Quadrant Lower Outer Right Quadrant 174.5 C50.511 Lower Outer Left Quadrant 174.5 C50.512 Lower Outer Unspecified Quadrant 174.5 C50.519
Payment For the first year ICD-10 is in place, Medicare claims will not be denied solely based on the specificity of the diagnosis codes as long as they are from the appropriate family of ICD-10 codes. This is NOT a free pass
Modalities & ICD-10 Brachytherapy SRS/SBRT IORT
Brachytherapy A modality of treatment by which radioactive sources (seeds) are utilized to deliver radiation near the tumor or target area. Sources may be sealed or unsealed Sealed sources are delivered through applicators Unsealed sources are delivered orally, by injection, or by instillation into body cavities.
Brachytherapy Categorized in three ways: Rate Anatomical Position Complexity
Brachytherapy Rate LDR- Low dose rate 2 Gy per hour HDR- High dose rate > 12 Gy per hour Medium dose rate (less commonly used)
Low Dose Rate (LDR) Brachytherapy Longer exposure time when afterloading Utilized for permanent seed implant cases Utilized in treatment of Thyroid cancer Used in Interstitial applications May be permanent or temporary
High Dose (HDR) Brachytherapy Used frequently for gynecological cases Referred to as remote afterloading Requires placement of catheters, needles or other applicators Also used after balloon angioplasty Usually administered in a series of fractions Always a temporary implant
HDR Brachytherapy Advantages: Short treatment time Ease of use Reliable Q/A Personnel safety Common Sources Iridium 192 Cesium 137
Brachytherapy Anatomical Position Interstitial- directly inserted into tumor Intracavitary-inserted into a body cavity Surface application- placed directly on the external surface area. Ex. eye, skin or breast
Brachytherapy Complexity LDR- determined by number of sources HDR- determined by number of channels
LDR Brachytherapy Sources o Palladium 103 o Iodine 125 o Cesium 131 o Gold 198 o Iridium 192 o Cesium 137
Brachytherapy Isodose Plans 77316-77318 Identifies the radiation distribution surrounding one or more brachytherapy radioactive sources. Determines the exact distribution of radiation to the treatment volume and adjacent normal structures around the brachytherapy sources. May be reported more than once during the course of treatment.
Radiation Oncology Brachytherapy Isodose Planning o Codes were identified as being reported with basic dosimetry calculations over 75% of the time Deleted Codes 77326 77327 77328 New Codes 77316 Brachytherapy isodose plan; simple, includes basic dosimetry calculations 77317- Intermediate 77318- Complex 24
Radiation Oncology 77316 Brachytherapy isodose plan; simple (calculation(s) made from 1 to 4 sources, or remote afterloading brachytherapy, 1 channel), includes basic dosimetry calculation (s) 77317 Brachytherapy isodose plan; intermediate (calculation(s) made from 5 to 10 sources, or remote afterloading brachytherapy, 2-12 channels), includes basic dosimetry calculation (s) 77318 Brachytherapy isodose plan; complex (calculation(s) made from over 10 sources, or remote afterloading brachytherapy, over 12 channels), includes basic dosimetry calculation (s) 25
LDR Brachytherapy Treatment Location: Intracavitary CPT Codes Number of Sources CPT Code Description 1 to 4 77761 Intracavitary radiation source application; simple 5 to 10 77762 Intracavitary radiation source application; intermediate Over 10 77763 Intracavitary radiation source application; complex Location: Interstitial Number of Sources CPT Code Description 1 to 4 77776 Interstitial radiation source application; simple 5 to 10 77777 Interstitial radiation source application; intermediate Over 10 77778 Interstitial radiation source application; complex
HDR Treatment Delivery 77785 HDR: Simple * 1 Channel
HDR Treatment Delivery 77786 HDR: Intermediate * 2 12 Channels
HDR Treatment Delivery 77787 HDR: Complex * Over 12 Channels
HDR Treatment Delivery Coding Note.. When services are performed in POS 21 or 22, or other facility setting, physicians reporting these codes must use modifier 26, professional component.
Example: Vaginal HDR Physician Visit & Facility Visit Physician Clinical Plan Special Treatment Procedure 99XXX-99XXX Or 99XXX-99XXX 77263 Clinical Treatment Plan 77470 -Note justifying the use of this code Simulation, Calculations & Devices 77295 or Brachytherapy Plan 77316 77300 77332 77290 77280- Starting with treatment delivery Brachytherapy Treatment Delivery 77785 Insertion Code 57156 Radiation Source C1717
Brachytherapy Surgical Procedure Codes (Applicable to LDR & HDR) Anatomical Region CPT Code Description Skin 17999 Unlisted procedure, skin Breast 19296 Placement of expandable catheter, on different date of partial mastectomy. Breast 19297 Placement of expandable catheter, on same date of partial mastectomy. Breast 19298 Use for multiple tube or button type brachytherapy. Trachea & Bronchi 31627 Bronchoscopy, rigid or flexible
Brachytherapy Surgical Procedure Codes (Applicable to LDR & HDR) Anatomical Region CPT Code Description Lung 31643 Bronchoscopy, rigid or flexible with placement of catheter Lung 32553 Placement of interstitial device for radiation therapy guidance, single or multiple Head & Neck 41019 Placement of needles, catheters, or device into the head and/or neck region Head & Neck 0190T Placement of intraocular radiation source applicator
Brachytherapy Surgical Procedure Codes (Applicable to LDR & HDR) Anatomical Region CPT Code Description Upper Gastrointestinal 43241 Upper gastrointestinal endoscopy, with tube or catheter placement Abdomen, Peritoneum & Omentum 49411 Placement of interstitial device(s) for radiation therapy Female Genital 55920 Placement of needles or catheters into pelvic organs for subsequent interstitial radioelement application
Brachytherapy Surgical Procedure Codes (Applicable to LDR & HDR) Anatomical Region CPT Code Description Female Genital 57155 Insertion of uterine tandem and or/ vaginal ovoids. Female Genital 58346 Insertion of Heyman capsules Female Genital 58999 Unlisted procedure, female genital system Prostate 55875 Transperineal placement of needles or catheters into prostate
Surface Application Brachytherapy Isodose Plans o 77316-77318 Treatment Delivery-77789 Clinical example- Postoperative treatment of pterygium Documentation is a procedure or operative note.
Coding Complexities 182.0 Corpus uteri, except isthmus Included endometrium, fundus & myometrium C54 Malignant neoplasm of corpus uteri o o o o o C54.0 Malignant neoplasm of isthmus uteri (lower segment) C54.1 Malignant neoplasm of endometrium C54.2 Malignant neoplasm of myometrium C54.8 Malignant neoplasm of overlapping sites of corpus uteri C54.9 Malignant neoplasm of corpus uteri, unspecified Concerns: Documentation Specificity
Coding Complexities 183.2 Malignant Neoplasm of fallopian tube C57.0 Malignant Neoplasm of fallopian tube o C57.00 Malignant neoplasm of unspecified fallopian tube o C57.01 Malignant neoplasm of right fallopian tube o C57.02 Malignant neoplasm of left fallopian tube Concerns: Laterality
Coding Complexities Malignant neoplasm of prostate ICD-9 = 185 ICD-10 = C61
SRS/SBRT SRS-Stereotactic radiosurgery High dose delivery of radiation to a specific target- head/spine SBRT-Stereotactic body radiation therapy High doses of radiation using numerous fields to extra-cranial sites
SRS Delivery CPT Code Description 77371 Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt -60 based. 77372 Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; linear accelerator based. 77373 Multifraction, SRS treatment delivery for cranial lesions, all spine SRS and all SBRT lesions.
SRS Treatment Management CPT Code Description SRS-Specific Guidelines 77432 Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session) (The same physician should not report both stereotactic radiosurgery services [61796-61800] and radiation treatment management [77432 or 77435] for cranial lesions). For stereotactic body radiation therapy treatment use 77435. For use of a single fraction, complete course of therapy.
SBRT Delivery CPT Code Description 77373 Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions.
SBRT Treatment Management CPT Code Description SRBT-Specific Guidelines 77435 Stereotactic body radiation therapy, treatment management, per treatment course, to one or more lesions, including image guidance, entire course not to exceed 5 fractions (Do not report 77435 in conjunction with other treatment management codes 77427-77432) Professional charge for treatment management performed by the radiation oncologist. This code can be reported only once for the entire course of treatment not per fraction. This will apply to all extracranial SBRT up to a maximum of 5 fractions. It will apply to all lesions treated during that entire course of treatment.
Example: SBRT Patient Flow Physician Visit & Facility Visit Physician Clinical Plan Special Treatment Procedure 99XXX-99XXX Or 99XXX-99XXX Imaging Simulation Calculations & Devices 77295 or 77301 77300 77334 or 77338 Stereotactic Treatment Delivery 77373 77261-77263 Clinical Treatment Plan 77470 -Note justifying the use of this code Physician Treatment Management 77435 Documentation must include a management note Physics Services Special Physics Consult (77370) if ordered, performed, and documented Continuing Physics (77336)
Coding Complexities C34 Malignant neoplasm of bronchus or lung o Use additional code to identify: exposure to environmental tobacco smoke (Z77.22) exposure o tobacco smoke in the perinatal period (P96.81) history of tobacco use (Z87.891) occupational exposure to environmental tobacco smoke (Z57.31) tobacco dependence (F17.-) tobacco use (Z72.0) Concerns: Additional coding and documentation Laterality
IORT Intraoperative Radiation Therapy o Radiation treatment occurring within an operative session o Breast Cancer o Single Dose o Delivery codes 77424 IORT, treatment delivery, X-ray, single treatment session 77425 IORT, treatment delivery, electrons, single treatment session o Management code 77469 Intraoperative radiation treatment management Physician Only 77470 Included not billable
Coding Complexities Anatomical Location ICD-9 ICD-10 Nipple Right 174.0 C50.011 Nipple Left 174.0 C50.012 Nipple Unspecified 174.0 C50.019 Central Right 174.1 C50.111 Central Left 174.1 C50.112 Central Unspecified 174.1 C50.119 Upper Inner Right Quadrant 174.2 C50.211 Upper Inner Left Quadrant 174.2 C50.212 Upper Inner Unspecified 174.2 C50.219 Quadrant Lower Inner Right Quadrant 174.3 C50.311 Lower Inner Left Quadrant 174.3 C50.312 Lower Inner Unspecified 174.3 C50.319 Quadrant Upper Outer Right Quadrant 174.4 C50.411 Upper Outer Left Quadrant 174.4 C50.412 Upper Outer Unspecified 174.4 C50.419 Quadrant Lower Outer Right Quadrant 174.5 C50.511 Lower Outer Left Quadrant 174.5 C50.512 Lower Outer Unspecified Quadrant 174.5 C50.519
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