QUESTION: A thoracic surgeon asked, ”In regards to helping with the planning of an extra cranial SBRT boost to a solitary lung tumor, can I use 61793 like the neurosurgeons uses for gamma knife/intracranial SRS, or is there a special SBRT planning charge that the thoracic surgeon can capture while helping the radiation oncologist”?

 ANSWER: There is no revenue sharing code for any surgeon to use for chest.  This continues to be a prevalent thought among some surgeons, I am not sure where it came from, but there is not a usable code. Also, the use of SBRT is sole modality therapy, not for use as a boost. The neurosurgeons codes have changed this year, 61793 was discontinued, replaced by 61796 - 61799.

Which of the following codes have no units with regards to multiples on a given date of service?

a)     Basic Dosimetry

       Calculations (77300)

b)     3D Simulations (77295)

c)      Complex Isodose Planning (77315)

d)     Both B and C

In Radiation Oncology, multiple differing factors go into scoring levels of complexities.  When any grouping of codes uses multiple areas to determine a level of complexity, this grouping will never have Units on a given date of service.  Some codes are also billable once per course, which negates the use of units for the ENTIRE course.

Question: The patient is a 14 years old, who is paralyzed with a diagnosis of advanced osteosarcoma.  He was seen at a large cancer facility in another state and the parents were told they could not help the young man.  The parents want to come in and talk with the Radiation Oncologist at our center for another opinion.  Since it is the parents, and not the patient coming in for a consultation, how would one bill this? 

 

Answer: This case raises many interesting issues. He has no referring physician so you cannot use the consultation codes 99241-99245 for E/M services.  Instead use the office new patient work up codes 99201-99205 if the patient is seen and evaluated.  The results can then be discussed with the patient and the family, but not sent to any other physician unless requested by the patient. If the patient is not involved at all (not physically present), then no E/M code can be billed, because no service was rendered to him personally. You need his written permission (or power of attorney as a juvenile), to even speak with the parents (HIPAA) and discuss his case.  If he is willing to let them talk to you about his case, but he is not there, then you need to arrange a value for time spent in personal consultation, and collect your fee from the parents. No insurance can be billed for this type of service.

An HDR patient has three catheters put into place, only one of which is actually used for treatment.  There are 6 dwell or stop positions overall.  What is the MOST correct code to bill for the Treatment Delivery in your 2009 Global billing setting?

a.      77782-26

b.      77782

c.       77785-26

d.      77785

In January of 2009 codes 77781-77784 were deleted and became obsolete.  New codes were created using the number of “channels” used to determine level of complexity.  77785 is one channel, 77786 is 2-12 channels and 77787 is 12+ channels.

To bill 77421 does the physician have to be present?

There are still some questions on the billing of 77421. Chief among these is the issue of direct physician supervision. Does the physician need to be in the building to legitimately bill for this code? Can the physician be remote with computer access? Does this contradict Transmittal 82 (Change Request 5946) which specifically addresses the supervision and defines the supervision as “Personal Supervision – a physician must be in attendance to bill this procedure?

 

Stereotactic x-ray guidance, 77421, does require direct physician supervision of images.  Beyond this requirement for direct supervision, the interpretation of “direct” is left up to the physician; the intent is real time evaluation of images prior to delivery of therapy.

The following is my opinion, but others agree with me, this procedure is done on a computer, with the physician looking at images, and communicating any needed changes to the therapist in charge of the daily treatment of the patient. This can be done from any computer where the images can be manipulated and corrected by moving the isocenter or portal images to achieve fusion of images and record the appropriate shifts that are needed, which then translates to machine couch corrections.  In real life and real time, the physician is remote from the patient, only manipulating the images, not in direct attendance with the person being treated.  How far away the computer screen is from the patient may be an issue, but the intent of real time corrections is the important criteria.