Q: When an interventional radiologist performs a radioembolization of hepatic tumor(s) and also acts as the authorized user (AU) for the procedure, what documentation requirements are necessary to code for 77263, 77300 and 77295?
A: Currently, there are no specific documentation requirements for radioembolization regarding these three codes.
For interventional radiologists acting as authorized users for radioembolization, 77263 describes the treatment planning process, 77925 describes 3D radiotherapy planning and 77300 describes the dosimetry calculation. Therefore, 77263 and 77925 would be completed prior to 77300.
Clinical treatment planning codes are defined as simple (77261), intermediate (77262) and complex (77263). According to the 2025 CPT Professional, these codes include interpretation of special testing, tumor localization, treatment volume determination, treatment time/dosage determination, choice of treatment modality, determination of number and size of treatment ports, and selection of appropriate treatment devices. Complex treatment planning is defined as highly complex blocking, custom shielding blocks, tangential ports, special wedges or compensators, three or more separate treatment areas, rotation, or special beam considerations combination of therapeutic modalities.
Per recent SIR guidelines on coding for radioembolization procedures, clinical treatment planning usually includes interpretation of available advanced imaging studies, tumor localization, treatment volume determination, treatment time and dosage determination, choice of treatment modality, and selection of appropriate treatment devices. These same guidelines suggest that documentation to support coding for 77263 include both indications and goals of the proposed treatment plan as well as a description of the dose prescription parameters, such as the specific dose constraints for the target(s) and nearby critical structures. Information on embolization of normal liver arterial supply to avoid normal liver radiation from a proximal treatment position, use of two microcatheters at two different positions to reduce normal liver radiation exposure, or coiling adjacent non-target arterial branches can be included.
Just as each patient treated will have different tumor location and volume, so will each patient have different prior imaging studies to review (such as CT, MRI or prior angiography), prior surgical history, prior radioembolization procedures, etc. Therefore, inclusion of specific information to justify coding 77263 will be patient-specific and could include work performed separate from an initial E&M encounter, such as prior angiographic studies, cross-sectional imaging, previous treatment, the Tc99m-MAA scan and 3D reconstructed imaging to plan the Y-90 delivery.1 As the treatment planning is often performed on a separate date of service from the initial patient visit (E&M), it may be helpful, but not required, to document the treatment planning on a separate date to differentiate the physician work required that is unique to treatment planning.
After the treatment planning is complete and the decision is made to proceed with Y-90, the dosimetry calculation will be performed. This is coded with 77300, which requires documenting patient-specific data to determine the total amount for administration. Per the CER Volume 5, Issue 3, Summer 2009, dosimetry involves determining the amount, rate and distribution of radiation emitted from a radiation source. According to the same CER article, a simple report or sign off by the interventional radiologist to document verification, review and approval is required. As the dosimetry calculations are often performed on a separate date of service from the Y-90 mapping or Y-90 administration, it may be helpful to document the dosimetry calculations on a separate date to differentiate the physician work required that is unique to dosimetry calculations.
As dosimetry practices for radioembolization continue to evolve, some patients may require more tailored treatment planning with voxel-based dosimetry requiring 3D radiotherapy planning to include dose volume histograms (DVH). This additional planning occurs following the administration of Y-90 by first acquiring advanced imaging and performing a final calculation of the dose distribution within the liver and to surrounding nearby critical structures. The documentation of the isodose distributions and DVH with inclusion of the target and at least one critical structure from the treatment planning system would be coded with 77295.
Q: When performing percutaneous endoscopic gallstone removal, when would it be appropriate to report add-on code 47550?
A: Although add-on code 47550 is in the endoscopy section of the AMA CPT Codebook, this does not imply that the code is appropriate to be used as an add-on code to the other endoscopy codes listed thereafter, 47552–47556. Add-on code 47550 describes intraoperative biliary endoscopy and would therefore not be reported with endoscopy codes described for percutaneous approaches, 47552–47556.
When performing endoscopic gallstone removal via percutaneous access, code 47554 would be reported. 47554 represents a daughter code, instead of an add-on code, to the parent code 47552, which describes biliary endoscopy, percutaneous via T-tube or other tract. Note that if a fluoroscopic-guided gallstone removal is performed, then this would instead be coded with add-on code 47544. Given that these procedures are performed via a percutaneous tract—and following a stone removal, a drain would again be placed—a drain exchange, such as 47536, would serve as the base code.
Therefore, if percutaneous endoscopic gallstone removal is performed via existing cholecystostomy tube access with subsequent exchange of the cholecystostomy tube at the end of the procedure, then both codes 47554 and 47536 would be reported. However, if percutaneous fluoroscopic gallstone removal is performed via existing cholecystostomy tube access with subsequent exchange of the cholecystostomy tube at the end of the procedure, then code 47536 with add-on code 47544 would be reported.
1 Clinical Examples in Radiology (CER) Volume 11 Issue 3 Summer 2015
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