Members of the Coding and Reimbursement Subcommittee recently reviewed and revised our coding recommendations for radioembolization procedures. The following article outlines the most up-to-date recommendations. I thank C. Matthew Hawkin, MD, FSIR; Timothy Swan, MD, FSIR; Ammar Sarwar, MD, FSIR; Waly Pabon-Ramos, MD, MPH, FSIR; Curtis Anderson, MD, PhD; Minhaj Khaja, MD, MBA, FSIR; and Robert Kennedy, MD, for their contributions to this article.
Coding for the planning procedure
Diagnostic arteriography
All selective catheter placements and diagnostic imaging for this first session are separately reportable with the appropriate selective catheterization codes (36245–36248) and associated radiological supervision and interpretation (RS&I) codes (75726 and 75774, if appropriate). (See additional notes below for further information on these diagnostic codes.)
Embolization
Embolization of nontarget vessels to prevent administration of radioactivity to nontarget vascular beds is reportable using code 37242. Note that embolization in this setting is considered to take place in one “operative field” so even when more than one vessel is embolized, only a single embolization code is reported. Also note that angiography performed during and following the embolization is an included service within the embolization code and is not separately reportable.
Injection of Tc-99m MAA and NM reporting
The intra-arterial injection of Tc-99m macroaggregated albumin (MAA) during the planning procedure and subsequent nuclear medicine imaging is reportable using code 78803. Note that 78803 (tomographic SPECT) is reported by the individual responsible for supervision and interpretation (S&I) of the MAA exam which, depending on practice arrangements, may be an individual separate from the IR physician.
Coding for radiation planning and dosimetry
Dosimetric treatment planning
The clinical treatment planning process includes interpretation of special testing, tumor localization, treatment volume determination, treatment time/dosage determination, choice of treatment modality, and selection of appropriate treatment devices. Institutions licensed to administer Y-90 must have an Authorized User (AU) who is responsible for the pre-procedure dosimetry and treatment planning and may be reported using codes 77261–77263 depending on the complexity of the planning and appropriate documentation. Note that the complex therapeutic treatment planning code 77263 is reported when the AU utilizes the following data in planning for dose and timing of treatment; angiographic studies, cross-sectional imaging, previous treatment, the Tc-99m MAA scan, and 3D reconstruction imaging to plan the treatment of Y-90 delivery. Documentation to support the use of 77263 must include indications and goals of the proposed treatment as well as description of dose prescription parameters such as the specific dose constraints for the target(s) and nearby critical structures.
Simulation
Simulation is the process of defining relevant normal and abnormal target anatomy and acquiring the images and data necessary to develop the optimal radiation treatment process for the patient. If the AU utilizes angiographic studies, cross-sectional imaging, prior therapies, results of the Tc-99m MAA scan and/or 3D imaging reconstructions for dosimetric calculations, the work of simulating the effects of the radiation therapy on the targeted tissue is separately reportable using the complex simulation code 77290. Documentation for simulation code 77290 should include planned treatment catheter position, quantity of radioactivity (i.e., activity) to be implanted, target volume in the liver, tumor-to-normal ratio (if calculated), liver-to-lung shunt ratio, and absorbed doses for the tumor, lung and normal liver (if applicable).
Medical physicist
If the services of a qualified medical physicist are required for the safe delivery of the therapeutic isotope, this work is separately reportable using 77370. When medically indicated1 and ordered by the AU, a special physics consultation is reported with 77370, which is a practice expense-only code for medical physicist services.
Handling of radiation source
Per NRC regulations, a record of the Y-90 dose in the facility or office must be documented and the AU responsible for safe handling, receipt, accounting and storage of the Y-90 may report 77790 (supervision and handling of a radiation source) for this service.
Coding for the treatment procedure
Single-doctor (interventional radiologist is the authorized user)
Any selective catheter placements are reportable using the appropriate codes (36245–36248). The associated RS&I codes should not be routinely reported since angiography is confirmatory and considered to be part of the therapeutic procedure. However, these RS&I codes (75726 and 75774), if appropriate, may be reportable if pre-procedural documentation indicates suspicion of new vascular flow patterns or the detrimental effect of chemotherapy on vessels. Once the appropriate artery is selected for therapeutic treatment, the Y-90 dose is delivered and reported with 37243 and 79445 (for the supervision of radiopharmaceutical therapeutic injection). 37243 includes RS&I, as well as any additional embolizations (such as flow redirection to preserve adjacent organs) performed in the same session as radioembolization.
Two doctors (interventional radiologist is not the authorized user)
In this situation, the IR reports only the catheter placement codes (36245–36248) and any associated angiographic S&I codes (75726 and/or 75774), if necessary and appropriately documented, as described above. A second, licensed physician (acting as the AU) may be involved in the planning and delivery of the Y-90 dose. In this two-doctor model, the AU has material involvement in the planning, dosimetry and administration (actually injects the Y-90), so the AU reports 77778 describing the work of application of an interstitial radiation source, (complex) in this setting.
If the IR injects the radiopharmaceutical under the supervision of the AU (who plans the dosimetry calculations), the IR reports 37243 for the embolization procedure and the AU reports 79445 for the supervision of radiopharmaceutical therapeutic injection.
Coding for same-day planning and treatment procedures
Current practice of Y-90 radioembolization is evolving and some centers may perform all three of the above stages in a same day delivery model. However, it should be noted that none of these stages are delivered in the same session. Each of these sessions require distinct procedural reports, outlining all of the services performed in that session. In this situation, reporting of services by the IR who also is the AU is identical to the above recommendations except that catheter placement and RS&I codes for angiography should be reported with a -59 modifier.
This article does not outline payment modifiers that may be required for claims processing. Check with local payor guidelines on potential modifiers that may need to be appended to CPT codes mentioned in this article.
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Every reasonable effort has been made to ensure the accuracy of this guide; but SIR and its employees, agents, officers and directors make no representation, warranty or guarantee that the information provided is error-free or that the use of this guide will prevent differences of opinion or disputes with payers. The publication is provided “as is” without warranty of any kind, either expressed or implied, including, but not limited to, implied warranties or merchantability and fitness for a particular purpose. The company will bear no responsibility or liability for the results or consequences of the use of this manual. The ultimate responsibility for correct use of the Medicare and AMA CPT billing coding system lies with the user. SIR assumes no liability, legal, financial or otherwise for physicians or other entities who utilize the information in this guide in a manner inconsistent with the coverage and payment policies of any payers, including but not limited to Medicare or any Medicare contractors, to which the physician or other entity has submitted claims for the reimbursement of services performed by the physician.
Reference
- Justifiable indications pertinent to Y-90 therapy include: brachytherapy combined with external beam radiotherapy, analysis of previous radiation therapy with assessment of cumulative radiation dose to critical organs, fetal dose in pregnant patients, or personal attendance of a physicist during treatment.
