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

• Malignanto Secondary

• In situ

• Uncertain behavior

o C codes (malignant)

o 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-10Anatomical 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

Quadrant

174.2 C50.219

Lower Inner Right Quadrant 174.3 C50.311

Lower Inner Left Quadrant 174.3 C50.312

Lower Inner Unspecified

Quadrant

174.3 C50.319

Upper Outer Right Quadrant 174.4 C50.411

Upper Outer Left Quadrant 174.4 C50.412

Upper Outer Unspecified

Quadrant

174.4 C50.419

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

BrachytherapyRate

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 fractionsAlways a temporary implant

HDR BrachytherapyAdvantages:

• Short treatment time

• Ease of use

• Reliable Q/A

• Personnel safety

Common Sources

• Iridium 192

• Cesium 137

BrachytherapyAnatomical 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

BrachytherapyComplexity

LDR- determined by number of sources

HDR- determined by number of channels

Brachytherapy Sources• LDR

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

24

Deleted Codes New Codes

77326

77327

77328

77316 Brachytherapyisodose plan; simple, includes basic dosimetrycalculations77317- Intermediate77318- Complex

Radiation Oncology• 77316 Brachytherapy isodose plan; simple

(calculation(s) made from 1 to 4 sources, or remote afterloadingbrachytherapy, 1 channel), includes basic dosimetry calculation (s)

• 77317 Brachytherapy isodose plan; intermediate(calculation(s) made from 5 to 10 sources, or remote afterloadingbrachytherapy, 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

CPT CodesNumber 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: Intracavitary

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

Location: Interstitial

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 DeliveryCoding 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 HDRPhysician Visit & Facility Visit •99XXX-99XXX

•Or 99XXX-99XXX

Physician Clinical PlanSpecial Treatment Procedure

•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 gastrointestinalendoscopy, with tube or catheter placement

Abdomen, Peritoneum & Omentum

49411 Placement of interstitialdevice(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 uterio C54.0 Malignant neoplasm of isthmus uteri (lower segment)

o C54.1 Malignant neoplasm of endometrium

o C54.2 Malignant neoplasm of myometrium

o C54.8 Malignant neoplasm of overlapping sites of corpus uteri

o 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 tubeo 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/SBRTSRS-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 radiosurgeryservices [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 •99XXX-99XXX•Or 99XXX-99XXX

Physician Clinical PlanSpecial Treatment Procedure

•77261-77263 – Clinical Treatment Plan•77470 -Note justifying the use of this code

Imaging Simulation Calculations & Devices •77295 or 77301 •77300•77334 or 77338

Stereotactic Treatment Delivery •77373

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 ComplexitiesAnatomical 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

Quadrant

174.2 C50.219

Lower Inner Right Quadrant 174.3 C50.311

Lower Inner Left Quadrant 174.3 C50.312

Lower Inner Unspecified

Quadrant

174.3 C50.319

Upper Outer Right Quadrant 174.4 C50.411

Upper Outer Left Quadrant 174.4 C50.412

Upper Outer Unspecified

Quadrant

174.4 C50.419

Lower Outer Right Quadrant 174.5 C50.511

Lower Outer Left Quadrant 174.5 C50.512

Lower Outer Unspecified

Quadrant

174.5 C50.519

Next Steps…• Auditing

• Monitoring

• Education

• Resources

Questions??