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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??
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