1. Section 8 Radiation Oncology Dosimetry CPT Codes 77300 - 77370
Susan Vannoni
3:15 to 4:00 PM Section #8
031314
Modified For 81

2. Basic Dosimetry Calculations 77300 IS A GLOBAL BILLING CODE2
Basic Dosimetry Calculations
(External Beam)
77300 Basic Radiation Dosimetry Calculation.
This procedure may be billed any time during a course of radiation therapy, and as many times as necessary.
77300 IS A GLOBAL BILLING CODE

3. Occurrence Rate 2013 77300 4.01 per case, conventional treatment
Electron treatment
per case, all modalities
per case IMRT (did not change with switch to use of 77338)
The averages is about Dosimetries per conventional block, 77334, and 1.01 per for IMRT.
These ratios are lower for 2013 due to a drop in the average number of IMRT beams being used per case.

4. Computer Versus “Hand” Calculations3
Computer Versus “Hand” Calculations
Only one may be charged for the required two independent means of calculating the basic dosimetry.

5. Computer calculations (Varis/Aria)
NIB
Computer calculations (Varis/Aria)

6. 5
MU CHECK IS COMPUTER GENERATED, BUT IS CONSIDERED A SECOND (HAND) DOSE CALCULATION

7. Documentation Requirements9
Documentation in the medical record must include an explanation of the need for multiple basic dosimetry calculation .
Each calculation should be identified specifically as to its necessity, i.e., central axis depth dose, critical organ dose, off-axis dose, abutting fields, etc. This statement may need to be on the comment line of the HCFA 1500 form for payment by Medicare
ONLY ITEMS USED CLINICALLY MAY BE BILLED

8. Basic Dosimetry Calculations 773009
What’s it for?
Any calculation performed that constitutes a component of the Dosimetry Record, monitor unit calcs (MU), decay calcs, off axis factors, etc.
Who normally documents/bills/captures this codes?
Dosimetry, Physicist or Therapists.
When is this codes normally billed?
This code can occur almost any time during the course of therapy
What Documentation is suggested for this code?
The calculation itself, signed by the physician, and Dosimetry.
What are the common documentation errors identified with this code?
Not having a physician’s order and, not being signed by the physician
What are the common billing errors?
Missing individual calculations due to not recognizing dosimetry documentation.
20/150

9. Treatment Planning CT Scan and Isodose plans11
Isodose planning is based upon data from CT scans
There is no longer any billing allowed for the treatment planning CT 77014, as this code has been retired. The CT procedure is done as part of the planning process.
If a full diagnostic CT scan is done, this may be billed as a diagnostic procedure if it has been read by a diagnostic radiologist.

10. 77305 – 77315 ARE GLOBAL BILLING CODES
Teletherapy Isodose Plan(s) 10
Simple Isodose Plan
Intermediate Isodose Plan
Complex Isodose Plan
77305 – ARE GLOBAL BILLING CODES

11. TWO FORMATS OF ISODOSE DISPLAY15
COLOR WASH DOSE PATTERN Hot, red, colors are higher dose, with blue and green lower dose
ISODOSE DOSE LINE PATTERN, each line indicates a boundary of dose, graduating out from the central highest dose

12. 16
Teletherapy isodose plans developed through the use of IMRT, or three dimensional techniques are to be reported as part of the codes 77295, or and not to be billed separately as

13. 16
Clinical Changes
Clinical variations of the patient during therapy may necessitate a new plan being made and reported.
The radiation oncologist must document the reasons for the rendering of an additional isodose plan.

14. Documentation Requirements16
Documentation Requirements
Documentation maintained in the patient’s medical record must include an explanation of the need for both the initial as well as any subsequent isodose plan.

15. Isodose Dosimetry 77305- 77315 17 What’s it for?
Isodose Dosimetry is a representation of dose formed by a confluence of one or more treatment beams on an area of interest.
Who normally captures these codes?
Dosimetry or Physicist.
When are these codes normally billed?
Upfront, after Simulation, and later in the course of therapy with reduced fields.
What Documentation is suggested for these codes?
The plan must be signed by the physician, and a Planning note is advised to more fully document the procedure.
What are the common documentation errors?
These are normally documented quite well with very few errors. The most common problem is the lack of a clear physician’s order for the plan.
What are the common billing errors identified?
Observe rules; 0nly one Isodose Plans on a given date, do not Bill this service with
3-D or IMRT.

16. 77321 IS A GLOBAL BILLING CODE
Special Beam Plan 18
This code is to be utilized when a treatment decision for any special beam consideration is required, such as the use of electrons, heavy particle beams or other nuclear beams.
The use of electrons as a portion of, or as the sole modality for the treatment of a particular problem is the most common use of this code.
77321 IS A GLOBAL BILLING CODE

17. Isodose Plan may be Needed for Electron TreatmentIB 21
Isodose Plan may be Needed for Electron Treatment

18. 22
Electron boost port 77321
Post operative
Parotid tumor

19. Electron boost to breast23
Electron boost to breast

20. 23
Typical basal cell carcinoma of the tip of the nose treated with electrons

21. Coding Guidelines Electrons 7732124
This special beam consideration code is to be billed only one time for the course of treatment.
We recommend that it be billed on the first day of clinical use to treat the patient.
This special beam is billed as daily treatment delivery with the code based on the maximum energy of the treatment machine, not related the electron energy utilized for treatment

22. 24
A specific report is not required by Medicare, however it will help in the documentation and justification of electron usage (RAC 2011)
ONCOCHART

23. Special Beam 77321 24 What’s it for?
The use of a particulate beam in the treatment of a patient, such as electrons, protons, or neutrons.
Who normally captures this code?
Dosimetry, Physics or the Treating Therapist.
When is this code normally billed?
The first day of particulate beam therapy being delivered.
What Documentation is suggested for this code?
The use of electrons, protons, or neutrons in treatment.
What are the common documentation errors with this code?
Not following your LMRP/LCD rules on this code.
What are the common billing errors identified?
Not knowing the CCI rules, billing with edited 773xx codes.
Not recognizing that the particulate beam was used.

24. 77331 IS A GLOBAL BILLING CODE25
SPECIAL DOSIMETRY
Special/Microdosimetry
Special/microdosimetry consists of the use of special radiation measuring and monitoring devices for determining the specific dosage of radiation at a given point.
77331 IS A GLOBAL BILLING CODE

25. 25
This code covers the use of thermoluminescent dosimeters, solid state diode probes, special dosimetry probes, film dosimetry, or other methods for measuring the specific dosage at a given point.
These procedures must be done at the direct request of the radiation oncologist.
Medical necessity must be documented in the chart. This code may be reported for each specific location of measurement.

26. Narrative Microdosimetry report 7733128

27. Special Dosimetry 77331 29 What’s it for?
The use of Diodes, TLDs, and other beam measuring devices
Who normally captures this code?
Treatment Therapist and/or Physicist.
When is this code normally billed?
Within the first few fractions of any new field being treated.
What Documentation is suggested for this code?
A Physics/Physician report documenting the measurement, and any actions to be taken as a result of the readings.
What are the common documentation errors identified with this code?
Not being signed by the physician or physics.
Not having a specific physician’s order for the procedure.
Failure to establish medical necessity for the procedure
What are the common billing errors?
Not understanding what a diode is, how it is performed, and where it is documented. Failure to observe CCI edits with other 773XX codes.

28. 30
TREATMENT DEVICES

29. 77332 -77334, 77338 ARE GLOBAL BILLING CODES30
CPT Codes
Treatment Devices; Simple
Treatment Devices; Intermediate
Treatment Devices; Complex
77338 – IMRT Single Block Charge
, ARE GLOBAL BILLING CODES

30. Occurrence Rate, Blocks 201430
Occurrence Rate, Blocks 2014
77332 is <2% occurrence rate
77333 is <1% occurrence rate
77334 is 98% occurrence rate
Immobilization devices account for 27% of 77334, about 1.64 per case.

31. 77332 Simple Treatment Devices36
Simple Treatment Devices
Treatment Devices, design, construction or selection; Simple (single block, single bolus)
Usually no special fabrication is necessary for these blocks; pre-made blocks may be used.

32. Simple Treatment Block36
Simple Treatment Block
80/150

33. Bolus The use of bolus usually constitutes a simple device.37
The use of bolus usually constitutes a simple device.
It is a rare situation where a simple bolus is the only treatment device used.
If some other treatment device is used, the most complex of these will drive the level of complexity for that port.
A simple bolus used with a complex device will cause the charge to be driven to the higher level of complexity You may not charge for the bolus.
85/150

34. 39
Intermediate Treatment Devices
Treatment Devices, design, construction or selection; Intermediate (more than one area of port blocked - blocks, stints, bite blocks, special bolus)

35. 39
The most common intermediate treatment device will be simple blocking, but covering multiple areas of the port.
Simple blocking covering two different areas, such as multiple bone metastasis is considered intermediate

36. 40
Stints
A pre-fabricated stint used to modify a patient’s anatomy for the proper delivery of a radiation dose is billed as an intermediate treatment device. A custom stint is a complex device (ACR, 2001)

37. 40
Custom Stint 77334

38. 40
BILL AS
77334
A custom stint is being used to distance the electron treatment port away from the underlying gum

39. MULTIPLE SIMPLE SKIN LESIONS41
MULTIPLE
SIMPLE
SKIN
LESIONS
1= Simple
2= Intermediate
3+= Complex
This case has 3 or more sites;
Treatment planning is complex 77263
Simulation (clinical simulation) is complex 77290
Blocks, treatment devices, are each simple, X 3
Dosimetry is done for each port, X 3

40. 77334 Complex Treatment Devices41
Complex Treatment Devices

41. Complex treatment device42

42. Multi-leaf or Dynamic Collimation (MLC)42
Multi-leaf or Dynamic Collimation (MLC)
This procedure must be planned in the same comprehensive and complex fashion as custom field blocking and is reported as

43. Compensator IMRT is still 7733442
Blocking for IMRT 77338
In the case of IMRT treatment, each portal may use MLC custom shaped blocking,
For Medicare, all government insurance, and most private insurance, MLC must be reported as IMRT beam modifier,
Compensator IMRT is still 77334

44. Eye Shields 77334
An eye shield is a complex multi-use device. 43

45. Its application is highly complex and precise
Its application is highly complex and precise The radiation Oncologist must clinically place this eye shield with each treatment. 43

46. Immobilization Devices47
Immobilization Devices
Treatment devices may be used for patient immobilization to accurately reproduce the set up on a daily basis.
These devices are fabricated under the direct supervision of a physician and are specifically designed for an individual patient’s treatment course. (ACR, 2001)

47. Bead filled vacuum bags are complex multi-use devices.47
Bead filled vacuum bags are complex multi-use devices.
Each vacuum bag is utilized only for a single patient throughout the entire course of therapy.

48. Breast Board 47
BILL AS
77332

49. 47
According to the ACR/ASTRO Code Utilization & Application Subcommittee, the multiple setting breast board is now considered as a simple treatment device.
This opinion represents a consensus of coding practices from around the country, but does not constitute permission or prohibition for a given billing practice.

50. 49
COMPENSATOR
A compensator is a device that will shape the profile of the beam to compensate for uneven patient contours across the flat face of the treatment port to even out the dosage to the treatment area.
The most common use of a compensator will be to compensate for the steep slope of the chest wall.
A compensator, if custom designed for a particular situation, may be billed individually and in addition to other complex treatment devices.

51. 49
REGARDLESS OF COMPLEXITY OF DESIGN OR USE, ALL COMPENSATORS WILL BE BILLED AS 77334

52. FOR TOTAL BODY TREATMENT 77334
CUSTOM COMPENSATOR
FOR TOTAL BODY TREATMENT 77334 50

53. Proton Tissue compensator50
Proton Tissue compensator
77334

54. Milled brass proton beam shaping compensator
NIB
Milled brass proton beam shaping compensator
77334

55. IMRT COMPENSATOR
77334
NIB

56. 50
Rice bolus
Square tissue compensator to evenly distribute the dose over the tumor volume. Complex compensator, 77334, in addition to the mask, 77334
Tumor volume

57. 50
This is the patient 6 months after completion of radiation therapy to the scalp lesion.

58. IMRT Compensator Blocking Each block or fluence is billed as 7733451
When cast compensators are utilized for IMRT blocking.
Each block or fluence is billed as 77334
Note; this is still the same as in previous years, do not use the single code for compensator blocking

59. 52
Regardless of the complexity or design of the conventional therapy treatment device, some form of narrative may be required

60. 52
Device report for two immobilization devices, each of these will be billed as 77334, complex device.

61. WHEN TO BILL TREATMENT DEVICES53
WHEN TO BILL TREATMENT DEVICES
Date of DESIGN of device
Date of CREATION of device
Date of USE of device

62. Treatment Devices 53 SP134/150 What are they for?
Blocking (cast or MLC) wedges, compensators, Brachytherapy devices.
Who normally documents/bills/captures these codes?
Dosimetry, Treatment or Simulator Therapist, physics or physician.
When are these codes normally billed?
They can occur anytime in the course of therapy.
What Documentation is suggested for these codes?
The design on DRRs for a block. A written report may be generated if required by your insurance carriers. Photographs are useful.
What are the common documentation errors with these codes?
Insufficient documentation to support the use of the device.
Lack of Physician statement of medical necessity.
What are the common billing errors identified?
Not understanding the specific rules of CCI and MUE edits
Not understanding which device is immobilization and which is blocking.
Not knowing that professional and technical rules are different.
Not recognizing that the procedure was performed.
SP134/150

63. Special Physics CPT Codes55
Special Physics CPT Codes
Continuing Medical Physics Services
Special Medical Physics Consult

64. 55
Special Physics Codes
The two special physics codes and are considered as technical services only.
The physician may not bill for these procedures, however the physician is legally responsible for all physics procedures performed in his department.

65. 77336 Continuing Medical Radiation Physics55
77336 Continuing Medical Radiation Physics
The safe use of radiation requires the continuing medical physics services to ensure that the treatment being delivered conforms precisely to the physician’s intent and prescription from a technical (medical physics) point of view.
These services are typically described using and are distinctly provided by the medical physicist for each patient.
These services are provided by or under the supervision of a qualified medical physicist.

66. 55
77336
77336 was devised many years ago to account for a general, single reimbursement value per week covering a multitude of relatively small physics services that are performed for each patient undergoing treatment
These are not to be considered as quality control features but, are essential to assure the accuracy and safety of the radiation treatment as it is being delivered in an ongoing fashion hence, the name Continuing Medical Radiation Physics in support of the therapeutic radiologist.

67. Patient Services covered by the radiological physics code 7733656
Weekly checking of the patient’s treatment record
Confirmation of the proper mathematics related to daily chart entry
Verification of the accuracy of the dose calculations
Accuracy of daily entry in the treatment log relative to the physician’s prescription
Proper utilization of the various treatment aids
Assurance of the accuracy of treatment device design
Translation of computer generated data to the daily treatment log pages
Assurance that the physician’s prescription is being followed exactly

68. 77336 56
The tasks provided by the physicist are essential in ensuring that the physician’s prescription is being followed accurately during the course of radiation therapy.
Documentation of physics services performed is essential.
These services (77336) are not considered as special physics calculations (77370) and are not to be billed as such. (ACR, 2001)

69. IMRT weekly physics report 7733657
IMRT weekly physics report 77336

70. CONTINUING PHYSICS WITH BRACHYTHERAPY58
Multiple procedures may be performed and billed by the physicist for his work related to a course of Brachytherapy.
Most of these procedures are covered under the continuing physics code or a special physics consultation
See the list on page 60.

71. Continuing physics report, 77336, for Brachytherapy59
Continuing physics report, 77336, for Brachytherapy

72. Continuing Medical Physics 7733659
What’s it for?
The Medical Physicist weekly involvement in insuring proper patient treatment.
Who normally documents this code?
The Physicist.
When is this code normally billed?
Weekly (every 5 fractions) during a course of therapy.
What Documentation is suggested for this code?
A worksheet or electronic document showing that the Medical Physicist has reviewed the week’s treatment.
What are the common documentation errors with this code?
Inadequately documenting services rendered.
What are the common billing errors identified?
This code can be billed any time during the course of the five fractions. Know the many CCI edits against this code . This is a technical only code, never bill a professional component.

73. 60
Special Medical Radiation Physics Consultation
This code is used in a consultative situation describing a very specific procedure that is carried out by the medical radiological physicist at the direct request of the radiation oncologist.
This code describes a special situations requiring the expertise of the medical radiological physicist to completely analyze a problem and develop a summary for the radiation oncologist.
The physicist must render a special written report to the radiation oncologist.

74. A direct request by the physician for this procedure is required.
Computerized physician order [CPO] requesting a physics consultation. This consultation will ultimately be billed as a special physics consult.
A direct request by the physician for this procedure is required. 60

75. 60
77370
This procedure is performed to directly benefit an individual patient, and is patient specific and distinctly different from the broader multi-patient issues addressed by the Code
The radiation oncologist will be expected to analyze and sign off on the report. The findings may be used to design or modify the treatment situation under analysis.

76. Special Physics Consult The Right Doctors – The Right Technology61
Special Physics Consult
A review of the previous port films from Baptist Hospital show the port extended to the mid-portion of the body of C-7.
Recommendation: A central axis beam splitting upper edge of the treatment port will allow close abutment of the port covering T-1 with the previous field at C-7. Calculations of the gap will require 1.3cm on the skin resulting in beam crossing below the level of the spinal cord.
NSD decay of the 3000 rads delivered to the previous field would indicate, at maximum, a 10% reduction in equivalent dosage however, if the ports are properly set, there should be no additive effect between the two portals.
Physicist Physician
The Right Doctors – The Right Technology
230 North Midwest Boulevard – Midwest City, OK – (405)

77. 62
Some of the recent edits of Medicare will not allow any other series code to be billed on the same date as or
These codes should be reported on separate dates, and cannot be billed together.
77336 can be reported any time within the 5-day period of a week of therapy Check your LCD

78. 63
The technical component of and codes recognizes the efforts of the physicist, dosimetrist, and auxiliary personnel.
No professional charges will be made for these services by the Physician, medical radiation physicist or dosimetrist.

79. Medicare assumes that a physics assessment (77336) is reported once for every week (five fractions) of external beam treatment.
For other forms of radiation therapy that do not adhere to the five-fraction/week rule (e.g. brachytherapy, stereotactic), code may be reported as medically necessary and supported by documentation.
A special physics consult (77370) is typically required only once per course of radiation therapy. 63

80. Special Medical Physics Consultations 7737064
Special Medical Physics Consultations 77370
What’s it for?
This is a requested consultation, and it should be documented as answering a difficult question on a specific patient.
Who normally captures this code?
Medical Physicist.
When is this codes normally billed?
Once per treatment course at any time
What Documentation is suggested for this code?
A narrative type document by the physicist explaining the physics problem being requested by the physician.
What are the common documentation errors identified with this code?
A Special Physics Consult must be performed, and must be documented in the medical record to bill the service.
Medical necessity must be evident.
What are the common billing errors identified?
Multiple CCI edits exist against 77370, almost all 773xx codes are edited against it.
150/150

81. PRINCIPLES OF BILLING, CODING AND COMPLIANCE IN RADIATION ONCOLOGY
BMSi 2014
End sect 8

82. END OF SECTION 8 8

83. NEW PROGRAM FORMAT
Dr. Bogardus will not be here in person, but he will be available and participating using a live video simulcast from the BMSi office in Oklahoma City.
This is a live two way communication, and the audience is encouraged to interact as we have always done in the past.

84. Bolus Buildup Simple device40
Bolus Buildup Simple device

85. 77332 SIMPLE GENERIC DEVICES PRE MADE CAST ELECTRON BLOCKS
NIB
77332 SIMPLE GENERIC DEVICES
PRE MADE CAST ELECTRON BLOCKS

86. 26
DIODE
PROBE

87. MOSFET SOLID STATE DOSIMETER27
MOSFET SOLID STATE DOSIMETER
SINGLE USE DEVICE
77331

88. IMPLANTABLE TRANSPONDER MOSFET DOSIMETER27
IMPLANTABLE TRANSPONDER MOSFET DOSIMETER
Single use implantable dosimeter coupled with a telemetric passive transponder
Capable of recording cumulative daily dose
Approved for use in prostate
Generally two are implanted
Urology code for implantation Medicare professional $ (2008)
Hospital code A Medicare technical ~ $1,200.00

89. 27
Hand held
wand
Reader
circuit
Antenna
Passive solid
State circuit
Mosfet

90. 77421 Stereoscopic localization, report daily for IGRT 7733127
77421 Stereoscopic localization, report daily for IGRT
77331
Special Dosimetry, can report cumulative dose, per dosimeter
EACH OF THESE PROCEDURES REQUIRES A SEPARATE REPORT

91. Mosfet implanted dosimeter/marker report for micro dosimetry28
Mosfet implanted dosimeter/marker report for micro dosimetry
Two versions of report, narrative and brief

92. Record and Verify Systems are not reportable as 77331.29
77331 is not appropriate, and could not be reasonably defended, for a room survey following Brachytherapy.
Record and Verify Systems are not reportable as
Record and verify is part of standard quality assurance and carries no reimbursable component.
60/150

93. 19
Electrons
The characteristics of electrons are such that a higher level of care of the patient, special attention by the treatment machine personnel, and an extensive knowledge of the physics and interaction of electrons with tissue, is required of all personnel.
35/150

94. The use of Electrons 22
Electrons may enable the radiation oncologist to re-treat an area that has previously been heavily irradiated.
Electrons are most often used as a boost to an area that is either receiving or has received a separate photon beam in addition to the electrons.
If the center does not have a KV unit, then Electrons may be the best modality for treating small primary skin malignancies or skin metastasis.

95. Standard Machine Wedge45
77334
A wedge is a device that shapes the profile of the treatment beam to compensate for an angular plane of entry
Standard Machine Wedge

96. The most common immobilization device in 1970 was 3-M masking tape
NIB
The most common immobilization device in 1970 was 3-M masking tape

97. Can I bill for the tape as a complex treatment device?

98. Rectal balloon prostate immobilization device
NIB
Inflation device
Inflatable balloon
Adjustable depth stop
Vent
Rectal balloon prostate
immobilization device
Depth gauge
This is a customizable complex immobilization device, but it cannot be billed daily by the physician for each new device used. Hospitals may be able to bill a supply code daily for the device. Some physicians are generating a comprehensive 5 day report and billing the use of these devices (77334) on a weekly basis

99. NIB
Typical narrative report for the daily use of rectal balloon prostate immobilization devices, bill as one time every 5 uses, documentation required, may not be paid by Medicare, CHECK YOUR LCD

100. Aquaplast Face Mask 50
77334
119/150

101. ACCUFORM IMMOBILIZATION DEVICE51
BILL AS in addition to the Aquaplast face mask

102. 43
For private pay or commercial insurance plans, the code per fluence may still be valid. Basic Dosimetry may still be billed one per fluence. CHECK YOUR LCD

103. 52
Conventional Treatment Compensator documented by a physics report

104. 44
For Medicare and most insurance, you must report IMRT blocking as 77338, one time per IMRT treatment plan, the basic Dosimetry may still be billed per fluence

105. 49
Alpha Cradle
77334
CCN Page 211 – Figure 12.33A

106. Multiple complex treatment devices47
Multiple complex treatment devices
107/150

107. Custom Immobilization Device
NIB
Custom Immobilization Device
77334
Tumor volume
Device
Tongue
Fixation/Immobilization device fabricated to separate the tongue from a lesion in the palate

108. Continuing Quality Assurance58
Continuing Quality Assurance
Machine calibration (usually done monthly)
Interlock checks (usually done monthly)
Source verification (usually done weekly or monthly)
General radiation safety issues

109. This report may be billed as a special physics consultation 7737064
This report may be billed as a special physics consultation 77370