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y-90 radioembolization article 

Interventional Radiology Meets Radiation Oncology – The y-90 Story

When a physician is performing an interventional procedure valued in the range of $4,000 – $6,000 for the professional component, attention to thorough and accurate documentation is a requirement for maximal reimbursement.  Each case presents its own individual set of circumstances and a well-constructed operative report will tell the story of the case step-by-step.  Each artery or branch into which a catheter is placed for diagnostic imaging or intervention is assigned a separate CPT code, and so the operative report must describe with specificity each catheter placement.  When these descriptions are in a logical, sequential order, certified coders say that this allows them to better understand every aspect of the case so they can then accurately identify and apply up to 45 CPT codes to maximize reimbursement for it.  A descriptive evaluation of each artery supports payment of the codes that are submitted for reimbursement.

 

The advent of procedures such as yttrium-90 radioembolization in the treatment of liver tumors brings with it additional challenges for the interventional radiologist (IR) that make clear documentation in operative reports even more critical.  While radioactive seed placement procedures are well known in radiation oncology practice, and interventional radiologists are quite familiar with arterial embolization, these two disciplines are merged in the palliative treatment of liver tumors using yttrium-90 (commonly referred to as y-90) microspheres placed by intra-arterial embolization.  The procedure is now being performed by interventional radiologists in community-based private practices as well as in academic medical centers. 

 

A typical y-90 case includes the initial patient visit, a diagnostic angiogram and treatment planning, followed by pre-treatment embolization therapy and the y-90 radioembolization treatment.  SPECT nuclear medicine scans for tumor localization and CT scans for therapy planning may also be obtained.  For interventional radiologists, the documentation of treatment planning, radiation dosimetry calculations and placement of radioactive sources have not been part of their lexicon until now.  It is these unfamiliar disciplines, along with more comprehensive Evaluation and Management visits, that set this procedure apart from the more routine IR cases. 

Here is a description of the codes that are unique to radioembolization, along with the documentation requirements that will allow maximal coding and reimbursement:

• Evaluation and Management codes.  In most cases CPT 99201 - 99205 are used for the Initial Outpatient Office Visit.  Documentation of the steps performed during the visit is critical for compliant coding.  The primary determinant used for the level of coding may be either by meeting and documenting all of the criteria for a history, a physical exam and level of medical decision-making, or by the amount of face-to-face time spent with the patient.  When using time as the controlling factor, the physician must document the duration of the encounter with the patient and also state that over half the time was spent on counseling and coordination of care, along with the nature of the counseling and care coordination.  Any subsequent office visits would be coded using CPT 99211 – 99215 for Established Patient Office Visit.  IR’s are often tempted to use one of the Office Consultation codes, CPT 99241 - 99245, which offer higher reimbursement.  However, it is important to note that even if all the criteria for billing these codes is met, Medicare does not reimburse for them.  In addition to meeting all of the criteria for office visit coding described above, the request and reason for the referral must be included within the patient’s medical record, and a written report of the visit must be issued to the requesting physician.  A key factor in the use of consultation codes is that the IR must be evaluating the patient to determine if the y-90 procedure is a viable option.  The IR must continue to keep the requesting physician informed of the outcome of the visit.
• Clinical Treatment Planning, CPT 77261 - 77263, is a radiation oncology series of codes that may be used in y-90 cases.  These codes are billed once per case.  When the IR is handling the case without the involvement of a radiation oncologist, he must document the treatment plan separately from the procedural report.  The treatment planning report includes:
• a review of any prior relevant imaging and any biopsy or prior surgery results,
• any treatment already received,
• correlation of the physical exam with such prior testing,
• treatment volume determination,
• toxicity or tolerance concerns,
• treatment time and dosage, sequence of treatment modality,
• determination of the number and size of treatment ports,
• orders and medical necessity for imaging guidance, including frequency and imaging modality,
• any concerns or variables unique to the patient and documentation of care coordination
• Basic Radiation Dosimetry Calculation, CPT 77300, is billed for the dose calculation portion of the treatment plan.   A calculation worksheet may be used, and the final results are documented in the treatment plan described above.  Documentation of dosimetry calculations includes the physician’s order, identification of the areas being treated, the calculation of the radiation dose distribution, and evidence that the calculations were reviewed, signed and dated by the physician.  A y-90 case might include several calculations, each billed separately.  In cases requiring extra work over and above the basic dosimetry, CPT 77470 Special Treatment Procedure may be used.  Use of this code requires documentation of prior treatment and outcomes, review of current CT and liver function studies, and ECOG performance status in addition to dose calculation entry.  It should be evident that there is additional physician work. 
• Supervision, Handling and Loading of the radiation source, CPT 77790.  When no radiation oncologist is involved, the IR must prescribe the y-90 and sign the Medical Directive, which becomes a part of the case documentation.  Note that this is a technical-component code but it is still appropriate in a freestanding facility.

 

 

 

Administration of radiopharmaceutical, intra-arterial, CPT 79445, is used to report the delivery of the microsphere dose.  The dose administration is done as part of an arteriogram and documentation of its placement, including the amount of the dose actually delivered, is contained in the operative report of the arteriogram.  This nuclear medicine code offers the best description of the y-90 radioembolization treatment.  The use of CPT 79445 in addition to coding for all of the other testing, evaluation, treatments and dosimetry is supported by the American Medical Association’s CPT Education and Information Services. Most importantly, Medicare and other insurance payers are consistently making reimbursement for CPT 79445 when it is used in the context of y-90 radioembolization.  Certain payers have designated HCPCS Level II code S2095 to be used in place of CPT 79445.  Some maintain that CPT 77778, Administration of interstitial radiation source, is more appropriate but Medicare has clearly ruled that CPT 77778 may not be used for intra-arterial infusion.

Attention to the detailed documentation requirements that support this sophisticated coding and billing is essential, not only to obtain maximum reimbursement for the procedure but also to avoid any potential repayments and fines due to a Medicare Recovery Audit Contractor (RAC) audit or insurance company retrospective review of cases.  Elements that are often missing in procedural documentation are fluoroscopy time, sedation starting and ending times, and specificity of the arteries and anatomic sites accessed.

 

Structuring the operative report in a logical fashion begins with the basics of patient information, surgical team, fluoroscopy time, sedation times, and indications for the procedure.  These items are followed by a hierarchical description of the procedure in the sequence performed, including the various arteries or branches entered.  It is important to report these steps in their order so that reviewers, including coders, know what to expect and can understand the complexity of the procedure.  Separate identification of the steps performed by the primary physician, as distinguished from those of the assisting physician, allows the appropriate application of coding modifiers.  Just as important as the procedural description is the description of the results of the procedure, which would include a description of the vessels’ patency or sclerosis, a diagnostic evaluation of the vessels, and whether the embolization procedure was successful or not.

 

Adherence to such a structure in creating the operative report will help the physician avoid incomplete reports, and it will enable the coders to bill for every possible aspect of the procedure performed in order to maximize reimbursement.

 

Documentation Guidelines for y-90 Microsphere Therapy Performed by Interventional Radiologists 

 

Clinical Service	Potential CPT Codes	Documentation Guidelines
Pre-treatment office visit or consultation	99201 – 99205 Initial Office Visit 99211 – 99215 Subsequent Office Visit 99241 – 99245 Office Consultation (not for Medicare patients)	Request for consultation, if appropriate. Evaluation and management key elements, including: history, physical exam, level of medical decision-making; or the amount of face-to-face time spent with the patient. Clinical diagnoses, listing the most pertinent to microsphere therapy as the primary one. Report of consultation to requesting physician, if appropriate.
Pre-treatment radiation planning	77261 – 77263 Clinical Treatment Planning, billed once per case.	Physician’s consideration of proposed plan(s) and detail of the selected plan(s). Documentation includes: Review of prior imaging, biopsy or surgery Any treatment already received Correlation of physical exam with prior testing Treatment volume determination Toxicity or tolerance concerns Treatment time and dosage, sequence of treatment modality Determination of number and size of ports Orders and medical necessity for imaging guidance, including frequency and modality Any concerns or variables unique to the patient Care coordination
Pre-treatment radiation planning	77300 Basic Radiation Dosimetry Calculation, billed as often as necessary.	Physician’s order Identification of the areas being treated Calculation of the radiation dose distribution Time dose factor, central axis depth dose Physician review, signature and date
Pre-treatment radiation planning	77470 Special Treatment Procedure	Used when extra planning time is required above and beyond Basic Radiation Dosimetry Calculation. Documentation includes: Prior treatment and outcomes Review of current CT, liver function studies and ECOG performance in addition to dose calculation entry
Treatment	77790 Supervision, Handling and Loading of Radiation Source	Physician’s prescription and Medical Directive for the microsphere dose, including a statement about the observation of radiation safety standards.  Technical-component charge, but also appropriate in a freestanding facility.
Treatment	79445 Administration of radiopharmaceutical, intra-arterial	The portion of the radioembolization procedure that reports the delivery of the microsphere dose.  Document the dose of y-90 administered to the tumor bed.