CPT codes – 76000, 77336, 77334, 77290, 77300, 17999, 19296,31643, 55860 – Non-Intracoronary, Brachytherapy:

Procedure code and Description

76000 FLUOROSCOPE EXAMINATION 31654 BRONCH EBUS IVNTJ PERPH LES

 76001 FLUOROSCOPE EXAM EXTENSIVE 31654 BRONCH EBUS IVNTJ PERPH LES

Radiation oncology consists of two primary treatment modalities: External Beam Radiation Therapy (EBRT) and brachytherapy. Brachytherapy is a type of radiation therapy that utilizes natural or manufactured radioactive isotopes or radionuclides that are temporarily or permanently implanted to treat malignancies or certain benign conditions and derives a physical advantage based upon the inverse square law of physics. Brachytherapy is accomplished by placing small encapsulated radioactive elements (aka, “seeds” or “sources”) directly in or near the tumor or treatment site. There are currently three basic clinical brachytherapy formats: interstitial applications, intracavitary applications (also called “intraluminal”) and surface applications (placed directly on the skin or other external target surface). Brachytherapy may use a solid radioactive source such as a seed or liquid colloid isotopes and may be either temporary or permanent. Further, brachytherapy may be high- or low-dose rate.

Brachytherapy may be used independently as the sole treatment or as an adjunctive treatment in combination with external beam therapy and/or other modalities such as surgery or chemotherapy.

Brachytherapy may be performed concomitantly with surgical resection or in conjunction with procedures such as endoscopy or angioplasty, which are required to achieve access to the site of the disease. There are two distinct phases required to complete the process known as brachytherapy: the insertion of non-radioactive applicators or conduits that receive or transmit the radioactive material into the body and the loading of the radioactive material (the active or therapeutic agent) into the conduits or directly into tissue.

The typical requirements of brachytherapy may involve:

Brachytherapy (other than coronary, which is discussed in another policy) is routinely designated complex (77263) because it requires complex treatment volume design, dose levels near normal tissue tolerance, analysis or special tests, complex fractionation, or delivery concurrent with other therapeutic modalities or treatment of previously irradiated tissues. If brachytherapy is used as an adjunct to external beam therapy, a single complex treatment planning code is used to encompass both modalities, unless provided by a different provider in a different place of service.

Brachytherapy requires certain calculations be made throughout the course of treatment. Each necessary basic dosimetry calculation may be submitted when performed for brachytherapy treatment.

The delivery of brachytherapy often requires special arrangements with the operating room and radiation safe ward, coordination of the applicator insertion process with other specialists, preparation and provision of the applicators and related equipment, scheduling and integration of required physics support, and acquisition and preparation of the radiation sources.

Brachytherapy is often delivered in conjunction with external radiation, chemotherapy or surgery. Complex integration of these processes with brachytherapy may make a special treatment procedure code appropriate.

For brachytherapy, simulation may require the use of imaging examinations of the implanted sources or applicator(s) containing dummy (i.e., non-radioactive) sources. These films of the implanted sources are used to develop isodose curves and other dosimetry and may be billed separately, when appropriate. CPT code 77295 may be billed as part of the brachytherapy process when the needed parameters are included (i.e., three-dimensional (3D) volume reconstruction with dose volume histogram for target and normal tissues, etc.). Code 77295 precludes the use of codes 77326–77328 for the same treatment volume.

Brachytherapy requires an isodose plan. The plan determines the dose at each implanted source and throughout the treatment volume and doses to surrounding normal tissue.

Where brachytherapy techniques require the manual loading of an isotope (low-dose rate), the supervision, loading and handling of the isotope may be separately reported.

Selection and placement of afterloading applicators and the loading and unloading of radioactive sources may be performed by the radiation oncologist alone or in collaboration with another physician. Applicator placement:

Treatment devices may include the use of certain templates, molds or other apparatus that may be required for specific clinical circumstances. Premanufactured, commercially available devices are simple devices.

In some instances, measurement of the delivered radiation dose may be used to guide and determine the dose to selected positions within or around the implant treatment volume.

Indications:

Brachytherapy may be indicated as a primary or adjunctive therapy in a variety of tumors. A dose rate is selected based on the individual needs of the patient. Low-Dose Rate (LDR) and High-Dose Rate (HDR) brachytherapy are two delivery systems for brachytherapy which use radioactive material to deliver a dose of intensive radiation therapy to a specific well-defined local site (treatment volume). In both LDR and HDR, the treatment site should be defined and accessible to the applicators that are the delivery medium for the radioactive sources. This is done to treat a primary or metastatic neoplasm while sparing sensitive, adjacent normal tissues. LDR and HDR procedures may be given with the intent to cure, palliate or obtain local control (either cure or palliation). Both may be given in conjunction with a course of External Beam Radiation Therapy (EBRT), or as a single modality.

Limitations:

CPT Evaluation and Management (E/M) codes are available for use by the physician when seeing new patients in the office, the freestanding clinic or the hospital setting.

The physician’s professional component for the brachytherapy procedure includes any necessary hospital admission and hospital care during the time the patient is undergoing the brachytherapy procedure. Admission, subsequent hospital care and discharge day summary are included in the global fee for brachytherapy procedures.

Breast Brachytherapy by Balloon Catheter(s)

Payment for the insertion of the device necessary for placement of breast brachytherapy radiation source beads will be allowed, although the literature remains equivocal on the efficacy of this mode of brachytherapy. Nevertheless, until definitive literature is available, payment for this service will continue as long as the following criteria, based on a White Paper prepared by breast surgeons in 2003, are followed and clearly documented in the patient’s medical record. If these criteria are not met, the service will be denied as not medically reasonable and necessary.

All three requirements must be met:

The afterloading balloon catheter may be placed at the same operative session as the performance of the breast surgery (CPT code 19297) or at a subsequent session (CPT code 19296) when the following criteria are met:

An ultrasound may be performed to evaluate the presence, size and location of the fluid cavity, though this is a part of the procedure and not billed separately.

CPT code 19298 is used for placement of multiple tube or button-type catheters, whether done at the same session or subsequently, and these same above criteria must be met and documented in the record.

Compliance with the provisions in this policy is subject to monitoring by postpayment data analysis and subsequent medical review.

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

12X, 13X, 85X

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

CPT/HCPCS Codes

Billing for Brachytherapy Sources – General

Brachytherapy sources (e.g., brachytherapy devices or seeds, solutions) are paid separately from the services to administer and deliver brachytherapy in the OPPS, per section 1833(t)(2)(H) of the Act, reflecting the number, isotope, and radioactive intensity of devices furnished, as well as stranded versus non-stranded configurations of sources. Therefore, providers must bill for brachytherapy sources in addition to the brachytherapy services with which the sources are applied, in order to receive payment for the sources. The separately payable sources are found in Addendum B of the most recent OPPS annual update published on the CMS web site. New sources meeting the OPPS definition of a brachytherapy source may be added for payment beginning any quarter, and the new source codes and descriptors are announced in recurring update notifications.

Each unit of a billable source is identified by the unit measurement in the respective source’s long descriptor. Seed-like sources are generally billed and paid “per source” based on the number of units of the source HCPCS code reported, including the billing of the number of sources within a stranded configuration of sources. Providers therefore must bill the number of units of a source used with the brachytherapy service rendered.


Definition of Brachytherapy Source for Separate Payment

Brachytherapy sources eligible for separate billing and payment must be radioactive sources, meaning that the source contains a radioactive isotope. Separate brachytherapy source payments reflect the number, isotope, and radioactive intensity of sources furnished to patients, as well as stranded and non-stranded configurations.

 Billing of Brachytherapy Sources Ordered for a Specific Patient

A hospital may report and charge Medicare and the Medicare beneficiary for all brachytherapy sources that are ordered by the physician for a specific patient, acquired by the hospital, and used in the care of the patient. Specifically, brachytherapy sources prescribed by the physician in accordance with high quality clinical care, acquired by the hospital, and actually implanted in the patient may be reported and charged. In the case where most, but not all, prescribed sources are implanted in the patient, CMS will consider the relatively few brachytherapy sources that were ordered but not implanted due to specific clinical considerations to be used in the care of the patient and billable to Medicare under the following circumstances. The hospital may charge for all sources if they were specifically acquired by the hospital for the particular patient according to a physician’s prescription for the sources that was consistent with standard clinical practice and high quality brachytherapy treatment, in order to ensure that the clinically appropriate number of sources was available for the implantation procedure, and they were not implanted in any other patient. Those sources that were not implanted must have been disposed of in accordance with all appropriate requirements for their handling. In general, the number of sources used in the care of the patient but not implanted would not be expected to constitute more than a small fraction of the sources actually implanted in the patient. Under these circumstances, the beneficiary is liable for the copayment for all the sources billed to Medicare.

 Billing for Brachytherapy Source Supervision, Handling and Loading Costs

Providers should report charges related to supervision, handling, and loading of radiation sources, including brachytherapy sources, in one of two ways:

1. Report the charge separately using CPT code 77790 (Supervision, handling, loading of radiation source), in addition to reporting the associated HCPCS procedure code(s) for application of the radiation source;

2. Include the supervision, handling, and/or loading charges as part of the charge reported with the HCPCS procedure code(s) for application of the radiation source.

Do not bill a separate charge for brachytherapy source storage costs. These costs are treated as part of the department’s overhead costs.

Payment for New Brachytherapy Sources

Not otherwise specified (NOS) brachytherapy source codes are available for payment of new brachytherapy sources for which source codes have not yet been established: C2698 (Brachytherapy source, stranded, not otherwise specified, per source), and C2699 (Brachytherapy source, non-stranded, not otherwise specified, per source). The payment rates for these NOS codes are based on a rate equal to the lowest stranded or non-stranded payment rate for such sources, respectively, on a per source basis (as opposed, for example, to per mCi). Once CMS establishes a new HCPCS code for a new source, the new code will be assigned to its own APC, with the payment rate set based on consideration of external data and other relevant information, until claims data are available for the standard OPPS rate making methodology.

Correspondence Language Policy/Example Number 6.70000 – CPT “separate procedure” definition

For example, the code descriptor for CPT code 76000 (“Fluoroscopy (separate procedure), up to one hour physician time, other than 71023 or 71034 (eg, cardiac fluoroscopy)”) includes the “separate procedure” designation. When radiological supervision and interpretation (RS&I) for percutaneous transhepatic biliary drainage with contrast monitoring (CPT code 75980) is performed, the procedure described by CPT code 76000 does not meet the definition of a “separate procedure”. Therefore, CPT code 76000 cannot be reported separately and is bundled into CPT code 75980. Correspondence Language Policy/Example Number 7.70000 – More extensive procedure

For example, CPT code 72240 describes radiologic supervision and interpretation (RS&I) for cervical myelography. CPT code 72270 describes RS&I for myelography of two or more spinal regions (i.e. cervical/thoracic region, lumbar/thoracic region, lumbar/cervical region). If the myelography RS&I performed includes two or more spinal regions, one of which is the cervical region, the procedure described by CPT code 72270 is more extensive than the one described by CPT code 72240. Therefore, CPT code 72240 is bundled into CPT code 72270.

Extremity Imaging

Global and Physician Professional Payment coding & reimbursement guide 2017 SKELETAL HEALTH SOLUTIONS Additional Information:

1. Fluoroscopy reported as CPT Codes 76000 or 76001 is integral to many procedures including, but not limited, to most spinal, endoscopic, and injection procedures and should not be reported separately. For some of these procedures, there are separate fluoroscopic guidance codes which may be reported separately.

2. Fluoroscopic guidance reported as CPT 77002 is considered “bundled” with certain arthrography supervision and interpretation services (i.e., CPT Codes 73085, 73115,  73580 and 73615).

NCCI Procedure-to-Procedure (PTP) edits can be found on the CMS website: https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.htm

1. American Medical Association (AMA), 2017 Current Procedural Terminology (CPT), Professional Edition. CPT codes and descriptions only are copyright 2016 AMA. All  rights reserved. The AMA assumes no liability for data contained herein. No fee schedules, basic units, relative or related listings are included in CPT. Applicable FARS/DFARS Restrictions Apply for Government  Use. Centers for Medicare & Medicaid Services (CMS), 2017 Healthcare Common Procedure Coding System (HCPCS) codes, available at http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/Alpha-Numeric-HCPCS.html.

2. The 2017 physician relative value units (RVUs) are from the 2016 RVU file available on the CMS website at as of April 19, 2017.

3. The national average 2016 Medicare rates to physicians shown are based on the 2017 conversion factor of $35.8887 and do not reflect payment cuts due to  sequestration. Medicare payment for a given procedure in a given locality in 2017 should be available in the Medicare Physician Fee Schedule Look-up file accessible through the CMS website at
http://www.cms.gov/apps/physician-fee-schedule/overview. aspx. Any payment rates listed may be subject to change without notice. Actual payment to a physician will vary based on geographic location and may also differ based  on policies and fee schedules outlined as terms in your health plan and/or payer contracts.

Hologic Inc., provides this coding guide for informational purposes only. This guide is not an affirmative instruction as to which codes and modifiers to use for a  particular service, supply, procedure or treatment. It is the provider’s responsibility to determine and submit the appropriate codes and modifiers for any service, supply, procedure or treatment rendered.
Actual codes and/or modifiers

used are at the sole discretion of the treating physician and/or facility. Contact your local payer for specific coding and coverage guidelines. Hologic cannot  guarantee medical benefit coverage or reimbursement with the codes listed in this guide.  

ICD-9-CM Codes That Support Medical Necessity

The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.

Medicare is establishing the following limited coverage for CPT/HCPCS codes 77326, 77327, 77328, 77750, 77761, 77762, 77763, 77776, 77777, 77778, 77785, 77786, 77787, 77789, 77790 and Q3001:

Covered for:

Note: Limited coverage is not being established for the other services referenced in the LCD at this time.

Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.

Documentation Requirements