CPT Code 77280: Billing and Coding Guidelines for Radiation Oncology

Touseef Riaz

May 26, 2022

CPT Code 77280

Current Procedural Terminology (CPT) code 77280 falls under Clinical Treatment Planning (External and Internal Sources) for Radiation Treatment. CPT Code 77280 is maintained by the American Medical Association (AMA). Chapter 9 of CPT coding comprises billing codes for radiology services with codes ranging from 70000 – to 79999. Radiology services or procedures are sub-categorized into the following:

  1. Evaluation and Management (E&M) Services
  2. Non-interventional Diagnostic Imaging
  3. Interventional/Invasive Diagnostic Imaging
  4. Nuclear Medicine
  5. Radiation Oncology

CPT Code 77280-ucontrolbilling

 77280 CPT code description:

CPT code 77280 falls under Radiation Oncology of Radiology services. This code describes a simple level of service. According to AAPC, this CPT code for radiation treatment can be defined as:

“Use of a simulator or other imaging modality to determine the size and location of ports to be used for radiation therapy.” 

CPT Code 77280 description: 

Simple; simulation of a single treatment area.

CPT Code 77280 guidelines:

– Partial breast-high dose rate brachytherapy may be performed two times a day. The first therapeutic radiology simulation for the course of therapy may be complex and reported as CPT code 77290. However, subsequent simulations during the course of treatment shall be reported as CPT code 77280.

– IMRT plan (CPT code 77301) includes therapeutic radiology simulation-aided field settings. Simulation-aided field settings for IMRT shall not be reported separately using CPT codes 77280-77290.

– CPT codes 77280-77290 (Simulation-aided field settings) shall not be reported for verification of the treatment field during a course IMRT treatment.

Billing and coding guidelines for radiation Oncology:

Following the billing and coding guidelines for radiation oncology and using the correct codes ensures proper medical billing. However, errors in medical coding and billing result in the claim being denied or rejected.

Reasons for claim denials in Radiation Oncology:

There are several reasons/errors leading to claim denials for radiation oncology; some of the major reasons include the following:

  • If services are performed more frequently than they are generally accepted can result in claim denials as not medically necessary, i.e., excessive frequency.

– If the documentation doesn’t justify the reason behind the additional services or excessive frequency, it can lead to the claim being denied.

– If services for diagnosis that are listed as “non-covered” are performed, it will be denied.

– Providing the complete medical record is not necessary for the appeals of claim denials. However, the patient’s medical record that states the reason must be accompanied by the appeals for claim denials.

– The claim can be denied if all the documentation isn’t proper and specific to the patient under treatment.

– The claim will be denied as not medically necessary if the indications under the Coverage Indications, Limitations, and/or Medical Necessity section are not listed as covered.

– The freestanding facility cannot be paid for the technical component of radiation oncology services if a hospital inpatient is transported there. This payment will be denied unless the patient is treated as an outpatient at the freestanding facility after being discharged from the hospital.

– Per the course of therapy, the treatment planning is a professional service and is a one-time charge. Meaning it can’t be billed multiple times for a single course of treatment. The technical component is the responsibility of the physician in the treatment planning process.

Common CPT codes for Radiation Therapy:

Except for the 77280 CPT code, some of the other common CPT codes for radiation therapy include:

– CPT Code 77261:

Used when the volume of interest to be treated is clearly defined and easily encompasses the tumor while excluding normal tissue and structures. Simple planning requires a single treatment area of interest encompassed in a single port or simple parallel opposed ports with simple or no blocking.

Used when there is a moderate level of planning difficulty involved. It requires three (3) or more converging ports, two (2) separate treatment areas, multiple blocks, or special time dose constraints. 

Intermediate simulation for two (2) separate treatment areas. The provider uses a simulator or other imaging modality to determine the size and location of ports to be used for radiation therapy.

Complex simulation for three (3) or more treatment areas, or any number of treatment areas if any of the following are involved: 

  1. Particle
  2. Rotation or arc therapy
  3. Complex blocking
  4. Custom shielding blocks 
  5. Brachytherapy simulation
  6. Hyperthermia probe
  7. Verification
  8. Any use of contrast materials. 

– CPT Code 77431

Complete course of radiotherapy treatment that is divided into one or two small doses called fractions. This code covers one or two fractions only, and these two fractions must be given over a number of weeks.

– CPT Code 77432

Stereotactic radiotherapy treatment in which a three–dimensional coordinate system to locate small targets or lesions inside the brain is used. It involves the complete course of stereotactic radiotherapy treatment. 

The small targets are destroyed with precision using externally generated ionized radiation. There’s only one session for this treatment, and this code represents the professional component only.

– CPT Code 77435:

Stereotactic body radiotherapy treatment involves a three–dimensional coordinate system. It is done to locate small targets or lesions inside the body except for the brain and spinal cord. It involves the complete course of stereotactic radiotherapy treatment. 

The entire course of treatment does not exceed five fractions and targets one or more lesions. The small targets are destroyed with precision using externally generated ionized radiation. 

– CPT Code 77469:

Complete course of intraoperative radiation treatment in which physician administers radiation therapy in the form of irradiating X–rays or electron beams. This treatment is done directly to the exposed tumor during surgery. 

CPT Code 77470:

Special radiotherapy procedures require special consideration from the provider in the overall management of radiotherapy treatment.

Process of Care for Radiation Oncology:

The process of care for radiation oncology can be broken down into six steps:

  1. Consultation with the patient
  2. Preparing for the treatment:
    1. Clinical Treatment planning
    2. Simulation
  3. Medical radiation physics, treatment devices, special services, and dosimetry.
  4. Delivering the radiation therapy
  5. Management of the radiation therapy treatment
  6. Follow-up care management
  1. Clinical Treatment Planning:

After the evaluation of the patient in the initial consultation, the radiation oncologist makes a decision to administer radiation therapy treatment. The patient’s extent of the disease and overall condition, integrated with the plan of the therapy, the clinical treatment planning process is triggered. CPT codes 77261, 77262, and 77263 are clinical treatment planning procedure codes. These billing codes are the professional charges for the healthcare physician. Specific and proper parameters are determined by the radiation oncologist in clinical treatment planning for the therapeutic management plan. For each patient’s safe and effective radiation treatment/therapy, the clinical treatment planning parameters also include overall:

  • Clinical aspects
  • Physical aspects
  • Technical aspects

Clinical treatment planning also includes:

  • Determining the treatment modality
  • Total dose
  • Fractionation
  • The need for planned field changes
  1.     Simulation:

The next step in radiation oncology is targeting the tumor physically or the treatment volume to ensure treatment delivery accuracy. It is the step after proper parameters for the patient’s treatment plan are determined in the clinical treatment planning. Simulation involves defining:

  • Target anatomy (Normal and abnormal)
  • Acquiring the data and images necessary to develop the optimal radiation treatment process.
  • All of this without actually delivering the radiation therapy.

The exact treatment position of the patient is determined by the radiation oncologist involving the radiation therapist’s assistance. It is done by using simulation equipment. This step involves using CPT codes, including CPT codes 77280-77290 and +77293. Depending on the type of cancer, clinical response of the patient, and radiation therapy, the simulation may be repeated over the course of treatment.

Challenges associated with Radiation Oncology Billing:

There are several challenges associated with radiation oncology medical billing. These errors and challenges affect the revenues and reimbursements of the healthcare practice and physicians. Errors in medical billing and coding lead to the claims being denied or rejected. Some of the common mistakes include:

  • Incomplete or inaccurate claims
  • Incomplete documentation
  • Service frequency
  • Upcoding
  • Under coding
  • Unbundling

In order to overcome these errors and challenges:

  • Verify patient insurance coverage, eligibility criteria, and information
  • Accurate, complete, and organized patient records and documentation
  • Keep up with the coding and billing guidelines as well as the payer’s coding requirements.

Radiation Oncology:

Radiotherapy or radiation therapy is a treatment option for cancer that uses high-energy waves to destroy the cancer cells. This approach is based on the type and stage of cancer along with any other health conditions of the patient.

Radiation therapy utilizes high-energy x-rays (photons) for cancer treatment. These waves are delivered via a linear accelerator and are painless and invisible. The radiation oncologist is the lead or primary physician for radiation therapy. However, the entire team may comprise:

– Radiation therapy nurse

– Dosimetrist

– Radiation therapist

How does it work?

Several different types of cancers can be treated by radiation therapy via both external and internal radiation therapy.

External Radiation Therapy:

External radiation therapy involves the use of an external machine aiming radiation at the location of cancer. By changing the directions of the device, these radiations target or aim precisely at the cancerous part.

Internal Radiation Therapy:

Based on the type of cancer, radiation treatment involves inserting the radiation source (solid or liquid) inside the body. Solid source internal radiation therapy is also known as brachytherapy. Similar to external radiation therapy, internal radiation therapy also treats a specific part of the body. Brachytherapy involves inserting seeds, ribbons, or capsules with radiation sources near the tumor or in the body. 

Types of cancers that can be treated by radiation therapy:

Several types of cancers can be treated using the external radiation beam. However, cancers of the head, breast, neck, eye, prostate, and cervix are most often treated by internal radiation treatment, e.g., brachytherapy.

Systemic Radiation Therapy drugs are also used to treat various types of cancers including prostate, bone, and thyroid. Systemic radiation therapy drugs are known as radiopharmaceuticals.

Frequently Asked Questions (FAQs)

  • What is CPT code 77280 in medical billing?

Current Procedural Terminology (CPT) code 77280 falls under Clinical Treatment Planning (External and Internal Sources) for Radiation Treatment. It is a Simple; simulation of a single treatment area. And can also be defined as:

“Use of a simulator or other imaging modality to determine the size and location of ports to be used for radiation therapy.”

  • What are common CPT code 77280 errors?

There are several challenges associated with the radiation oncology billing; some of the common challenges include:

– Incomplete or inaccurate claims

– Incomplete documentation

– Service frequency

– Upcoding

– Under coding

  • How do you prevent the CPT code 77280 coding errors?

In order to overcome the errors and the challenges in radiation oncology billing:

– Verify patient insurance coverage, eligibility criteria, and information

– Accurate, complete, and organized patient records and documentation

– Keep up with the coding and billing guidelines as well as the payer’s coding requirements.

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