Susan Vannoni
031314
81 Modified For 04-10-14

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

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77300 4.01 per case, conventional treatment
77300 1.31 Electron treatment
77300 5.38 per case, all modalities
77300 6.05 per case IMRT (did not change with switch to use of 77338)
The averages is about 1.58 Dosimetries per conventional block, 77334, and 1.01 per 77338 for IMRT.
These ratios are lower for 2013 due to a drop in the average number of IMRT beams being used per case.
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3

NIB
Computer calculations (Varis/Aria)

MU CHECK IS COMPUTER GENERATED, BUT IS
CONSIDERED A SECOND (HAND) DOSE
CALCULATION
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9
•
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

Basic Dosimetry Calculations 77300
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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

Treatment Planning CT Scan and Isodose plans
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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.

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77305 - Simple Isodose Plan
77310 - Intermediate Isodose Plan
77315 - Complex Isodose Plan
77305 – 77315 ARE GLOBAL BILLING CODES

TWO FORMATS OF ISODOSE DISPLAY 15
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

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Clinical variations of the patient during therapy may necessitate a new plan being made and reported.
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Documentation Requirements
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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.

Special Beam Plan 77321 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

Isodose Plan may be Needed for Electron Treatment
77315
77321

Electron boost port
77321
Post operative
Parotid tumor
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Typical basal cell carcinoma of the tip of the nose treated with electrons

Electrons 77321
• This special beam consideration code is to be billed only one time for the course of treatment.
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• 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

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

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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.

77331 - 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
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• 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.
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• 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.

Narrative Microdosimetry report 77331 28

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.
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77332 - Treatment Devices; Simple
77333 - Treatment Devices; Intermediate
77334 - Treatment Devices; Complex
77338 – IMRT Single Block Charge
77332 -77334, 77338 ARE GLOBAL BILLING CODES
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77332 is <2% occurrence rate
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77333 is <1% occurrence rate
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77334 is 98% occurrence rate
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Immobilization devices account for 27% of 77334, about 1.64 per case.
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77332 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.
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80/150
Simple Treatment Block 36

• The use of bolus usually constitutes a simple device.
• It is a rare situation where a simple bolus is the only treatment device used.
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• 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
77334. You may not charge for the bolus.
85/150

77333 Intermediate Treatment Devices
Treatment Devices, design, construction or selection;
Intermediate (more than one area of port blocked - blocks, stints, bite blocks, special bolus)
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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)
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BILL AS
77334
A custom stint is being used to distance the electron treatment port away from the underlying gum

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MULTIPLE
SIMPLE
SKIN
LESIONS
1= Simple
2= Intermediate
This case has 3 or more sites;
Treatment planning is complex 77263
3+= Complex
Simulation (clinical simulation) is complex 77290
Blocks, treatment devices, are each simple, 77332 X 3
Dosimetry is done for each port, 77300 X 3

77334 Complex Treatment Devices
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Blocking for IMRT
In the case of IMRT treatment, each portal may use MLC custom shaped blocking,
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Eye Shields 77334
An eye shield is a complex multi-use device.
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43 Its application is highly complex and precise.
The radiation Oncologist must clinically place this eye shield with each treatment .

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)
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Vacuum Bags 77334 Bead filled vacuum bags are complex multi-use devices.
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Each vacuum bag is utilized only for a single patient throughout the entire course of therapy.

BILL AS
77332
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According to the ACR/ASTRO Code
Utilization & Application Subcommittee, the multiple setting breast board is now
considered as a simple treatment device.
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This opinion represents a consensus of coding practices from around the country, but does not constitute permission or prohibition for a given billing practice.

COMPENSATOR
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• 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.

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NIB
Milled brass proton beam shaping compensator
77334

IMRT COMPENSATOR
77334
NIB

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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

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

IMRT Compensator Blocking
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Each block or fluence is billed as 77334
Note; this is still the same as in previous years, do not use the single 77338 code for compensator blocking

Regardless of the complexity or design of the conventional therapy treatment device , some form of narrative may be required
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Device report for two immobilization devices, each of these will be billed as
77334, complex device.

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WHEN TO BILL TREATMENT DEVICES

Date of DESIGN of device
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Date of CREATION of device
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Date of USE of device

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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

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77336 - Continuing Medical Physics Services
77370 - Special Medical Physics Consult

The two special physics codes 77336 and 77370 are considered as technical services only.
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The physician may not bill for these procedures, however the physician is legally responsible for all physics procedures performed in his department.

77336 Continuing Medical Radiation Physics
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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
77336 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.

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
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•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 .

Patient Services covered by the radiological physics code 77336
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•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

77336
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)
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IMRT weekly physics report 77336

CONTINUING PHYSICS WITH
BRACHYTHERAPY
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Multiple procedures may be performed and billed by the physicist for his work related to a course of Brachytherapy.
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Most of these procedures are covered under the continuing physics code 77336 or a special physics consultation 77370.
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See the list on page 60.
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Continuing physics report, 77336, for Brachytherapy

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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.

77370 Special Medical Radiation Physics Consultation
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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.

Computerized physician order [CPO] requesting a physics consultation. This consultation will ultimately be billed as a 77370 special physics consult.
A direct request by the physician for this procedure is required.

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 77336.
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.
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Special Physics Consult
A review of the previous port films from Baptist Hospital show the port extended to the midportion 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 73110 – (405) 737-8455

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Some of the recent edits of Medicare will not allow any other 77300 series code to be billed on the same date as 77336 or 77370.
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

• The technical component of 77336 and
77370 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.
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Medicare assumes that a physics assessment (77336) is reported once for every week (five fractions) of external beam treatment.
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For other forms of radiation therapy that do not adhere to the five-fraction/week rule (e.g. brachytherapy, stereotactic), code 77336 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.

Special Medical Physics Consultations 77370
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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

BMSi 2014
End sect 8

8

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.

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77332 SIMPLE GENERIC DEVICES
NIB
PRE MADE CAST ELECTRON BLOCKS

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MOSFET SOLID
STATE
DOSIMETER
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Single use implantable dosimeter coupled with a telemetric passive transponder
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Capable of recording cumulative daily dose
Approved for use in prostate
Generally two are implanted
Urology code 55876 for implantation
Medicare professional $108.77 (2008)
Hospital code A4649
Medicare technical ~ $1,200.00

Antenna
Passive solid
State circuit
Mosfet
Reader circuit
Hand held wand
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77421
Stereoscopic localization, report daily for
IGRT
77331
Special
Dosimetry, can report cumulative dose, per dosimeter
EACH OF THESE PROCEDURES REQUIRES A SEPARATE REPORT

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

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.
60/150
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35/150
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.
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Electrons may enable the radiation oncologist to retreat 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.

77334
A wedge is a device that shapes the profile of the treatment beam to compensate for an angular plane of entry
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The most common immobilization device in
1970 was 3-M masking tape
NIB

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

Inflation device
NIB
Inflatable balloon Adjustable depth stop Vent
Depth gauge
Rectal balloon prostate immobilization device
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

NIB
Typical narrative report for the daily use of rectal balloon prostate immobilization devices, bill as
77334 one time every 5 uses, documentation required, may not be paid by Medicare,
CHECK YOUR LCD

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119/150

ACCUFORM IMMOBILIZATION DEVICE 51
BILL AS 77334 in addition to the Aquaplast face mask

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For private pay or commercial insurance plans, the code 77334 per fluence may still be valid.
Basic Dosimetry 77300 may still be billed one per fluence. CHECK YOUR LCD

Conventional
Treatment
Compensator
77334 documented by a physics report
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For Medicare and most insurance , you must report
IMRT blocking as 77338, one time per IMRT treatment plan , the basic Dosimetry 77300 may still be billed per fluence

77334
CCN Page 211 – Figure 12.33A 2002
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Multiple complex treatment devices
107/150
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77334
Custom Immobilization Device NIB
Tumor volume
Device
Tongue
Fixation/Immobilization device fabricated to separate the tongue from a lesion in the palate

Continuing Quality Assurance
•Machine calibration (usually done monthly)
•Interlock checks (usually done monthly)
•Source verification (usually done weekly or monthly)
•General radiation safety issues
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This report may be billed as a special physics consultation 77370