Anyone associated with ASCs is aware of the sweeping changes CMS has instituted to the facility payment system. Few specialties or procedures have undergone more changes than prostate brachytherapy.
When coding for prostate brachytherapy, think in terms of coding for each "component" of the procedure. There are several steps of the brachytherapy procedure that are separately reportable, and several supplies and implants now have new codes associated with them.
Procedural components
Prostate brachytherapy involves insertion of needles or catheters through the perineum into the prostate. Once these needles are placed into the desired areas of the prostate, radioactive sources known as seeds are then placed via the needles into the prostate. This is done under imaging guidance.
A urologist will often perform the needle placement portion of the procedure, and a radiation oncologist/radiologist will perform the source implantation. In many cases, one physician will perform the entire procedure. Whether one or two physicians perform the procedure, the facility coder will assign the same CPT codes: 55875 for the needle insertion and 77778 for the source implantation. 77778 is for complex source application, which, according to the Sept. 2005 CPT Assistant, is for application of more than 10 sources. Prostate brachytherapy normally involves application of between 40 and 150 sources. According to the code descriptor for 55875, it includes a cystoscopy performed at the same session as brachytherapy.
The non-wage adjusted transitional payment for 2008 is $1377.66 for 55875 and $243 for 77778. This includes the procedural component of the code and the imaging component, which we discuss next.
Imaging components
Imaging is normally performed throughout a prostate brachytherapy session. An ultrasound volume study of the prostate (76873) is often performed perioperatively. Ultrasound guidance for placement of the needles and sources into the prostate (76965) is also performed. Fluoroscopic guidance (77002) is often performed in addition to ultrasound guidance.
While the ultrasound volume study of the prostate, code 76873, is a "separate procedure," it bundles into 77778 per CCI edit rules. This code should therefore not be coded separately and is considered included in 77778.
Ultrasound and fluoroscopic guidance do not bundle into the main procedure codes (55875 and 77778) per CCI edits; however, they are assigned payment indicator N1, which means that their payment is "packaged" into or included in the payment for the main code. When looking at the payment for 55875, we can consider the $1377.66 to include payment for ultrasound and fluoroscopic guidance.
We know that bundled codes should not be separately reported on a claim, but what about packaged codes? According to CMS, packaged codes should not be listed separately on a claim. However, the charge for the packaged code should be added to the charge for the main procedure on the same line item.
For example, let’s say your facility charges $5,500 for code 55875 and $600 for code 76965-TC. There would be no separate line item for code 76965-TC on the claim; however, the charge of $600 would be added to the charge for 55875. Therefore, the 55875 line item charge would be $6,100 instead of $5,500.
Commercial payors have typically not yet incorporated the packaging concept for ASCs, and a separate payment for 76965-TC may be available, as this code is not bundled into any other brachytherapy procedure.
Supply and source components
As stated earlier, brachytherapy involves the use of needles and radioactive sources. This year, ASCs can use HCPCS Level II C codes associated with these materials. These C codes were previously restricted to hospital outpatient departments paid through the outpatient prospective payment system.
Needles used in brachytherapy can be coded using C1715. C1715 is reported per needle, not per procedure. Code C1715 has an N1 payment indicator and its payment is packaged into the main procedure code 55875.
Brachytherapy sources should be coded to the appropriate C code as shown in the table below. Two codes have been developed for sources that do not yet have a HCPCS code assigned: C2698 for stranded sources and C2699 for non-stranded sources. Make sure you only use these codes for sources that are FDA-approved and marketed and that consist of a radioactive isotope consistent with CMS’s definition of a brachytherapy source eligible for separate payment, as discussed in the Nov. 24, 2006 final rule (71 FR 68113).
HCPCS Code Descriptor
C2638 Brachytherapy source, stranded, Iodine-125, per source
C2639 Brachytherapy source, non-stranded, Iodine-125, per source
C2640 Brachytherapy source, stranded, Palladium-103, per source
C2641 Brachytherapy source, non-stranded, Palladium-103, per source
C2698 Brachytherapy source, stranded, not otherwise specified, per source
C2699 Brachytherapy source, non-stranded, not otherwise specified, per source
When coding for brachytherapy sources, you should enter the total number of units prescribed and acquired for the beneficiary on the line item for the appropriate HCPCS code. For stranded sources it is important to code per source and not per strand.
But what if most, but not all, of the sources acquired for a patient are implanted into that patient? Medicare will cover the few brachytherapy sources that were not implanted in the following circumstances:
1. The sources were specifically acquired by the ASC for the particular beneficiary according to a physician’s prescription that was consistent with standard clinical practice and high-quality brachytherapy treatment.
2. The sources that were not implanted in that beneficiary were not implanted in any other patient.
3. The sources that were not implanted were disposed of in accordance with all appropriate requirements for their handling.
4. The number of sources used in the care of the beneficiary — but not implanted — would be expected to constitute a small fraction of the sources actually implanted in the beneficiary.
If these circumstances are not present, then it would not be appropriate to bill Medicare for the non-implanted sources. Commercial payors may have different guidelines for billing non-implanted sources.
Medicare payment for brachytherapy sources is at contractor-priced rates.
Associated procedures
There are other procedures associated with brachytherapy that you may code in addition to those already described. Computer-generated, three-dimensional reconstruction may be used for brachytherapy. Documentation is required with three-dimensional reconstruction and dose distribution. The scan images used for computer data entry should be based on three-dimensional depictions of the implanted site. The source positions may be digitized directly from these images or the three-dimensional reconstruction, and the tumor volume and normal tissue image may be merged electronically. Code 77295 can be used to report this at a non-wage adjusted transitional payment of $561.48 for 2008. Please note that simple three-dimensional representations by treatment planning computer programs derived from planar radiographic images are not sufficient justification for the use of this code.
When you perform basic dosimetry calculation during brachytherapy (the determination of dwell times other than those times estimated in the isodose plan), you can report code 77300 (transitional payment of $44.18). You should include the treating physician’s prescription, as well as documentation of the calculation, in the patient’s chart.
Coding for brachytherapy can be challenging. Breaking the coding down to manageable components will help you to get the most for each procedure while ensuring correct coding and compliance.
Mr. Rodriguez (denis.rodriguez@email.com) is a senior ASC coder and compliance auditor for The Coding Network, the country’s largest specialty-driven coding and auditing company. For more information, visit www.codingnetwork.com.