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Optimizing Reimbursement for Radioembolization: The Importance of Adequate Documentation

Clinical trials evaluating the use of Yttri-

um-90 (Y90) transarterial radioemboliza-

tion for hepatic tumors date back to the

1960s.1 In recent years, Y90 has been increasingly

utilized in treating hepatic metastases and hepatocel-

lular carcinoma (HCC) with improved outcomes.2 In

1999, the US Food and Drug Administration (FDA)

approved the use of TheraSphere (BTG) particles

for HCC via the humanitarian device exemption.

Subsequently, in 2002, SIR-Spheres (Sirtex) par-

ticles were approved for the treatment of hepatic

colorectal cancer metastases with adjuvant intrahe-

patic artery chemotherapy of FUDR (floxuridine).

Since then, Y90 has been utilized for a variety of

off-label indications, such as neuroendocrine tumor

metastases, breast metastases, uveal melanoma metas-

tases, cholangiocarcinoma, sarcoma, prostate cancer,

ovarian metastases, melanoma, renal cell carcinoma,

Rishi Chopra, MS1; Jason C. Hoffmann, MD1; Amanjit S. Baadh, MD2 From 1Winthrop University Hospital, Department of Radiology, Mineola, New York, and 2Rush University Medical Center, Department of Interventional Radiology, Chicago, Illinois.

ABSTRACT: Purpose: This article aims to review radioembolization-specific coding guidelines so that interventional radiologists can develop a better understanding of what documentation is essential in their reports, leading to appropriate authorization and reimbursement. Background: Over the past 10 years, interventional radiologists (IRs) have been performing increasing numbers of radioembolization procedures in treatment of hepatic malignancy. This article will review coding for radioembolization procedures, from initial interventional radiology clinic visit to postprocedure follow-up imaging. The article will highlight the importance of adequate documentation during clinic visits, image-guided interventions, and postprocedure cross-sectional imaging to ensure efficient insurance authorization and maximal reimbursement. Materials and Methods: The treatment of liver tumors with radioembolization merges key concepts well known to radiation oncology and interventional radiology practices. A typical radioembolization case includes the ini-tial patient consultation; a diagnostic angiogram to allow for treatment planning and possible pretreatment embolization of arteries such as the gastroduodenal artery, right gastric artery, and/or supraduodenal artery; and the actual yttrium-90 radioembolization treatment. SPECT nuclear medicine scans for tumor localiza-tion and contrast-enhanced multiphasic cross-sectional imaging for therapy planning and follow-up are also obtained. Thorough documentation of patient history, indications for treatment, appropriateness of therapy, and dosimetry calculations by interventional radiologists are critical to obtain procedural approval by insur-ance companies and appropriate reimbursement. This article will detail the current procedural terminology codes relevant to radioembolization and highlight the importance of adequate documentation throughout the treatment process. Conclusion: The emergence of radioembolization in the treatment of hepatic malignancy brings challenges for IRs that make clear, precise documentation critical. An understanding of radioembolization coding will allow IRs to provide improved documentation, leading to more efficient treat-ment authorization and reimbursement by insurance companies.

Key words: yttrium-90, radioembolization, interventional oncology, reimbursement, billing, codingCopyri

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and other hypervascular metastases.3,4 Radioembo-

lization has demonstrated efficacy in the treatment

of colorectal carcinoma liver metastases, with reports

indicating improved overall survival from 9 months

to 15.4-17.2 months.2,5 This burgeoning use of Y90

radioembolization as a successful, novel treatment

modality for liver tumors requires interventional ra-

diologists to familiarize themselves with coding, so

that they are prepared to provide clear documen-

tation in procedure reports to obtain authorization

and optimize reimbursement.

Traditionally, interventional radiologists performed

arterial embolization and radiation oncologists per-

formed brachytherapy. However, Y90 radioemboli-

zation unites both of these disciplines via Y90 mi-

crospheres that are placed intra-arterially by an

interventional radiologist. Over the past decade, in-

terventional radiologists have been performing in-

creasing numbers of radioembolization procedures

in the treatment of intermediate- to advanced-stage

liver-only or liver-dominant hepatic malignancy.

However, unlike more traditional interventional on-

cologic procedures, Y90 radioembolization requires

more comprehensive initial evaluation and manage-

ment visits. Additionally, the documentation of treat-

ment planning, radiation dosimetry calculations, and

placement of radioactive sources are usually under

the purview of radiation oncology and unfamiliar

territory for the interventional radiologist. Conse-

quently, these new developments present novel chal-

lenges with regards to coding and billing.

Coding for the administration of Y90 can be quite

complex, as the multiple components of the procedure

can result in a complicated procedure report. Each

case presents a unique set of circumstances, and thus,

it is essential that a well-organized operative report

be maintained. For example, a separate current pro-

cedural terminology (CPT) code is assigned to each

artery into which a catheter is placed for diagnos-

tic imaging or intervention, and the operative report

should describe this in detail. In order to receive ap-

propriate procedural approval by insurance payers as

well as optimum reimbursement, it is imperative that

interventional radiologists adequately document the

patient history, indications for treatment, appropri-

ateness of therapy, and dosimetry calculations. Thus,

an understanding of peer-reviewed guidelines and/

or other reasons for treatment can be critical for ap-

propriate payment. Logical and sequential documen-

tation of the procedure allows certified coders to bet-

ter understand every aspect of the case so that they

can then accurately identify and apply CPT codes to

optimize reimbursement.

This article will review radioembolization-specific

coding guidelines so that interventional radiologists

recognize the importance of proper documentation

during clinic visits, image-guided interventions, and

postprocedure cross-sectional imaging to ensure op-

timum reimbursement. In addition, this article will

review the coding for radioembolization procedures

from initial patient consultation to postprocedure

follow-up imaging.

PROCEDURE OVERVIEWIn entirety, the Y90 procedure involves (1) an ini-

tial patient consultation; (2) diagnostic angiogram to

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allow for treatment planning; (3) possible pretreat-

ment embolization of arteries; (4) SPECT nuclear

medicine scans for evaluation of shunt fraction and

tumor localization; (5) cross-sectional imaging to

evaluate tumor volumes, overall tumor burden, plan

treatment, and confirm liver-only or liver-dominant

disease; (6) Y90 radioembolization treatment; and

(7) clinical follow-up — including office visits, labs,

and multiphasic contrast-enhanced cross-sectional

imaging. As previously stated, this procedure re-

quires proficiency in certain aspects of clinical care

that are less familiar to the interventional radiolo-

gist, such as comprehensive initial evaluation and

management visits as well as radioactive seed place-

ment, which presents novel challenges with respect

to coding for reimbursement.

OVERVIEW OF CURRENT PROCE-DURAL TERMINOLOGY CODES

Coding for the procedure involves billing for 3

clinical services: (1) pretreatment office visit or

consultation, (2) pretreatment radiation planning,

and (3) treatment (Figure 1).

Pretreatment Office Visit or Consultation

The CPT codes for “pretreatment office visit or

consultation” are (1) 99201 – 99205 “initial office

visit,” (2) 99211 – 99215 “subsequent office visit,”

and 99241 – 99245 “office consultation” (not for

Medicare patients).

It is imperative to properly document the request

for consultation, document key elements of evalua-

tion and management (history, physical exam, level

of medical decision making, and/or the amount of

time spent with the patient), report any clinical di-

agnoses (listing the most pertinent to microsphere

therapy as the primary diagnosis), and provide a re-

port of consultation to the requesting physician if

appropriate (Tables 1 and 2). Although interven-

tional radiologists may be tempted to use the CPT

99241-99245 “office consultation” codes, which

Figure 1. Overview of current procedural terminology codes.

1. Clinical service: pretreatment office visit or consultation a. 99201 – 99205 initial office visitb. 99241 – 99245 office consultation

2. Clinical service: pretreatment radiation planninga. 77261 – 77263 clinical treatment planning b. 77300 basic radiation dosimetry valculation c. 77470 special treatment procedure

3. Clinical service: treatmenta. 77790 supervision, handling, and loading of radiation sourceb. 79445 administration of radiopharmaceutical, intra-arterial

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offer greater reimbursement, Medicare does not re-

imburse for these codes even if all requirements are

met.

Pretreatment Radiation PlanningThe CPT codes for “pretreatment radiation plan-

ning” are (1) 77261 – 77263 “clinical treatment

planning,” (2) 77300 “basic radiation dosimetry cal-

culation,” and (3) 77470 “special treatment proce-

dure.”

“Clinical treatment planning” offers insight into

the considerations regarding the procedure plan and

also outlines details of the selected plan. This should

include a review of prior imaging/biopsy/surgery,

details of any treatment already received, correla-

tion of physical exam with prior testing, treatment

volume determination, toxicity or tolerance con-

cerns, treatment time/dosage and sequence of treat-

ment modality, orders and medical reasons for im-

aging guidance (including frequency and modality),

TABLE 1. NEW PATIENT VISIT

CPT code 99201 99202 99203 99204 99205

REQUIRED KEY COMPONENTS (3/3 REQUIRED)

History and exam

• Problem-focused ✓

• Expanded problem-focused ✓

• Detailed ✓

• Comprehensive ✓ ✓

Medical decision making (complexity)

• Straightforward ✓ ✓

• Low ✓

• Moderate ✓

• High ✓

CONTRIBUTORY FACTORS

Presenting problem (severity)

• Self-limited or minor ✓

• Low to moderate ✓

• Moderate ✓

• Moderate to high ✓ ✓

Counseling

Coordination of care

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any concerns or variables unique to the patient, and

care coordination. If an interventional radiologist is

performing the procedure without a radiation on-

cologist, the treatment plan must be documented

separately from the procedure report. The “basic ra-

diation dosimetry calculation” should include the

physician’s order, identify the areas being treated,

provide the dose (GBq), and include a physician sig-

nature and date. “Clinical treatment planning” can

only be billed once per case, whereas “basic radia-

tion dosimetry calculation” can be billed as often as

necessary. Finally, the “special treatment procedure”

is used when extra time is required beyond the ba-

sic radiation dosimetry calculation, and this should

include prior treatment and outcome, a review of

current computed tomography (CT), liver function

studies, Eastern Cooperative Oncology Group per-

formance, and a dose calculation entry.

TABLE 2. ESTABLISHED PATIENT VISIT

CPT Code 99201 99202 99203 99204 99205

REQUIRED KEY COMPONENTS (2/3 REQUIRED)

History and exam

• Problem-focused ✓ ✓

• Expanded problem-focused ✓

• Detailed ✓

• Comprehensive ✓

Medical decision making (complexity)

• Straightforward ✓ ✓

• Low ✓

• Moderate ✓

• High ✓

CONTRIBUTORY FACTORS

Presenting problem (severity)

• Self-limited or minor ✓

• Low to moderate ✓

• Moderate ✓

• Moderate to high ✓ ✓

Counseling

Coordination of care

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TreatmentLastly, the CPT codes for “treatment” are (1) 77790

“Supervision, Handling and Loading of Radiation

Source” and (2) 79445 “administration of radio-

pharmaceutical, intra-arterial.”

In terms of specific treatment codes, this will de-

pend on whether the “authorized user” is the in-

terventional radiologist or someone else, such as

nuclear medicine physician or radiation oncologist.

Thus, the billing in terms of the treatment codes

will have some variability based on the infrastruc-

ture at each institution.

When documenting “supervision, handling, and

loading of radiation source,” it is important to note

the physician’s prescription and medical directive for

the microsphere dose, which includes a statement

about the observation of radiation safety standards

as well as the technical component charge (but also

appropriate in a freestanding facility). For “admin-

istration of radiopharmaceutical, intra-arterial,” the

dose of Y90 microsphere and its successful delivery

to the tumor bed should be recorded.

Postprocedure scintigraphy is typically utilized

following both the mapping procedure and the ra-

dioembolization procedure. The imaging that oc-

curs in the nuclear medicine department after ad-

ministration of Tc-99m macroaggregated albumin

or Yttrium microspheres can be planar (78201) or

SPECT (78205) liver imaging. This report is typi-

cally dictated by the nuclear medicine physician.

PITFALLS IN DOCUMENTATIONThe consequences of incomplete documentation

are not strictly restricted to reduced reimburse-

ment, as it can also result in an audit conducted

by a medical recovery audit contractor or insurance

company, which may generate additional fines and

repayments. The most common components miss-

ing in the procedure report are fluoroscopy time,

sedation start and end times, and a detailed account

of the arteries and anatomic sites accessed.6

It is important for the interventional radiologist

to know which procedures are covered by Medi-

care, Medicaid, and particular private insurers. With

respect to Y90, Medicare has reimbursed providers

under the hospital code C2616 in the hospital out-

patient setting. The FDA indicates that Y90 is ap-

proved for the treatment of unresectable metastatic

liver tumors from primary colorectal cancer with

adjuvant intrahepatic artery floxuridine (FUDR)

chemotherapy.7 On the other hand, Medicaid may

or may not reimburse, and consequently, the hos-

pital should review their Medicaid fee schedule to

determine the level of reimbursement. In the past,

Y90 therapy has been reimbursed by Aetna, An-

them, Cigna, United Healthcare, Health Net, Hu-

mana, Oxford, and Blue Cross/Blue Shield.7

When using Y90 off label, it is paramount to ad-

here to standard coding rules, especially if reim-

bursed by Medicare. If appropriate listed codes ex-

ist, these should be used to describe the procedure.

On the other hand, if no appropriate codes exist,

use “not otherwise classified or unlisted” procedure

codes. The interventional radiologist should also

submit supporting clinical documentation explain-

ing medical necessity of the off-label use.

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CONCLUSIONThe addition of Y90 radioembolization to the ar-

senal of the interventional radiologist has created a

unique set of challenges to proper reimbursement. A

more comprehensive initial evaluation and clinical

management, documentation of treatment planning,

radiation dosimetry calculations, and administration

of radioactive sources are unfamiliar territory that

requires clear and precise documentation. An un-

derstanding of radioembolization coding will al-

low interventional radiologists to provide improved

documentation, leading to more efficient treatment

authorization and optimum reimbursement.

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bolization with Yttrium-90 microspheres: review of

an emerging treatment for liver tumors. Future Oncol.

2007;3(1):73-81.

2. Mahnken AH, Spreafico C, Maleux G, Helmberger

T, Jakobs TF. Standards of practice in transarte-

rial radioembolization. Cardiovasc Intervent Radiol.

2013;36(3):613-622.

3. Giannini EG, Farinati F, Ciccarese F, et al; Italian Liver

Cancer (ITA.LI.CA) group. Prognosis of untreated

hepatocellular carcinoma. Hepatology. 2015;61(1):184-

190.

4. Liu DM, Cade DN, Knight J, et al. Yttrium-90 radio-

embolization. Endovasc Today. 2008 June. Available at:

evtoday.com/pdfs/EVT0608_08.pdf

5. Kallini JR, Gabr A, Salem R, Lewandowski RJ. Tran-

sarterial radioembolization with yttrium-90 for the

treatment of hepatocellular carcinoma. Adv Ther.

2016;33(5):669-714.

6. Sirtex. Coding sheet January 2016: pre-treatment

mapping and microspheres administration: hospital

outpatient, ASC and physician services. Available at:

http://www.sirtex.com/media/70435/2016-sirtex-

coding-sheet-updated032116-final.pdf

7. Healthcare Administrative Partners. How to docu-

ment y-90 radioembolization cases to maximize reim-

bursement. Available at: http://info.hapusa.com/Blog/

bid/72834/How-to-Document-Y-90-Radioemboli-

zation-Cases-to-Maximize-Reimbursement

Editor’s note: The authors have completed and re-turned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no financial relationships or conflicts of interest regarding the content herein.

Manuscript received April 20, 2016; manuscript ac-cepted June 29, 2016.

Address for correspondence: Amanjit S. Baadh, MD, Rush University Department of Radiology, 1653 W Congress Pkwy, Chicago, IL 60612, United States. Email: andybaadh@yahoo.com.

Suggested citation: Chopra R, Hoffman JC, Baadh AS. Optimizing reimbursement for radioemboliza-tion: the importance of adequate documentation. Intervent Oncol 360. 2016;4(8):E136-E142.

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