Section 6Section 6Clinical Treatment PlanningClinical Treatment Planning

For External Beam,For External Beam,Brachytherapy & Brachytherapy &

HyperthermiaHyperthermia

Modified for Modified for 04-10-144040

0313140313141:30 to 2:00 PM1:30 to 2:00 PM

Carl R Bogardus, Jr MD

The Physician’s Clinical The Physician’s Clinical Treatment Plan is the single Treatment Plan is the single most important document in most important document in the clinical recordthe clinical record

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THE CLINICAL TREATMENT PLAN

It is here that the Physician describes in detail the plan of therapy.

The plan lays out the initial logic of the proposed course of treatment.

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DescriptionDescription

•The clinical treatment planning The clinical treatment planning process is a comprehensive process is a comprehensive cognitive effort performed by the cognitive effort performed by the radiation oncologist for every radiation oncologist for every patientpatient..

•This is a professional service of This is a professional service of the physician performed at the the physician performed at the beginning of a course of radiation beginning of a course of radiation therapy.therapy.

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The course of therapy should be

planned as completely as

possible before the first treatment is

delivered.

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Multiple types of Multiple types of clinical treatment clinical treatment plan formats are plan formats are

available available depending upon depending upon

the proposed the proposed mode of therapy mode of therapy

to be plannedto be planned

NIBNIB

Each of these Each of these has an entirely has an entirely different set of different set of

questions to questions to be answeredbe answered

It must be understood that treatment planning is usually a one-time charge per course of therapy. CPT does not allow the flexibility of reporting multiple treatment plans for a single course of treatment unless a major change in the course of therapy has occurred.

If the patient develops a new problem, AND A NEW ICD-9 CODE IS NEEDED, then, a new or modified course of radiation therapy will be required, and a new treatment planning code may be reported at that time.

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Second Clinical Treatment Plan Warning

The original plan may be modified as the course of

therapy progresses and the patient’s condition changes

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Occasionally the clinical treatment plan will be modified more than one time. Each modification may change the intent of the plan but is not a billable event.

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Occasionally the entire intent of the plan must be

changed, still use the addendum format.

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If a change is made in the physicians clinical treatment plan is often a very good idea to also include a note in the weekly progress note outlining that these changes have occurred..

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Additional clinical Treatment Plans

Absolute CCI edits will prohibit payment for additional plans.

Multiple plans may be required if different modalities are being utilized such as a mixture of photons and electrons.

The physician must establish medical necessity for any additional plans.

Payment may still be denied.

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Documentation Documentation RequirementsRequirements

Definition of the Definition of the field of treatmentfield of treatment Selection of the Selection of the beam energybeam energy to be used to be used Selection, or combination, of Selection, or combination, of treatment treatment

modalitiesmodalities Identification of the Identification of the tumor volumetumor volume Identification of Identification of critical structurescritical structures An indication of the An indication of the time/dosetime/dose plan of therapy plan of therapy An indication of the estimated An indication of the estimated final target final target

dosagedosage An indication of any An indication of any limiting dosageslimiting dosages or dose or dose

pointspoints

• Documentation must be maintained in Documentation must be maintained in the patient’s medical record to the patient’s medical record to include evidence of the planning include evidence of the planning processprocess covering, but not limited to: covering, but not limited to:

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RATE OF RATE OF OCCURRENCEOCCURRENCE 77261 Simple 3% 77262 Intermediate 1% 77263 Complex 96%77263 Complex 96%

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CPT Codes 77261 - Therapeutic Radiology Treatment Planning;

Simple77262 - Therapeutic Radiology Treatment Planning;

Intermediate77263 - Therapeutic Radiology Treatment Planning;

Complex

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CODES 77261 – 77263 ARE PROFESSIONAL CODES ONLY

Basic Definitions asPublished in CPT 2009

77261 Simple Treatment Planning

A few advanced disease treatment situations will fall within the category of simple treatment planning:

Small, single ports with simple or no blocking on a patient with a relatively uncomplicated history

Many benign disease treatments.

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- Clinical Case - Carcinoma of the breast with bone metastasis.

This patient was initially diagnosed four years ago with a carcinoma of the breast. The patient underwent a radical mastectomy followed by multi-drug chemotherapy.

A bone scan showed metastatic disease in the T1-T2 area. She was treated with radiation therapy and had a good response. She now returns with a painful lumbar spine with a positive MRI scan.

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Metastatic disease to the lumbar spine77

NIBNIB

CCN Page 121 – Figure 10.01B 2002

Simple treatment planning caseSimple treatment planning case NIBNIB

Simple Plan 77261

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Basic Definitions asPublished in CPT 2009

77262 Intermediate Treatment Planning

Two separate treatment areas

Patients with bone metastasis in two different sites, bone and brain metastasis

Uncomplicated lung cancer, whole pelvis irradiationor other uncomplicated situations

Simple parallel opposed portals

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- Clinical Case -

62-year-old female, twenty years post-menopausal.

Patient recently had a D & C, which showed adenocarcinoma of the endometrium with involvement of 2/3 of the wall of the uterus.

She is now post-hysterectomy and is being planned for radiation therapy to the whole pelvis.

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The treatment planning will be at the intermediate level.

There are two sets of intermediate blocks, the AP/PA and laterals.

7726277262

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Basic Definitions77263 Complex Treatment Planning

The patient may have early or advanced disease, which is complex in its distribution.

The treatment volume may contain multiple critical structures that may require planning of special protection.

Brachytherapy hyperthermia, chemotherapy, or surgery, may be planned.

Three or more areas may require treatment.

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- Clinical Case -

53-year-old male with a diagnosis of a primary brain tumor, a Glioblastoma multiforme.

Recently operated by the neurosurgeon with subtotal removal of the primary tumor.

The patient is now being seen in Radiation Oncology to be treated postoperatively with IMRT to the high risk area in an attempt to prevent recurrence.

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The location in the brain, and the use of complex IMRT treatment makes this a very complex treatment plan.

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- Clinical Case -

53-year-old female with Stage IV carcinoma 53-year-old female with Stage IV carcinoma of the breast, post chemotherapy.of the breast, post chemotherapy.

Collapse of T5 due to metastatic disease.Collapse of T5 due to metastatic disease.

Patient now being treated with Taxol.Patient now being treated with Taxol.

Patient cautioned regarding cross Patient cautioned regarding cross toxicity of treatment with toxicity of treatment with concurrent chemotherapy.concurrent chemotherapy.

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Complex treatment planning Complex treatment planning

casecase

CCN Page 125 – Figure 10.05 2002

There may be special circumstances where relatively simple treatment may become complex due to the proximity of critical structures, previous treatment fields, chemotherapy, or other situations. These cases require very thorough documentation as to reason and benefit.

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The concurrent use of chemotherapy drives The concurrent use of chemotherapy drives the treatment planning to the complex level.the treatment planning to the complex level.

Historical BackgroundHistorical Background The definitions for simple, intermediate, and complex treatment planning, dosimetry, simulation, and treatment delivery slowly evolved over the years from the first mention in AMA/CPT for radiation therapy in the early 1970's.

The ACR/ASTRO User's Guide for 2007 continued to expand and change the definitions of simple, intermediate, and complex until today the literal interpretation of these definitions can place over 95% of all radiation therapy procedures at the complex level.

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Assignment of the level of treatment Assignment of the level of treatment planning should not be done until the planning should not be done until the physician has fully described all of the physician has fully described all of the parameters of the case.parameters of the case.

The treatment plan complexity The treatment plan complexity level must be set, dated, and level must be set, dated, and billed prior to the first day of billed prior to the first day of treatmenttreatment..

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Definitions

The assignment of the correct CPT Code for all radiation oncology procedures depends not only upon the primary factors relating to that procedure, but the complex interrelationship with other procedures performed before, during, or afterwards.

This protocol will allow you to weigh all of these factors and arrive at the correct level of complexity assignment. ONCOCHART performs this function automatically.

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Scoring Treatment Planning

• These factors form the foundation of a simple plan.

• An intermediate group of factors have a higher level of intensity and may require more than one to allow the appropriate elevation of complexity to the intermediate level.

• There are other factors that carry enough time and work requirements to bring planning into the complex realm.

There are basic factors that must always be present in treatment planning:

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Start the scoring process at the complex level. If any of these items are found, then the score is complex.

If none are found, then look in the intermediate group.

If none found here, the score will be simple by default as there will always be one or more of the simple items needed for treatment.

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Scoring Clinical Treatment Planning

Complex FactorsComplex Factors; If any of these ; If any of these factors are found, factors are found, Clinical, Clinical, treatment treatment planning will be scored as 77263planning will be scored as 77263

Intermediate Factors; If any of these factors are found, clinical treatment planning will be scored as intermediate, 77262.

Minor or Simple Factors; If any or all of these factors are found, clinical treatment planning will be scored as simple 77261

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This is a typical radiation oncology prescription form developed by a NCI panel in 1970 and still used today in someCenters and hospitals.

For clinical conventional treatment planning, the basic questions don’t change

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ARIA-VARIANARIA-VARIANPHYSICIAN’SPHYSICIAN’STREATMENT TREATMENT PLANNINGPLANNINGDOCUMENTDOCUMENT

NOTE THE NOTE THE SAME SET OF SAME SET OF QUESTIONSQUESTIONSBEING ASKEDBEING ASKED

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ONCOCHART ONCOCHART Treatment PlanningTreatment Planning

SAME QUESTIONS, DIFFERENT FORMAT

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A Treatment Planning A Treatment Planning Narrative Should be Narrative Should be createdcreatedTo Complement the fill-To Complement the fill-outoutDocument for Document for completeness.completeness.

Note the use of Chemotherapy as well as IMRT.

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7726377263

Clinical Treatment Planning

What’s it for?The process utilized by the physician while developing a plan of care.

Who normally documents these codes?The Physician must produce a written document

When are these codes normally billed?When the prescription for treatment is written prior to the start of treatment.

What Documentation is suggested for this code?A written plan or filled out prescription form

What are the common errors identified with these codes?Inadequate documentation, Wrong level of complexity for the service documented, Incorrect date of service, Multiple billing of this one time per course of therapy code.

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PRINCIPLES OF BILLING, CODING AND

COMPLIANCE IN RADIATION ONCOLOGY

BMSi 2014 END SECT END SECT 66

End Section 6End Section 6

End Section 6End Section 6

CCN Page 122 – Figure 10.02 2002

The treatment planning will be

at the intermediate

level. There are two sets of

intermediate blocks, the AP/PA and laterals.

Four-port whole pelvisFour-port whole pelvis

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Complex Complex FactorsFactors

• Planning for IMRT, 3-D, or mixed beams.• Need for PET , MRI, or angiography for planning. • Three or more volumes to be planned• Moving portals, arcs.• Conformal collimation planned• Conformal shaped treatment blocks may be planned

to more than four ports• Conformal MLC blocking• Five or more ports planned for a single volume• Custom blocked, primary treatment with electrons• One or more complex isodose curves required to plan

the course of treatment• Use of brachytherapy is planned• Chemotherapy administered within the three months

prior to starting treatment• Concurrent chemotherapy planned with the course of

treatment• Re-treatment of a previous radiation therapy field

must be considered

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Intermediate Factors

•Two separate areas or volumes to be planned for treatment•Custom blocking for relatively simple treatment•Intermediate MLC blocking•Four or fewer ports per single volume of treatment to be planned•The physician must consider the consequences of treatingsensitive structures•Simple immobilization devices may be required•Simple isodose curve to be planned•The patient may be preoperative or postoperative•Microdosimetry, TLD, diode, etc., planned•Wedge or compensator to be planned for relatively simpletreatment•Custom designed bolus to be planned for relatively simpletreatment•Use of electrons planned as part of course of treatment

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Minor or Simple Factors

• Single area or volume to be planned for treatment• Simple or no blocking or bolus to be planned• Simple MLC Blocking• No special testing required.• Use of a single port or simple parallel opposed ports• Simple, unblocked electron port for small skin lesion• X-ray photons, any energy, cobalt 60 teletherapy,

kilovoltage, any energy• A single central axis dose point is all that is required

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This will be This will be afternoon afternoon session session covering covering

section section 66, 5, , 5, andand 99

Dr BogardusDr Bogardus

Dr BogardusDr Bogardus

Scott SimmonsScott SimmonsSusan VannoniSusan Vannoni

THIS SCHEDULE MAY BE MODIFIED DEPENDING UPON SPEAKER

AVAILABILITY

PRINCIPLES OF BILLING, CODING AND

COMPLIANCE IN RADIATION ONCOLOGY

BMSi 2013 END SECT END SECT 66Next Session at 1:30 to 3:00Next Session at 1:30 to 3:00

Section #5 E/M CodesSection #5 E/M Codes