By Tammy McCausland and Susan Vannoni
Susan Vannoni, founder and CEO of Radiation Oncology Consulting LLC (ROC), provides some helpful answers in this Q&A to common questions about treatment delivery and management of stereotactic radiosurgery (SRS) and stereotactic body radiotherapy (SBRT). All codes listed in this Q&AA are from the AMA CPT.
Responses to the questions in this Q&A regarding coding are the opinions of Radiation Oncology Consulting (ROC) and may not constitute the rulings of Medicare or private payers. ROC is not liable for any errors in these answers. Please check your specific carrier restrictions and review your local medical review policy (LMRP)/local coverage determinations (LCD). All coding must be supported by documentation of the facility’s records.
A: Stereotactic radiotherapy is defined as the use of external beam radiation using stereotactic guidance to deliver very precise doses of radiation. Stereotactic radiosurgery (SRS) is a non-surgical radiation therapy used to treat functional abnormalities and small tumors of the brain. Stereotactic body radiotherapy (SBRT) is used to treat small tumors of the body.
A: There are three techniques for delivering stereotactic radiation: Gamma Knife; CyberKnife (SRS and SBRT); and conventional external beam (SRS and SBRT). To clarify, SRS is considered the domain of the neurosurgeon, and it’s limited to the cranial vault. SRS is also limited to one fraction of treatment, which can be delivered using a Gamma Knife, a linear accelerator, a tomotherapy unit, or a CyberKnife unit.
A: Treatment Delivery (Technical):
77371 is the technical payment code when using a multi-source Cobalt 60 based unit.B
77372 is the technical payment code that one would use for SRS single treatment. This code is used for radiation treatment delivery.C
When the treatment is delivered to the cranial vault, and if the treatment exceeds one fraction, then the treatment delivery should be considered SBRT. SBRT is treatment delivery using one (1) to five (5) fractions. When the treatment is classified as SBRT, the cranial vault is included in the body. One question that persists is: “What if I do two treatments to the cranial vault? Is it still SRS?” No, it’s now considered SBRT. The technical payment then will be reimbursed as Stereotactic Body Radiation Therapy (77373D) per fraction.
Management Codes (Professional):
For one treatment (SRS), the management (professional) codes for the doctors is 77432E for management of Gamma Knife one (1) treatment only, or for CyberKnife, one (1) treatment only. When there is more than one treatment, the management code changes to SBRT management (professional) and the code that should be used is 77435F.
A: The number of treatments is important. Frequently, I get the question, “Can I give six SBRT fractions? Can I give seven SBRT fractions?” The answer that I frequently give to this question is if the treatment regimen exceeds five treatments, then it’s considered intensity-modulated radiation therapy (IMRT) or conventional therapy.
People seem to think that they can mix and match treatment modalities, and that should not be the case. One either uses stereotactic methodology or IMRT methodology for treatment delivery and management. If the course exceeds five fractions one should consider the treatment delivery (77386) for IMRT treatment delivery and the physician must then report their professional component as 77427G.
Only one of these management codes can be used, and the code should not be used on the same day of service or during the same course of treatment. For example, if one begins with IMRT, the professional code would be 77427 once per five fraction week. Never mix and match either SRS or SBRT with conventional methodologies such as IMRT. These codes—77427, 77432 and 77435—are mutually exclusive, and they can’t be used sequentially.
A: I think because they don’t understand the differences between SRS, SBRT, IMRT and conventional rules. The rules and edits change quarterly and one should stay abreast of the changes.
A: If one uses 77295 as there planning modality (not 77301), then one may capture a verification simulation (77280) prior to SRS treatment.
A: What isodose plan should I capture? Should I capture a three-dimensional isodose plan (77295), or do I capture an IMRT isodose plan (77301)?”
Historically, 3D isodose planning (77295) was always used for stereotactic forward-planned treatment and because you are using the treatment codes for either SRS or SBRT, my opinion is that one should use a 3D plan (77295). If one uses an IMRT plan (77301), the payers are going to be looking for the delivery of the treatments to be IMRT. One could bill a simulation if one uses 3D (77295) as one’s isodose planning methodology. However, if one’s using the IMRT plan (77301), one cannot bill any simulations (77280–77290) because they are bundled into the IMRT code.
Another question I’m asked constantly is, “Can we capture IGRT with SRS or with SBRT?” My answer is no, as guidance codes are bundled as is stated in the AMA ® CPT code book.
Another question not only from managers or administrators, but also from physicians is: “Is there anything specific insofar as dose that one needs to deliver when they’re using SRS or SBRT?” I don’t think there’s anything published as to what dose specifically to administer, but the dose, is determined by the tumor type and the goal of the physician specific to the patient’s case.
A: There are always questions about removal of the head frame. 20660, the code for application of the Gamma Knife stereotactic frame, includes removal, and that code is a neurosurgical code. It is not a code that is used in radiation therapy because it’s usually a neurosurgeon who puts this frame on for the stereotactic Gamma Knife.
A: To recap: SBRT is used as the technique of treating small localized lesions, so it’s done either by a linear accelerator, Tomotherapy or CyberKnife. It’s important to focus that this methodology is used for small lesions using a higher dose per fraction than conventional or IMRT treatment. A physician may treat a lung or a brain, and then might be inclined to want to do a “stereotactic boost,” but that’s not why it was designed. It was designed to treat small lesions, focusing on the tumor while sparing the normal tissue, and irradiating the tumor with high dose fractionation in five or less treatments.
A. Responses to the questions in this Q&A regarding coding are the opinions of Radiation Oncology Consulting (ROC) and may not constitute the rulings of Medicare or private payers. ROC is not liable for any errors in these answers. Please check your specific carrier restrictions and review your local medical review policy (LMRP)/local coverage determinations (LCD). All coding must be supported by documentation of the facility’s records.
B. AMA CPT defines this code as “Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion (s) consisting of one session.”
C. AMA CPT defines this code as “Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion (s) consisting of one session linear accelerator based.”
D. AMA CPT defines this code as “treatment delivery per fraction to one or more lesions, including image guidance, entire course not to exceed 5 fractions.”
E. AMA CPT defines this code as “Stereotactic radiation treatment management of crainial lesion (s) (complete course of treatment consisting of one (1) session.”
F. AMA CPT defines this code as “Stereotactic body radiation therapy, treatment management, per treatment course to one (1) or more lesions including image guidance, entire course not to exceed five (5) fractions.”
G. AMA CPT defines this code as “Radiation Treatment Management, five (5) treatments.”