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Coding & Billing
Getting Paid to Treat Prostate Cancer
Denis Rodriguez
Publish Date: August 7, 2008   |  Tags:   Financial Management

From a reimbursement standpoint, there's never been a better time for ambulatory surgery centers to treat prostate cancer with brachytherapy implants. Here are three reasons why:

Did You Know?

According to the American Cancer Society, about 180,000 to 200,000 new prostate cancer patients will be diagnosed and receive some type of treatment for the disease this year. In most cases, the treatment of choice is radiation, which has been shown to have equivocal cure rates in studies as compared to conventional prostate surgery, but with lower percentages of post-treatment complications of impotence and incontinence.

  • Beginning Jan. 1, CMS approved ASCs to bill for all technical services for the day of the implant of radioactive seeds. The CMS reimbursement approval includes the disposable radioactive seeds, which will be reimbursed on a per-seed basis.

Before the new payment system took effect, radiation oncologists had to bill for the radioactive seeds, which can range from $1,500 to $4,000 per case depending on their composition, palladium or iodine, and the quantity of seeds required for the treatment of the patient's cancer. At the rate of three to five cases per month for an average radiation oncologist, this was quite a burden on their practice.

  • Additionally, ASCs can continue to bill a facility fee, CPT code 55875, which has a reimbursement of $1,377.66, $154.64 more than the 2007 payment rate and one of the higher facility reimbursement codes for any ambulatory surgery center operating room case. After the four-year phase-in, the fully implemented payment rate will be $1,493.64.
  • In addition to the approval of these new codes, physician-owned surgery centers are now exempt from federal Stark regulations if they perform and bill for these codes. Up to December 2007, CMS considered prostate brachytherapy a "designated healthcare service" that fell under federal self-referral laws if physicians referred patients to ASCs in which they had ownership and those ASCs billed for the technical services and for the radioactive seed sources.

Getting Paid for Brachytherapy Sources That Weren't Implanted

When coding for brachytherapy sources, 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's important to code per source and not per strand. 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 weren't implanted under the following circumstances:

  • 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.
  • The sources that were not implanted in that beneficiary were not implanted in any other patient.
  • The sources that were not implanted were disposed of in accordance with all appropriate requirements for their handling.
  • The number of sources used in the care of the beneficiary but not implanted would not be expected to constitute more than a small fraction of the sources actually implanted in the beneficiary.

Absent these circumstances, it would be inappropriate 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.

— Denis Rodriguez, CPC, CCS

Coding tips
When coding for prostate brachytherapy, it's helpful if you 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. Let's review each of these components.

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, or seeds, are placed via the needles into the prostate. This is done under imaging guidance.

Often a urologist will perform the needle placement portion of the procedure and a radiation oncologist or radiologist will perform the source implantation. Many times one physician will perform the entire procedure. Whether one or two physicians perform the procedure, the facility coder will assign the same codes, 55875 for the needle insertion and 77778 for the source implantation. 77778 is for complex source application, which, according to the September 2005 CPT Assistant, is for application of more than 10 sources. Prostate brachytherapy normally involves the application of between 40 and 150 sources.

According to the code descriptor, 55875 includes a cystoscopy performed at the same session as brachytherapy.

The non-wage adjusted transitional payment for 2008 is $1,377.66 for code 55875 and $243 for code 77778. This includes the procedural component of the code as well as the imaging component, which we will discuss next.

Imaging components. Imaging is normally performed during every aspect of prostate brachytherapy. 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. Often fluoroscopic guidance (77002) is performed in addition to ultrasound guidance.

The ultrasound volume study of the prostate, 76873, is a "separate procedure" and bundles into 77778 per CCI edits. It is considered included in 77778; therefore you shouldn't code it separately.

Ultrasound and fluoroscopic guidance don't bundle into the main procedure codes (55875 and 77778) per CCI edits. But because they're assigned payment indicator N1, their payment is "packaged" into or included in the payment for the main code. When looking at the $1,377.66 payment for 55875, we can consider this to include payment for ultrasound and fluoroscopic guidance.

We know that we shouldn't separately report bundled codes on a claim, but what about packaged codes? According to CMS, packaged codes should not be listed separately on a claim. However, we should add the charge for the packaged code 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. The 55875 line item charge would therefore be $6,100 instead of $5,500.

Commercial payors by and large haven't yet incorporated the packaging concept for ASCs; separate payment for 76965-TC may be available as this code isn't bundled into any other brachytherapy procedure.

Supply and source components. For 2008, ASCs will be able to use HCPCS Level II C codes associated with needles and radioactive sources. These C codes were previously restricted to hospital outpatient departments under OPPS.

Code needles used in brachytherapy to C1715 (report C1715 per needle, not per procedure). Code C1715 has an N1 payment indicator and its payment is packaged into the main procedure 55875.

Code brachytherapy sources to the appropriate C code as shown in the table on page 27. Two codes have been developed for sources that don't yet have a HCPCS code assigned: C2698 for stranded and C2699 for non-stranded sources. Only use these codes for sources that are FDA approved and marketed and consist of a radioactive isotope consistent with CMS' definition of a brachytherapy source eligible for separate payment as discussed in the Nov. 24, 2006, final rule (71 FR 68113).

Coding for Brachytherapy Sources

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

Making it manageable
Coding for brachytherapy can be challenging. Breaking the coding down to manageable components will help you to get the most for each procedure and ensure correct coding and compliance.

Billing for Packaged Services: Don't Unbundle

How should you bill for packaged services, implants and devices under the new ASC payment system? Unlike the grouper payment system, the new payment system packages device payment into the procedure payment, meaning you shouldn't unbundle devices as separate line-item charges. But be sure the single charge reported for a device-intensive procedure includes not only such charges associated with the service as OR time and PACU use, but also charges associated with the implantable device, says CMS. If you bill a procedure code for a device-intensive procedure and don't include device charges in establishing the single line-item charge for the procedure, the procedure charge may be lower than the Medicare payment rates for that procedure code, which includes device payment. The contractor would make payment based on the provider's charges, possibly resulting in underpayment.

Let's look at rotator cuff repair (23412, 23410, 23420, 29827) with use of suture anchors (C1713). The suture anchors have an N1 status indicator, which signifies they're packaged. If you bill $5,000 for the rotator cuff repair and you used three $300 suture anchors for the case, then you'd bill for the CPT code for the rotator cuff with a charge of $5,900 on the claim form.

— Lisa Weston, CPC-H, LHRM

Ms. Weston ([email protected]) is director of ambulatory surgery center coding services for The Coding Network (www.codingnetwork.com).

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