Coding 101 for Radiation Therapists

The first few years for a radiation therapist are unlike any other time in their career. They have learned a lot while earning their degree and obtaining their American Registry of Radiologic Technologists (ARRT) certification. However, they are just starting to gain real experience with patient care.  

While patient care remains the top priority for radiation therapists, it’s important to acknowledge their involvement in charge capture and billing. Who is better than the person providing the services to the patient to capture the representative codes? Even if they’re not tasked with reporting billing codes or fully grasping billing intricacies, therapists bear the responsibility of doing their best to get it correct.  
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The Role of Radiation Therapists in Coding and Billing ​

The ARRT certification as a radiation therapist includes a Standards of Ethics, which includes a component on engaging in fraudulent billing practices. Whether a radiation therapist works in a hospital setting and only works with the hospital’s procedure codes or in an office setting with the standard procedure codes, they both represent the same services. Understanding the fundamentals of coding will assist radiation therapists as they continue to grow in their expertise and can open many opportunities to expand their careers. 

Types of Billing Codes

There are two different sets of codes used for billing outpatient services: 

1. Diagnosis codes represented by the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) 
2. Procedure codes represented by Current Procedure Terminology (CPT®) and Healthcare Common Procedure Coding System (HCPCS) 

Responsibilities in Diagnosis Coding (ICD-10-CM):

Most radiation therapists are not responsible for assigning the diagnosis code to each patient based on the physician’s initial visit or consult notes. However, they are responsible for knowing what they are treating their patients for and ensuring they select the correct ICD-10-CM code in ARIA® or MOSAIQ® when they capture the procedure codes for their work.  
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Supporting Medical Necessity:

Diagnosis codes support medical necessity, which is required for the CPT® codes to be properly reimbursed. A good rule of thumb is to remember, “Billing only occurs where the radiation occurs.” ICD-10-CM codes should support the immediate location where the radiation therapist is treating the patient. Because patients can be treated simultaneously — or at various times throughout their lives — for different diagnoses, it is crucial to appropriately capture the correct ICD-10-CM code for the services being provided. Whether the patient has both primary and metastatic (secondary) disease or just one of them, it is important to ensure the diagnosis codes reported on a particular day of service are accurate to support that day’s simulation, radiation treatment, or other service. 
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Updates and Considerations for ICD-10-CM Codes:

ICD-10-CM codes are updated twice per year by the Centers for Disease Control (CDC) and the Centers for Medicare and Medicaid Services (CMS). Updates are typically released approximately 4 months before they go into effect on 1 October each year. Recently, an additional update was added to go into effect on 1 April of each year. It is important to understand this as an ICD-10-CM code that was used earlier in the year may be different than what is used later in the year for the same diagnosis.
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Procedure Codes (CPT®/HCPCS):

CPT® codes are created and managed by the American Medical Association (AMA). The codes, their definitions, and applications for use are annually updated for billing purposes. HCPCS codes are also CPT® codes, but they refer to more than just the codes from the AMA. They also include those created by CMS to use for billing (e.g., G codes used for IGRT and radiation treatments in the office setting). Both of these codes are 5-digit numeric-only or alpha-numeric codes. If a radiation therapist is currently working with longer, multi-digit hospital codes, they may notice the CPT® or HCPCS codes embedded within them upon closer inspection. Hospital codes are converted to the recognized 5-digit code when billed to payers. 
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EMR Coding Responsibilities:

Radiation therapists must accurately capture codes in their EMR, such as ARIA or MOSAIQ, for the work and services provided to the patient. Even if they do not know all the nuances of billing and what can and cannot be billed together, they must capture their work. Inaccurate coding poses risks beyond improper reimbursement, including audits and penalties. 
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Importance of Correct Coding:

While CPT®/HCPCS codes represent what is to be paid for, ICD-10-CM codes determine if payment is received. It’s a key responsibility for radiation therapists to ensure everything provided to the patient for their diagnosis is communicated accurately to the billing staff to avoid improper reimbursement or not being reimbursed at all. Radiation therapists can stay up to date by understanding the “rules” for coding and billing, and how those rules can direct what can be billed and reimbursed. There are many resources available to assist them with doing so.  
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​Coding and Billing Considerations in Different Settings:

Hospital outpatient departments and freestanding centers adhere to different billing and reimbursement codes and regulations. Freestanding centers and physicians’ offices operate under CMS guidelines and are reimbursed via the Medicare Physician Fee Schedule (MPFS), while hospital outpatient departments follow CMS guidelines and are reimbursed through the Hospital Outpatient Prospective Payment System (HOPPS). CMS categorizes freestanding centers as non-facility settings and hospitals (both outpatient and inpatient) as facility settings. 
One example of how important it is for a radiation therapist to know their setting is the G codes. Those working in the non-facility setting will bill them for image-guided radiation therapy (IGRT) and radiation treatments (e.g., G6002, G6012, G6015, etc.), while facility settings will use CPT® codes (77387, 77412, 77385, etc.).  

IMRT Coding and Billing Practices Example:

Intensity-Modulated Radiation Therapy (IMRT) billing practices also differ between hospital outpatient departments and freestanding centers. Here are some key distinctions: 

• Facility Fee: Only available in the outpatient hospital setting, CMS guidelines allow for the billing of a facility fee (G0463). This fee covers the overhead costs associated with providing services in a hospital, such as the use of equipment, administrative staff, and infrastructure at the time of an evaluation and management (E/M) visit. This often represents the nurse’s time with the patient which is separate from any time the physician spends with the patient. This is not billable in the freestanding center or physician’s office.  

• Coding and Documentation: In the facility setting, the hospital uses the appropriate CPT® codes for IMRT services, such as CPT® 77385 for breast and prostate multileaf collimator (MLC)-based IMRT treatment delivery and 77386 for all other MLC-based IMRT treatment delivery. For the facility setting, the technical component of IGRT is included in the IMRT treatment, so it cannot be billed separately. Because the physician does not bill for treatments delivered in the hospital, they can bill for IGRT and will report the specific codes per the type of IGRT when their review is performed timely and following applicable rules. 

In a freestanding center, the G codes are used to bill treatment delivery, for IMRT regardless of the diagnosis, report code G6015 for all MLC-based treatments. Because the definition of G6015 does not state imaging is included, the IGRT performed and supported could be billed both technically and professionally. 

• Reimbursement Rates: CMS uses different methods for determining payment rates under MPFS and HOPPS. Generally, the hospital outpatient reimbursement rate plus the physician professional rate added together may be higher than the global (technical plus professional component) rate in a physician’s office. The reimbursement rates for both settings are updated annually.  
• Physician Supervision Requirements: CMS guidelines specify varying levels of supervision for therapeutic services such as direct supervision in a physician office and general supervision in hospital outpatient settings. However, hospitals may adjust and also require direct supervision. Direct physician supervision requires the physical presence of the physician in relation to clinical staff while billing for services directed by the radiation oncologist. Billing for physician work is different, physicians cannot supervise themselves and are expected to be on-site and personally performing the work they are billing for with the professional component. 

For services like stereotactic radiosurgery (SRS), stereotactic body radiotherapy (SBRT), and brachytherapy, there are different rules for physician presence. SRS and SBRT require the physician to provide direct supervision regardless of setting, and for any service with radionuclides, including GammaKnife with Cobalt-60 (Co-60), the physician must be personally present at the treatment console. 
There may be additional factors and variations depending on the specific circumstances and contracts between providers and CMS. Consulting the latest CMS guidelines and seeking professional billing advice is advised for accurate and up-to-date information. 
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CMS Proposed and Final Rule:

Some of the guidelines, regulations, policies, and payments referred to throughout this article are defined each year as part of the MPFS and HOPPS proposed and final rules. Many commercial payers follow CMS guidance, but the proposed and final rules are specifically published for Medicare/Medicaid. 

Proposed Rule:

Each year CMS proposes what they plan for the coming year for payment rates, HCPCS codes (specifically G codes), and other regulatory expectations in a “Proposed Rule” released around mid-July. Stakeholders, specialty societies, and healthcare professionals have 60 days to review and submit comments on recommended changes to the proposal before the changes go into effect. CMS considers these comments before publishing the updated codes and guidelines later in the year and making them official in the “final rule.” 
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Final Rule

CMS releases final rules for MPFS and HOPPS annually by 1 November, outlining new payment rates and regulatory guidelines effective 1 January of the following year. These rules incorporate feedback CMS received on proposed changes, with explanations for accepted or rejected suggestions. Due to tight deadlines, data volume, and potential legislative changes, a correction notice may be issued later to address errors or Congressional interventions. It’s crucial for stakeholders responsible for revenue tracking to stay updated on any last-minute adjustments, especially payment rates. 

The Role of Radiation Therapists in the Bigger Picture:

Understanding the intricacies of coding and billing may seem overwhelming for radiation therapists, but it plays a crucial role in providing quality patient care, especially for cancer patients. Accurate and compliant coding allows administrators to allocate resources effectively and ensures patients receive necessary treatments without financial strain. Improper charge capture can lead to denied claims, cause delays in treatment, and add financial stress for patients. It is essential for therapists to adhere to annual guidelines and ethical standards outlined by organizations like ARRT, ensuring clear documentation and accurate code selection. 

Therapists must be familiar with coding requirements specific to their practice setting, whether it’s a hospital outpatient department, freestanding center, or physician’s office. Staying updated on CMS guidelines and regulatory changes is vital for maintaining compliance and optimizing reimbursement rates. Ultimately, accurate coding isn’t just about financial reimbursement; it’s about supporting clinical decision-making, ensuring transparent documentation, and contributing to the overall cycle of patient care. By embracing their role in the revenue cycle, radiation therapists can enhance the quality of care they provide to patients.