September 2016

Radiology Billing and Coding: Radioembolization Reimbursement
By Melody W. Mulaik, MSHS, CRA, FAHRA, RCC, CPC, CPC-H
Radiology Today
Vol. 17 No. 9 P. 10

There are many types of percutaneous treatments available to treat liver tumors, depending on their stage and location. Interventional radiologists may perform radiofrequency ablation; cryoablation; chemical tumor ablation using ethanol, acetic acid, or chemotherapy drugs (chemoembolization); and/or radioembolization. Radioembolization is the use of radioactive microspheres to embolize the vessels feeding a liver tumor. The spheres kill cancer cells both by irradiation and by cutting off the blood supply to the tumor.

Radioembolization is also known as selective internal radiation therapy. While this procedure has wide acceptance and even payment by the Centers for Medicare & Medicaid Services for specific diagnoses, it is important to note that some third-party payers do not cover radioembolization because they consider it to be experimental, or alternatively, they cover it for very specifically defined criteria. For example, according to information published on Aetna's website (www.aetna.com/cpb/medical/data/200_299/0268.html), the company "considers intrahepatic microspheres (eg, TheraSphere, MDS Nordion Inc; SIR-Spheres, Sirtex Medical Inc) medically necessary for any of the following":

• treatment of neuroendocrine cancers (ie, carcinoid tumors and pancreatic endocrine tumors) involving the liver; for carcinoid tumors, intrahepatic microspheres are considered medically necessary only in persons who have failed systemic therapy with octreotide to control carcinoid syndrome (eg, debilitating flushing, wheezing, and diarrhea);

• unresectable, primary hepatocellular cancers (HCC);

• unresectable liver tumors from primary colorectal cancer; or

• preoperative use as a bridge to orthotopic liver transplantation for HCC.

Aetna, according to the company's website, "considers intrahepatic microspheres experimental and investigational for metastases from esophageal cancer and gallbladder cancer and other indications because of insufficient evidence in the peer-reviewed literature."

The coding information and guidelines provided in this article are based on authoritative guidance by the American Medical Association (AMA); however, the ultimate decision of coverage, coding, and payment is up to each individual payer. Individual payer guidelines should be reviewed and complied with to ensure compliant billing practices.

There are two agents that are approved by the FDA for radioembolization: SIR-Spheres and TheraSpheres. Both agents contain radioactive yttrium (Y-90). Federal regulations require radioactive materials to be handled by an "authorized user" (AU). The Nuclear Regulatory Commission allows an interventional radiologist to be an AU for Y-90 microspheres when the physician meets specific requirements for training and experience. If the interventional radiologist is not an AU, he or she may administer Y-90 treatment in collaboration with a radiation oncologist.

From a radiology perspective, the largest component of the procedure is usually the delivery of the radioactive microspheres, which is an embolization procedure. The embolization portion of the radioembolization procedure is reported with procedure code 37243 (Vascular embolization or occlusion, inclusive of all radiological supervision and interpretation, intraprocedural roadmapping, and imaging guidance necessary to complete the intervention; for tumors, organ ischemia, or infarction). Procedure code 37243 is reported once per operative field; for radioembolization procedures, this code is usually reported only once. If the patient has separate liver tumors in the right and left lobes that are both being treated during the same encounter, it would be appropriate to bill two units of 37243. Medicare does not recognize 37243 as eligible for modifier 50 (bilateral) so, if bilateral embolizations are performed in separate surgical fields, the second embolization should be reported with modifier XS (Separate structure), 76, or 59, or as instructed by the payer.

Catheter placements and diagnostic arteriograms are separately reportable. However, it is not appropriate to assign procedure codes for any celiac and left hepatic arteriograms performed for roadmapping in a patient who has had diagnostic arteriograms at a prior encounter. The most recent authoritative guidance provided for radioembolization was included in the Summer 2015 edition of Clinical Examples in Radiology, copublished by the AMA and the ACR. This publication stated that the arteriogram performed from the final catheter position immediately prior to Y-90 administration is reportable as a diagnostic study. That said, it is important to remember that appropriate documentation must always be present to support any assigned procedure codes. In order to code for that particular arteriogram, there must be documentation in the procedure note that describes a diagnostic study of the vessels and not just an indication of where the catheter was located prior to beginning the embolization.

An interventional radiologist who is an AU and who is acting as the sole treating physician can also report code 79445 (Radiopharmaceutical therapy, by intra-arterial particulate administration) for the delivery of the radiopharmaceutical. The interventional radiologist should not report this code when working together with a radiation oncologist, as in this situation the delivery of the radiopharmaceutical is included in the radiation oncologist's service. The interventional radiologist should not report code 77790 (Supervision, handling, loading of radiation source) as this is considered integral to 79445, according to the National Correct Coding Initiative Policy Manual.

When providing the Y-90 treatment independently (the IR physician is the AU), the interventional radiologist may also report the following services if performed and documented:

• 77263: Therapeutic radiology treatment planning; complex.
This code represents the use of "patient data including the angiographic studies, cross-sectional imaging, previous treatment, the Tc-99m MAA scan, as well as 3D reconstruction imaging to plan the dose and the timing of treatment," according to the Summer 2015 edition of Clinical Examples in Radiology. In order to report 77263, the physician must document how the studies were used to plan the treatment.

• 77300: Basic radiation dosimetry calculation, central axis depth dose calculation, TDF [time, dose, fractionation parameter], NSD [nominal standard dose], gap calculation, off-axis factor, tissue inhomogeneity factors, calculation of nonionizing radiation surface and depth dose, as required during course of treatment, only when prescribed by the treating physician.

Code 77300 represents the calculations performed to determine the radioembolization dose, either before or during the course of treatment.
In summary, an interventional radiologist who is an AU and is providing radioembolization independently may report the following services if appropriately documented and allowed by individual payer guidelines:

• embolization code 37243;
• radiopharmaceutical therapy code 79445;
• applicable codes for catheterization and diagnostic arteriograms;
• treatment planning code 77263 on the date when performed; or
• dosimetry code 77300 on the date when performed.

In addition to the CPT codes, there is also a HCPCS S code for radioembolization: S2095 (Transcatheter occlusion or embolization for tumor destruction, percutaneous, any method, using Yttrium-90 microspheres). The S codes are used primarily by Blue Cross Blue Shield plans and are not accepted by Medicare and many other payers. Providers who perform radioembolization should verify the preferred code assignment with the patient's payer prior to the procedure and obtain preauthorization for the treatment whenever possible.

In addition to the therapeutic procedure, there are diagnostic studies that are performed to identify any abnormal connections between the arteries and veins in a liver tumor that is scheduled to be treated with radioembolization. These connections allow blood to flow from an artery directly into a vein, and then back to the heart and into the patient's pulmonary arteries. When this type of shunting occurs, some of the microspheres will travel to the lungs instead of staying in the liver. Prior to Y-90 treatment, the physician must measure how much blood is being diverted in this way. If there is a significant amount of shunting, the patient cannot be treated with Y-90 because of the risk of blocking the pulmonary arteries.

The physician can determine the amount of shunting by injecting radioactive macroaggregated albumin (MAA) into the hepatic artery. The injection is performed during an arteriogram, after the interventional radiologist has placed a catheter into the artery supplying the tumor; the MAA particles are approximately the same size as the Y-90 microspheres. After the MAA injection, the patient's abdomen and chest are scanned with a gamma camera. If the scan shows that more than 20% of the MAA has gone to the lungs, the patient is not a candidate for Y-90 therapy. The MAA is biodegradable and will not permanently block the lung vessels.

There is not a specific CPT code for MAA shunt studies. Depending on the protocol and documentation, these studies may be reported as tumor localization studies or as liver scans. According to Clinical Examples in Radiology (Summer 2015), the scan performed after the radioembolization procedure to check for proper distribution of the Y-90 microspheres should be coded as 78205 (Liver imaging; SPECT).

Radioembolization is one of many effective options to treat liver tumors, but it is important that individual payer guidelines be obtained to ensure correct coding and billing practices and facilitate compliance and appropriate reimbursement.

— Melody W. Mulaik, MSHS, CRA, FAHRA, RCC, CPC, CPC-H, is president and cofounder of Coding Strategies, which provides specialty-specific auditing and educational services for physicians, hospitals, and billing companies nationwide.