(36245–36248). The associated RS&I codes should not be routinely reported since angiography is confirmatory and considered to be part of the therapeutic procedure. However, these RS&I codes (75726 and 75774) may be reportable in the appropriate clinical setting, such as if pre-procedural documentation indicates suspicion of new vascular flow patterns or detrimental effect of an interval therapy on the vessels. If the IR physician is an authorized user (a one-physician model), then, once the appropriate artery is selected for therapeutic treatment, the Y-90 dose is delivered and reported with 37243 (for the embolization of the tumor) and 79445 (for the intraarterial therapeutic radiopharmaceutical injection). Code 37243 includes all associated RS&I, as well as any additional embolizations (such as flow re-direction to preserve adjacent organs) performed in the same session as radioembolization.
In other workflows, the appropriate codes to report may change, such as when the physician administering the Y-90 is working together with another physician who is serving as the AU. The AU is responsible for the safe handling, receipt and storage of the Y-90 dose and ensures documentation of the work of handling and loading the source in alignment with Nuclear Regulatory Commission (NRC) regulations. If the IR physician is not an AU, s/he must work with someone who is an AU, which may be a nuclear medicine or radiation oncology physician. In this two-physician model, the IR physician reports the catheter placement codes (36245– 36248), any appropriate associated angiographic S&I codes (75726 and/or 75774), and 37243 for the embolization procedure. The separate AU reports the appropriate planning, dosimetry and administration codes for the work that s/he performs. This may include the previously mentioned intra-arterial injection code (79445). Documentation should clearly support who provided the work and the specific roles of any participating physicians.
Coding for the injection of Y-90 may also vary by payor. For example, the Blue Cross Blue Shield (BCBS) plans utilize HCPCS codes which begin with “S” for some procedures. HCPCS S2095 may be required by a BCBS payor; however, this code is not accepted by Medicare and many other payors. Providers who perform radioembolization should verify the preferred code assignment with the
patient’s payor prior to the procedure and obtain preauthorization for the treatment whenever possible.
The Y-90 source is not billed by the physician but is billed by the facility. It is important to note that the brachytherapy source is reported on the claim appropriately with HCPCS code C2616 in a quantity of one (1) for the entire vial.
Coding for post administration imaging or additional dosimetry during the process, when supported Following the administration of the Y-90 microspheres, additional imaging may be performed to review the distribution of the dose or to calculate the total dose delivered to the liver target(s) or other critical structures, such as the lungs. Assuming that the additional imaging obtained is medically necessary, the billable code will depend on what was ordered and performed. If a SPECT/ CT or SPECT was performed, the codes to select from would be 78803, 78830, 78831 or 78832, depending on the number of areas imaged. If a PET/ CT was ordered and performed, the “limited” code would be appropriate (due to the specific area related to the Y-90 administration) and billable with code 78814. If only planar imaging is performed in calculation of the final absorbed dose, this is billable with code 78801. Payment for this additional imaging may be payor dependent and may be secondary to limitations on the number or types of scans allowed.
Following the acquisition of PET/ CT, SPECT/CT or SPECT imaging, a dosimetry plan may be generated to assist in planning the amount of dose to deliver (when performed pre-SIRT) or to verify the distribution and amount of Y-90 delivered to the liver target(s) and other nearby critical structures. If there is a software processing mechanism, such as treatment planning software, which meets the criteria for 3-D dosimetry treatment planning (code 77295), then it may be billable. This 3-D treatment plan is not a clinical treatment plan like 77263, discussed earlier; this 3-D treatment plan measures and documents the planned or actually delivered dose of
Y-90 to the patient and the distribution to the intended target(s) and nearby critical structures. Documentation to support reporting this code must include: data from a volumetric scan; contours by the physician of the target volume and review and/or approval of critical normal structure contours by the medical physicist or dosimetrist; reconstruction of the contours on each slice of the scan, which allows for 3-dimensional rendering of the dose to the target and surrounding critical structures; analysis of the dose distribution using graphical tools, such as dose volume histogram (DVH) and three-dimensional dose displays (3-D dose clouds); and documentation of the treatment planning software generated 3-D plan with a 3-D representation of the dose cloud distribution and a DVH that includes the target/tumor volume and at least one critical nearby structure accounted for in the treatment of the patient. If the criteria for a 3-D treatment plan are not met (e.g., no contouring of volumes by the physician or only a tumor/target volume included on the DVH without a critical structure included), then the additional dosimetry could be billed using the unlisted code, 77399, for the work in determining the amount of Y-90 delivered to the liver and/or surrounding anatomy.
Coding for same-day planning and treatment procedures The current practice of Y-90 radioembolization is evolving and some centers may perform all three of the above stages in a same-day delivery model. However, it should be noted that these stages are still delivered sequentially in separate sessions. Each of these sessions requires distinct procedural reports, outlining all of the services performed in that session. In this situation, reporting of services by the IR physician is identical to the above recommendations EXCEPT that catheter placement and RS&I codes for angiography should be reported with modifier –59 to denote the separate sessions.
Disclaimer: The Society of Interventional Radiology (SIR), American College of Radiology (ACR), and Society of Nuclear Medicine & Molecular Imaging (SNMMI) are providing this billing and coding guidance for educational and information purposes only. It is not intended to provide legal, medical, or any other kind of advice. This guidance is meant to be an adjunct to the American Medical Association’s (AMA) Current Procedural Terminology (CPT® 2024). It is not comprehensive and does not replace CPT. Therefore, a precise knowledge of the definitions of the CPT descriptors and the appropriate services associated with each code is necessary for proper coding of physician services. CPT® codes, descriptions, and 2-digit modifiers only are copyright, 2024 AMA. All rights reserved.
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