Case Study

Activity 2

Patient CB is a 54 year old who originally presented in February of 2014. Initial

diagnosis was squamous cell carcinoma of the left tonsil. Initially, the patient was staged I
TIN0MO. CB completed 35 fractions to 70 Gy of IMRT treatments to the head and neck region
that included the primary tumor and left level 2 & 3 cervical nodes. In January of 2015, the
patient had a recurrence that was staged IVA T4N2MO. Radiation therapy was given to a mass
located in the left parapharyngeal space at the level of the nasopharynx to manage the disease.
For this course of treatment, the prescription of 28 fractions to 63 Gy was administered. For
these treatments, a VMAT technique was used in planning. This patient had insurance coverage
through Blue Cross Blue Shield. I will be reviewing the charges upon the return for treatment of
the recurrence in the nasopharynx. Listed are the CPT codes for the procedures associated with
the patients recurrence diagnosis beginning March 13, 2015.
CPT Code
31575

Quantity
1

99213

77290

77014

77334

Q9967-100-199

77370

77301

77338

77300

Description
Scope
(Pt was scoped prior to
treatment beginning)
Est Patient L3 Low/Mod
(Level of office visit)
Simulation Complex (CT
Simulation)
CT Tx Plan /Guidance (CT
simulation only)
Professional charge
TX devices Complex
(immobilization devices)
Mg/ml Iodine (Contrast)
Physics consult (Fusion with
PET)
IMRT TX Plan (Dosimetry)
IMRT TX Device
(Dosimetry)
Professional charge also
same code with modifier
charged
Basic Dose Calculation

77280

77386

28

77014

27

77336

(Charge for the

calculations)
Simulation Simple (Charge
for Simulation on tx table,
films etc.)
IMRT (NOT prost or breast)
Charge for treatment itself
Professional Charge by
physician for CBCT
interpretation
Con Rad Physics (Weekly
Chart Checks)

After reviewing the charges with our certified professional coder (CPC), I found that one
of the charges was increased from what was originally found in the patients electronic medical
record. He explained that the original office visit 99213 was actually billed a 99215. He was
able to bill the higher code due to other procedures performed at the same time during the visit.
This increased the level of service which increased the reimbursement of the visit. We also
discussed the differences between the professional and technical charges. A professional charge
is completed whenever the physician is involved with the procedure. For example, whenever a
CBCT is reviewed a professional charge is completed. But for the fusion, for example, although
the physician may discuss the fusion with the physicist there is not a professional charge that can
be billed.
This account had nothing that was alarming or concerning with the billing. The account
has been fully reimbursed and has a $0.00 balance. I learned a lot about the billing process and
its importance of accuracy to ensure the reimbursement.