Insurance/Billing /Coding Case Study

Heather Maurer
November 30, 2014

This patient is a 41 year old white female with Bulky, IIA, Hodgkins Lymphoma. She was
referred to radiation oncology for consolidation radiation therapy to residual disease and new
retrosternal, PET positive lesion. She had first presented to her primary care physician after 2
months of continual cough that was non responsive to bronchodilators. A chest x-ray was
performed in late 2013 revealing a mass in the right upper lobe measuring 7x9cm. This was then
followed by a chest CT in December 2013 confirming the mass, yet measuring 15x11cm. A PET
and bone marrow biopsy were done in January of 2014 which were negative for
subdiaphragmatic disease or mets to the bone.
This patients desired treatment would be a form of IMRT, so our department did a prior
authorization before planning. She has Blue Care Network PPO insurance and they approved
her to have a VMAT plan. Since we are in the network her treatments should be covered with
little out of pocket expense, and from what I can tell they covered all 20 fractions the doctor was
prescribing. The following is a list of all CPT codes billed to her account with the quantity billed
next to it.

This is a fairly accurate representation of charges I believe. All of these services have been
performed with proper documentation for proof. We have orders signed by staff showing the
simulation was ordered and preformed as well as pictures using the immobilization and a scan
showing the contrast. We also have the 4D scan for respiratory motion, the VMAT plan using 2
arcs in the computer system as well as CBCTs daily for alignment before treatment and a record
of the treatment given.

Code

Title

Quantity Description

77290

Sim Complex

Initial CT simulation

77620

Immobilization/mold

Use of custom immobilization equipment

Q9967 Isovue charge per ML

100

IV contrast delivered to pt upon Drs orders

77263

Inclusive Plan Complex

Plan based of CT images

77300

CA Depth Dose

2 angles

77301

IMRT Plan

IMRT calculation

77338

MLC for IMRT

MLCs with movement for IMRT planning

Insurance/Billing /Coding Case Study

Heather Maurer
November 30, 2014

77293

Respiratory Motion

CT simulation was done with 4D scan

77418

IMRT Tx

20

IMRT treatment was delivered (daily treatments)

77014

CT Guidance for RT fields

20

CBCT was performed daily for alignment prior to

treatment

This patients account appears to be in good standings with reimbursement completed.

Unfortunately our primary billing person no longer works directly in our department and has not
responded to her e-mail. I was able to talk with a few people who had a general idea about our
billing procedures to get most of my information though. I can see how this billing and coding is
needed, but it can also be extremely confusing. I have been told that the reimbursement we
receive is never the full amount billed, but it is what we accept from the insurance companies.
What I dont understand is if we accept this amount from the insurance companies then why isnt
this the amount we bill to those who dont have insurance? The only other concerning part to me
is the fact that some people are being denied the types of treatments that are needed because the
insurance companies have the right to say if it is necessary or not. I try to understand all sides
and I can see how insurance companies wouldnt want to pay top dollar for a palliative treatment
to just keep someone comfortable and they have to make that call at some point. Its sad to me
that so many places were billing for unnecessary treatment, plans, or procedures just for the
money which has required insurance companies to become more ridged with their allowances
and the people who are truly being affected by this are the patients in need.