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Jenny Kouri
DOS 752
November 20, 2015
CPT Encounters
In 2014, the Affordable Care Act (ACA) required (most) individuals to obtain health
coverage that must meet a minimum standard or to pay a fee when filing taxes if they have
affordable options but remain uninsured. The VA is under their own governmental umbrella of
health care. The VA healthcare meets the laws coverage standards and therefore is exempt from
the ACA. The VA healthcare covers solely active military service in the Army, Navy, Air Force,
Marines, or Coast Guard (or Merchant Marines during World War II), as long as Veterans are
honorably discharged. The VA healthcare is to serve those who served for our country. With VA
healthcare, veterans will receive health benefits with no enrollment fee, no monthly premiums,
and no deductibles. [1] VA healthcare must provide the best type of treatment for the patient. At
other health care facilities, coverage dictates the treatment of the patient. If a patient needs a
more conservative treatment approach such as VMAT or IMRT and their insurance does not
cover, the patient can only receive the treatment that can be covered such as 3D. At the VA, if
the patient requires SBRT, then they will receive SBRT no matter what. Since our department is
without our own CT machine, we have postponed SBRT treatments until the new CT is installed
and calibrated. If a patient comes in during this construction phase and the physician feels it is
best that the patient receives SBRT, then the patient will get outsourced to another hospital
(typically the University of Minnesota) that will preform SBRT. The VA pays the SBRT
treatment.
VA healthcare can be used alone or in combination of private health insurance or federal
programs such as Medicare and Medicaid. If a patient has other means of health care insurance,
the VA deciphers if their cancer is service related. For example, if 70% of a veterans prostate
cancer was proven from Agent Orange exposure in Korea, then the VA will compensate 70% of
their care and Medicaid/Medicare will cover the remaining 30%. If it is a non-service related
health issue, then the VA will bill the private insurance company.
Billing codes at the VA is different from most hospitals due to the VA health care
coverage. Billing is known as encountering. Daily charging is encountered as the workload

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preformed for that patient. The government pays the encounters documented. An example of a
patients encounters is shown below.
This Veteran is a 66-year-old male with high-risk prostate cancer. The patient was found
to have an elevated PSA of 26.2. The patient proceeded to undergo transrectal ultrasound-guided
biopsy of the prostate. The pathology report revealed adenocarcinoma with high-volume disease
with a Gleason score of 4+3=7. Perineural invasion was also reported. The prostate volume on
transrectal ultrasound was 77.7 mL. CT and bone scans were preformed but showed no findings
of metastatic disease. During consult, the physician discussed the options for treatment with
radiotherapy as an alternative to surgery and reviewed the side effects of pelvic radiotherapy for
high-risk prostate. Fiducial markers were surgically placed in the prostate to facilitate treatment
planning and image-guided treatment verification. The patient underwent CT simulation
positioned supine and immobilized using a vaclock. A planning CT of the pelvis was done and a
preliminary isocenter was chosen. A 3-point set-up was tattooed on the patient. The planning
MRI was co-registered to the planning CT using the fiducial markers. An IMRT plan was
designed for treatment to the pelvis including contour, delineation of radiotherapy volumes and
normal tissues, and dose distribution. A separate IMRT treatment plan was also designed for the
boost phase.
The pelvis was treated to a dose of 4600 cGy using a fraction size of 200 cGy to be
delivered once daily over 4 weeks using 18 MV photons via 7 field IMRT radiotherapy plan.
The total number of fractions delivered in this part of the course is 23. The radiotherapy dose
will be prescribed to the 95% isodose, which approximately encompasses the PTV.
This will be followed by a boost phase using a second IMRT treatment plan (8 field) to
treat the prostate and bilateral proximal seminal vesicles. The radiation energy for the boost
phase will be 6 MV photons and the radiotherapy dose will be prescribed to the 97% isodose,
which approximately encompasses the PTV. A fraction size of 200 cGy to be delivered once
daily over approximately 3 weeks will be used. The total number of fractions for the IMRT
boost phase will be 16. The cumulative dose to the prostate and bilateral seminal vesicles will be
7800 cGy given over fractions.
The rational for IMRT is for greater reduction in the dose to the rectum and bladder while
maintaining adequate coverage of the PTV and facilitate dose-escalation. Quality assurance will

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include daily kV onboard imaging and/or cone beam CT, weekly MV portal imaging, and weekly
clinic review.
The patient was given the ICD-9CM 185, carcinoma of prostate. In the chart below, the
red, green, and blue rows indicate encounters preformed by the radiation therapists, medical
physicists, and medical dosimetrists, respectfully. I felt that all encounters were done correctly.
The only encounter missing is the treatment consult. While I was looking up codes with the
chief therapist, we saw that the consult encounter was preformed, but it would not allow us to
navigate to it. Since there were 14 fields, a radiation dose calculation (CPT 77300) should have
been accounted for each field. According to his patients records, only 6 were encountered,
instead of 14. Two IMRT Dose Plans (CPT 77301) were encountered because this accounted for
both the primary and boost plan.
CPT
Code
77295
77263

Code Description
SIM CT 3D
Rad Ther Planning, Complex

Quantit
y
1
1

77301

IMRT Dose Plan

77338

Design MLC Device for IMRT

77334

Complex Device

77300

Rad Dose Calc

77370

77412
77387

Consult, Spec Medi Rad

Physics
Rad Tx Complex >1 MeV
Image Guidance

77386
77417

IMRT Tx
Port Films

14

77336

Continuing Med Physics

Consult

Every
5th Tx

77427

Tx Mgmt, 5 Treatments

Every
5th Tx

1
1

Definition
3D radiotherapy plan, including DVH
Requires complex blocking, custom shielding blocks, tangential
ports, special wedges or compensators, three or more separate
treatment areas, rotational or special beam considerations,
combination of therapeutic modalities
Intensity modulated radiotherapy plan, including dose volume
histograms for target and critical structure partial tolerance
specifications
Multi-leaf collimator (MLC) devices for IMRT, design, and
construction per IMRT plan
Complex (irregular blocks, special shields, compensators, wedges,
molds, or casts)
Basic radiation dosimetry calculation, central axis depth dose
calculation, TDF, NSD, gap calculation, off axis factor, tissue
inhomogeneity factors, calculation of non-ionizing radiation
surface and depth dose, as required during course of treatment,
only when prescribed by the treating physician
Special medical radiation physics consultation
Complex radiation treatment delivery
Guidance for localization of target volume for delivery of radiation
treatment delivery, includes intrafraction tracking, when performed
IMRT, includes guidance and tracking when performed, complex
Therapeutic radiology port film taken for every field of treatment
to verify MLC's and treatment position
Includes assessment of treatment parameters, QA of dose delivery,
and review of patient treatment documentation in support of the
radiation oncologist, reported per week of therapy
Daily treatment management and port film interpretation services
for a service of 5 fractions

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References
1. VA, Affordable Care Act, and You. U.S. Department of Veteran Affairs.
http://www.va.gov/health/aca/. Updated: October 15, 2015. Accessed: November 21, 2015.