2018 New Radiation Coding Rules Q&A Session
Wednesday, May 16, 2018
Note: All answers are based on coding rules at the time of the webinar. The radiation data items were very new at that time and instructions may have changed.
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Q: This may be planned to discuss later on in the talk, but if not, can you address how or if the "phases" will correlate with what we traditionally term as first course or subsequent treatment?
A: All of the phases are inclusive of first course treatment only.
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Q: Will we code only from the end of treatment summary? Previously there has been discussion that we can use end of treatment summary, treatment plan, simulation set-up etc. to code.
A: Generally speaking, you can assume that draining lymph nodes are included in a field that would be inclusive of those nodes, for example, you can assume cervical nodes are treated if treatment is delivered to the head and neck, or pelvic lymph nodes would be inclusive of treatment delivered to the whole pelvis. For other sites where it is not clearly evident that the lymph nodes would be included in the treatment field do not assume that those nodes are being treated. A question has been submitted asking if there will be future documentation guiding registrars as to which fields can be considered inclusive of draining nodes.
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Q: How does this affect palliative treatment for XRT when it is coded in both XRT and Palliative. Also when it is first course but is not coded for XRT. I hope this makes sense.
A: Palliative radiation should be coded as treatment if it is given during the first course time frame and destroys or modifies cancer tissue.
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Q: Is it correct to think that draining nodes are not involved nodes, just nearby nodes? If nodes are involved they would be in the first targeted volume?
A: Nodes do not have to be involved to be treated. The radiation oncologist may make a decision to treat the draining nodes in the event that undetected disease may be present. Draining nodes are synonymous with regional nodes.
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Q: How would IORT be coded? We currently use Orthovoltage (Xoft).
A: See the code definitions for Treatment Planning Technique for code 02-These types of treatments are sometimes referred to as electronic brachytherapy or orthovoltage or superficial therapy. Clinical notes may refer to the brand names of low energy x-ray delivery devices, e.g. Axxent®, INTRABEAM®, or Esteya®.
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Q: The draft manual says, for phase 1 dose per fraction their manual says use code '99998 not applicable, brachytherapy or radioisotopes administered to the patient' Are saying now that we should code the brachytherapy dose, like for prostate seeds?
A: You should collect the brachytherapy dose in cGy if available. If brachytherapy is delivered in one phase and external beam during another phase code the Total Dose data item each phase respectively, but code the final Total Dose data item as 999998. If brachytherapy is the only modality and you are able to code the dosage in cGy you should also code that dose in the final Total Dose data item.
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Q: How does palliative radiation fit into the new phase categories?
A: Palliative radiation should be coded as treatment if it is given during the first course time frame and destroys or modifies cancer tissue.
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Q: If radiation is given to the breast , axillary nodes and supracavicular nodes at the same time is it all phase 1?
A: Yes.
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Q: How do you code Endometrial Ca with External Beam and Tandem Insert HDR Brachytherapy?
A: This scenario represents 2 phases. Code the treatment that occurred first as phase 1 and the the other as phase 2. Code the Total Dose item in cGy for each phase, but code the final Total Dose item 999998.
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Q: Is there a separate table for applicable values for Radiation to Draining Lymph Nodes? (included in the slides is only the chart for values applicable to Radiation Primary Treatment Volume).
A: See slide 16 in the Power Point presentation. The lymph node coding structure is the same as the lymph node codes in the Primary Treatment Volume table with the exception for in the data item Radiation to Draining Lymph Nodes, the code to use for lymph node region, NOS, is code 08; whereas the code for lymph node region, NOS, for Primary Treatment Volume is code 09. When any one of the lymph node codes is used for Primary Treatment Volume, the data item Radiation Treatment to Draining Lymph Nodes should be coded 88.
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Q: CASE 2: Phase II Total Dose 004500. Isn't it suppose to be 04500 (5 digit)
A: The phase specific and the final Total Dose fields are all supposed to be 6 digits whereas the dose per fraction fields are 5 digits.
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Q: For the lung with the metastatic sites, why is the start date 01/07/18 instead of 01/25/18
A: The start date of radiation is not phase specific. This data item should be the start date of the first radiation given in first course treatment.
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Q: Lung case example, why isn't start date of the lung treatment used in the phase 1 treatment, rather than the date of the RT to mets. Also, where is the Radiation End date.
A: The start date of radiation is not phase specific. This data item should be the start date of the first radiation given in first course treatment.
The radiation end date was not included in this presentation as a new data item.
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Q: Is there documentation available when we should 'assume' lymph nodes are included in the treatment. Instructions to assume will result in registrars all coding it differently.
A: Not at this time.
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Q: Is an end date coded for each phase? I have not seen that field with a date in your examples under list of fields as you are going over each field, code and rationale for each phase. You state the start date but not end date in each example.
A: The start and end dates are currently not phase specific.
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Q: What is going to happen to CP3R measure CERRT - Radiation therapy is completed within 60 days of initiation of radiation among women with any stage cervical cancer, since there is not a field for treatment end date?
A: The data item for coding treatment end date will not go away.
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Q: Did you consider provided start & end dates for each phase?
A: The start and end dates are currently not phase specific.
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Q: Slides from a NAACCR webinar on 2/6/14 state that radiation I-131 (for Thyroid) is coded to volume Whole body (code 33) but have received recent communications stating this is to be coded to volume Thyroid, Could you please address?
A: The NAACCR webinar reflected the rules at that time. Instructions for coding volume when I-131 is given to treat a primary of the thyroid have changed soon after that webinar was presented. The current instructions are to code the volume as thyroid.
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Q: When you said that if radiation occurs first to a non-primary site and then next to the primary site [in one of the quizzes], do you mean that if XRT to a mets site occurred 1/1/18 andt hen primary site xrt occurred 3/1/18, [contind]
A: The current available instructions for Phase 1 Radiation Primary Treatment Volume (slide 9) state if one or more discrete volumes are treated and one of those includes the primary site, record the treatment to the primary site in this data item.
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Q: For total dose, are we recording planned dose or actual dose given in each phase? Example if a patient stops short or is given slightly more in error what is total dose, what is total in phase.
A: Always record the actual dose given.
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Q: When breast and LNs are being treated concurrently as in tangents and supraclavicular. Is this single phase, or phase I and phase II?
A: This scenario represents a single phase. The breast is the primary treatment volume and the supraclavicular nodes are coded in Radiation to Draining Lymph Nodes.
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Q: I didn't see date radiation ended on these examples. Is that not going to be required to get entered anymore?
A: Radiation end date was not addressed in this presentation as a new data item. Future scenarios will include a data item for Date Radiation Ended. The data item will continue to be collected in 2018.
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Q: In example # 4 lung: phase II list spine phase iii list the hip but they were administered on the same dates, does it make a difference which is site is listed first if phase II is given same dates?
A: It really doesn’t make a difference if the dates are the same. They were assigned the phase based on the #1 that appeared before “Lt Hip” in the treatment grid and #2 before “L4-S1”.
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Q: How would you code palliative XRT to brain and then XRT to primary site? Is the brain phase 1 and primary site phase 2.
A: If multiple discrete volumes are treated and one of those includes the primary site, code treatment to the primary site as Phase 1.
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Q: Are we to just assume the lymph nodes are included on the cervix example even though they're not listed as in the other scenarios?
A: The draining lymph nodes were coded in the external beam phase as the radiation was directed to the whole pelvis which would be inclusive of the pelvic nodes.
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Q: Could you please explain why the Phase I radiation to draining lymph nodes was coded as given in case 1? (My sound cut out during the explanation)
A: In case 1, the radiation was delivered to the head and neck which would be inclusive of the cervical nodes.
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Q: How did you know on Case 2 (Prostate) that the Phase I Treatment Modality (i-125 seeds) was 10, Brachytherapy, interstitial, LDR? As opposed to HDR?
Priority: N/A
A: The single administration of I-125 seeds is radiation that remains in the body for a lifetime and is considered low dose rate. High dose rate brachytherapy is administered and removed over a number of session.
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Q: When multiple volumes are given I understand the primary site is phase I. If mets is radiated first, then what is the actual start date? date of mets radiated before primary site. use the earliest date correct?
A: The start date is not phase specific and should be recorded as the first date radiation started.
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Q: Question on Case #4: We coded hip as phase 2 andL4-S1 as phase #3 because hip ws numbered #1 and L4-S1 was numbered #2. Why did you code then opposite us?
A: It really doesn’t make a difference if the dates are the same. They were assigned the phase based on the #1 that appeared before “Lt Hip” in the treatment grid and #2 before “L4-S1”.
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Q: Radiation txt that starts in 2017, and completes in 2018. Do we code by old rules or new 2018 rules?
A:Use the rules based on the date of diagnosis. For this scenario use the rules that apply to 2017.
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Q:Breast pt received IOERT at time of surgery and then received photons external beam afterwards, how do you code IOERT when it was considered as the boost as far as the phases. Also we are using just IOERT alone for treatment and is this just coded as phase 1.
A: Code this scenario in chronological order with the IOERT as Phase 1 and the external beam as Phase 2.
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Q:How would we handle more than 3 phases of RT?
A: If 4 or more phases, code the number of phases 04 and include the total dose from all phases in the final Total Dose field (unless simultaneous treatment to multiple volumes as in simultaneous treatment to metastatic sites, OR external beam and brachytherapy administered in first course treatment. If either of these scenarios occurs then the final Total Dose field must be coded 999998). The phase specific data items are currently limited to 3 phases.
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Q: I did not see Orthovoltage listed. At the last NCRA meeting, they stated that IORT would need to be coded as a 21 Orthovoltage. With the new coding, what code would be used?
A: See the Treatment Planning Technique Table definition for code 02- These types of treatments are sometimes referred to as electronic brachytherapy or orthovoltage or superficial therapy. Clinical notes may refer to the brand names of low energy x-ray delivery devices, e.g. Axxent®, INTRABEAM®, or Esteya®.
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