While obviously crude, the first treatments using ionizing radiation were performed using early brachytherapy techniques. One technique, developed in London circa 1934, employed the use of a radium "bomb." This bomb produced radiation from four radium sources placed close to the patient's skin. Each source focused on the cancer from a different angle, maximizing the dose to a localized area. Incredibly, protective devices for medical practitioners were non-existent.
Brachytherapy first gained popularity in the treatment of gynecological cases. The procedure typically utilized the tandem and ovoid insertion procedure with cesium. Other disease sites, including cancers of the head and neck, proved excellent candidates for this treatment method.
In the late 1970s and 1980s, treatment of prostate cancer utilizing radioactive seeds and low dose rate (LDR) was introduced at Memorial Sloan Kettering and other centers. Treatment with seed implants did not become a standard of care until the needles could be guided appropriately and the radioactive sources placed into the prostate in a consistent manner. The dosimetry and placement of the sources also was an issue as no appropriate guidance technology existed at the time. John Blasco, MD, a radiation oncologist in Seattle, helped pioneer the new guidance methods along with a urologist during the mid-'80s. This guidance method combined with refined dosimetry procedures became known as the "Seattle Method." The Seattle Method ushered in a new regimen of pre-procedure planning followed by post-planning to determine how the actual dose compared with the planned dose. Nelson Stone, MD, helped pioneer and popularize the "Stone Method" of live planning during the procedure followed by a post-procedure planning phase.
Early brachytherapy, the "bomb" (top); modern brachytherapy, an evolving treatment modality (bottom). images/courtesy James E. Hugh III
Reimbursement for brachytherapy procedures was problematic during the late '80s and early '90s as there were few codes for the urologist portion of this non-open procedure. Permission was initially obtained to use the "open" procedure CPT code 55860 to place the radioactive seeds or using the unlisted procedure code 55899. There were no correct prostate ultrasound codes so 76872 was used for the placement of the needles and the cystourethroscopy code was used along with various ancillary codes. Fluoroscopy 76000 and 76001 were employed as the standard as well.
The ultrasound volume study performed used CPT procedure code 76950 and others in the early years before the CPT code procedure 76873 was introduced in 2000. The radiation oncologist used the standard CPT code 77263 for "complex clinical planning," 77778 for the "interstitial application," "physics planning" code 77328, "handling and loading" 77790, and several other ancillary codes.
There was not wide acceptance of this new procedure with modern guidance to place the sources until Theragenics Corp., a producer of palladium radioactive sources, came onto the scene. Theragenics and AMAC®
collaborated to educate patients on the viability of prostate seed implants as an alternative treatment option.
AMAC and Theragenics helped appeal a seed implant reimbursement denial in a landmark case that forced Champus, now TriCare, to retroactively pay for prostate seed implants performed. This precedent-setting case opened the door for wide-scale acceptance and reimbursement of the procedure by insurance providers.
In 1994, the Health Care Financing Administration (HCFA)-now the Centers for Medicare and Medicaid Services-banned the use of many procedure codes that urologists had been using to charge for prostate seed implants. This unfortunate decision ostensibly ended prostate brachytherapy. AMAC and Theragenics petitioned and appealed HCFA's decision, which resulted in guidance whereby the urologist would "share" the code 77778 using modifiers 26-62.
This new guidance allowed both the urologist and the radiation oncologist to receive 62.5 percent of the Medicare allowable reimbursement. Use of prostrate seed implants increased but not to pre-1994 levels due to the complexity of the new coding modifiers. In 1996, a new code was released specifically for the urologists, 55859, now 55875; however, it was the Medicare allowable reimbursement low.
Eventually, the Medicare allowable increased appropriately, standard procedures were implemented, and reliable manufacturers emerged. As a consequence, prostate seed implants grew exponentially with manufacturers struggling to keep pace with the demand. In 2002 when intensity-modulated radiation therapy was subsequently introduced, there was a decline in prostate brachytherapy again.
A further advancement in brachytherapy came with the introduction of high-dose rate remote afterloading (HDR), in which a temporary implant of a high-dose iridium 192 source is placed near the tumor site using needles and catheters. The HDR unit was mobile with a remote lead storage receptacle for ease of use. Nucletron Corp. pioneered the early use of HDR. This treatment form was limited, though, because specific procedure codes had not yet been approved by HCFA. Due to the efforts of Nucletron, AMAC, and a few physicians, HCFA approved a Medicare allowable rate for HDR. Consequently, HDR became widely used to treat lung, gynecologic, head, neck, and today, breast cancers.
Starting in 2000 with advent of the Hospital Outpatient Prospective Payment System, all outpatient procedures were required to utilize CPT or HCPCS coding.
Due to problems implementing the new coding systems and the relatively high costs of radioactive source material and low rates of reimbursement, outpatient brachytherapy was virtually sidelined by hospitals. A great deal of effort by manufacturers, physicians, and other industry professionals was required to educate CMS officials on the wide-scale benefits and diverse applications for treatment with outpatient brachytherapy. Fortunately, the procedure became recognized by CMS as a viable treatment option and reasonable allowable rates were adopted in the early 2000s.
Procedure coding basics
Today, several distinct radiation oncology brachytherapy procedures are used. These include low-dose rate procedures, intracavitary (CPT codes 77761-77763), and interstitial (CPT codes 77776-77778). Intracavitary procedures involve the placement of the source material into a "natural" body cavity. Interstitial procedures use sutures or the placement of needles and/or catheters into the body. Other low-dose procedures include CPT code 77750, the infusion or instillation of radioelement solution injected into the body to treat bone metastases and cranial tumors. The procedure code 77789 is used for "surface application of radiation source" (in pterygium cases, for example).
High-dose brachytherapy employs HDR equipment such as naturally occurring high-activity sources. These types of procedures utilize 77785-77787 and Category III code, 0182T for electronic brachytherapy:
77785: Remote afterloading high-dose rate radionuclide, 1 channel
77786: 2-12 channels
77787: > 12 channels
0182T: High-dose rate electronic brachytherapy, per fraction.
Under all brachytherapy applications and procedure types, applicators or other devices must be inserted and correctly positioned in line with the initial planning before the source material can be delivered to the tumor. Imaging techniques, such as X-ray, fluoroscopy, ultrasound, CT scans, and MRI, are typically used to help guide the placement of the applicators to their correct positions, to further refine the treatment plan, and finally, to confirm correct placement of the applicator.
The following are some of the current CPT codes used for insertion of the needles, catheters, devices, or applicators into the body:
19296: Placement of radiotherapy afterloading expandable catheter (single or multichannel) into the breast for interstitial radioelement application following partial mastectomy, includes imaging guidance; on date separate from partial mastectomy.
19297: Concurrent with partial mastectomy (list separately in addition to code for primary procedure).
19298: Placement of radiotherapy afterloading brachytherapy catheters (multiple tube and button type) into the breast for interstitial radioelement application following (at the time of or subsequent to) partial mastectomy, includes imaging guidance.
20555: Placement of needles or catheters into muscle and/or soft tissue for subsequent interstitial radioelement application (at the time of or subsequent to the procedure).
31643: Bronchoscopy with placement of catheter(s) for intracavitary radioelement application.
41019: Placement of needles, catheters, or other device(s) into the head and/or neck region (percutaneous transoral or transnasal) for subsequent interstitial radioelement application.
55875: Insertion of needles into the prostate with/without cysto.
57155: Insertion of uterine tandems and/or vaginal ovoids for clinical brachytherapy.
57156: Insertion of vaginal radiation afterloading apparatus for clinical brachytherapy.
58346: Insertion of Heyman capsules for clinical brachytherapy.
55920: Placement of needles or catheters into pelvic organs and/or genitalia (except prostate) for subsequent interstitial radioelement
C9725: Placement of endorectal intracavitary applicator for high-intensity brachytherapy.
C9726: Placement and removal (if performed) of applicator into breast for radiation therapy.
C9728: Placement of interstitial device(s) for radiation therapy/surgery guidance (e.g., fiducial markers, dosimeter) for other than the following sites (any approach): abdomen, pelvis, prostate, retroperitoneum, thorax, single, or multiple.
The set of ancillary codes utilized in most LDR procedures for handling and loading of the radioactive source includes CPT code 77790 (this code should not be used for HDR). Physics planning in brachytherapy uses the set of codes 77326-77328. Additional codes used for planning are 77290 complex simulation, 77280 simple simulation (source verification) and simple treatment device, and 77332 (template or catheter).
Another common physics planning tool in brachytherapy is 3-D modeling coded as CPT code 77295. 3-D modeling allows the planning team to create a "virtual patient" where the physical relationships between the applicator(s), treatment site, and the surrounding healthy tissues areas can be studied. This study will ultimately allow the brachytherapy team to refine and tailor the treatment plan to the unique anatomy of each patient before the source is delivered.
Each time a brachytherapy procedure is performed a physicist conducts a decay factor measurement on the radioactive source to determine the actual intensity or strength prior to treatment. All radioactive sources will decay and have less strength over time and in some cases the half-life of the element is quite short. The CPT procedure code used for dose calculation is 77300.
The radiation sources used for brachytherapy are always enclosed within a non-radioactive capsule. The sources can be delivered manually, as in LDR, but are typically delivered through afterloading with HDR in order to protect health care professionals from radiation exposure. Once applicators, needles, and catheters or devices are correctly positioned, they are connected to the afterloader which delivers the radioactive source through a series of guide tubes. The source remains in place for a pre-specified length of time, per the treatment plan, and is returned back to the afterloader once the treatment is complete. After the devices are removed from the body, the procedure is complete.
In LDR, the same procedures are performed. Patients typically recover quickly after the procedure with minimal discomfort. The CPT code for sources that was used for all providers was 79900, until 2005 when it was deleted. After that, 79900 was replaced by Q3001 for physician offices. Starting in the early 2001, "C" codes were used for reporting radioactive sources in hospitals and in 2009 included ambulatory surgery centers. The high-dose afterloader HCPCS code, for example, is C1717.
Brachytherapy remains a major treatment modality for many cancer types and is considered a most highly efficacious and economical method of treatment delivery. Often the procedure is short in duration; treatment time is measured in days vs. weeks as in external beam radiation. Additionally, the treatment can typically be accomplished on an outpatient basis and poses lower risk to surrounding tissues. These factors make it a preferable option to many physicians and patients.
James E. Hugh III, MHA, CHBME, ROCC®, is senior vice president of AMAC®, Marietta, Ga. Current Procedural Terminology (CPT®) copyright 2010 American Medical Association. All Rights Reserved.