The August 2023 CTR Coding Break discusses coding radiation therapy. Registrars are encouraged to utilize the CTR Guide to Coding Radiation for coding radiation therapy treatment which is now available within the 2023 STORE Manual Appendix R. Today’s coding break objectives include Clarification on phase terminology and coding instruction, Coding the treatment volume when the primary site organ has been removed, and coding instruction for adding doses across multiple phases.
STORE defines a Phase as a set of treatments delivered with a unique combination of target volume, treatment fraction size, treatment modality, and treatment technique. A course of radiation is made up of one or more phases and each phase includes a target volume and a delivered prescription. A phase represents the radiation prescription that has actually been delivered. Phases can be delivered sequentially or simultaneously. In sequential phases, a new phase begins when there is a change in the anatomic target volume of a body site, treatment fraction size, modality or technique. The details of up to 3 phases of radiation can be collected, if there are more than 3 phases in a radiation course STORE instructs to collect and report details of the first 3 phases but report the actual number of first course phases in the Number of Phases of Radiation Treatment in this Course Field. Appendix R also contains Phase Order Rules: It is recommended that phases be summarized first in chronological order. If multiple phases start on the same day, then list the phases in order from highest Total Phase Dose to lowest. If multiple phases start on the same day and have the same Total Phase Dose then any order is acceptable.
Radiation Course Total Dose identifies the total cumulative dose of radiation administered to the patient across all phases during the first course of treatment. Doses should ONLY be summed across phases to create a Total Dose when all of the phases were delivered using the same major modality type targeting the same volume. If phases were delivered using two or more different major modalities (for example external beam and brachytherapy to the same body site), then code 999998. This is because there is no agreed upon standard for summing doses across different radiation modalities. It’s also important to note you should never add doses across different target volumes. When the phases target different volumes the total dose recorded is the highest dose delivered to any one phase. Doses are added across phases only when they are attributed to the same target volume.
Appendix R in the STORE manual provides instruction for coding the volume when the primary site organ has been removed. STORE states: in most cases code the volume to the organ removed. If the whole pelvis is treated following prostatectomy, hysterectomy or cystectomy code the volume to the organ of origin and lymph nodes to pelvic. There are two exceptions to this rule: Brachytherapy after hysterectomy is a gray area. If the vaginal apex is treated with brachytherapy after hysterectomy for cervical or uterine cancer, code the volume to 72 – Vagina because that is the target organ for treatment. Also, for patients with Breast Cancer receiving post-mastectomy radiation where all breast tissue has been removed, the treatment volume is coded to Chest Wall and not Breast.
