Things to Remember When Coding PCI Cases

*The following information is intended for those using ICD-10

Coding prophylactic cranial irradiation (PCI) cases can sometimes be challenging. PCI is often done following a course of radiation to the lung for patients with small-cell lung cancer who do not have evidence of brain metastasis. Here are a few things to remember when coding and documenting PCI cases.

  1. You have to indicate to the patient’s payer that the treatment is prophylactic. This is typically done by using ICD-10 Z29.8 (Encounter for other specified prophylactic measures). It is preferably placed before the primary tumor diagnosis (usually from the C34 lung series) but some carriers prefer it after the primary tumor diagnosis.
  2. Make sure the patient’s medical record indicates a response to the primary SCLC treatment and current performance status. Both of these items are often required to be at a certain threshold for PCI to be covered.
  3. Payers often have very specific requirements set out for PCI. It is important to know the patient’s payer’s specific rules, especially when the payer does not require prior authorization for radiation therapy.
  4. PCI claims require appeals more often than other radiation therapy claims. Therefore, it is important to make sure every I is dotted and every T is crossed in the patient’s medical record.
  5. If you need to send in medical records for prior authorization or for claims payment make sure to include pathology information.
  6. Last but definitely not least check the treating diagnosis listed on all records. Make sure it reflects the current brain therapy. If the treating diagnosis is carried over from another part of the chart this may need to be manually entered on each document.

While obtaining prior authorization and reimbursement for PCI can be difficult, these steps will help you to make sure your claims are on the right track.