Policy Statement
Radiation oncology (RT) involves the medical application of ionizing radiation to treat (sterilize or control) diverse malignant and/or benign tumors. RT involves the complimentary efforts of diverse medical professionals including physicians (who design the goals and constraints of treatment), dosimetrists (who perform the actual treatment planning of beam design and weightings) therapists (who actually give the treatments) as well as nurses and other administrative and support personnel.
Treatment is usually given via employment of photons but may employ, in constrained circumstances, alternatives such as Protons, electrons, carbon ions etc. Treatment may be planned (with increasing effort and conformality) either via 2-dimentional, 3-dimentional or IMRT techniques.
When treatment is given via emanations from linear accelerators or cyclotrons, with patients at some distance from the treatment machine, it is referred to as external beam radiotherapy i.e. EBRT. When tumors are destroyed via implantation of radioactive substances within such, it is referred to as brachytherapy.
EBRT may be given via a large number e.g. 30-45 of individually small dose radiotherapy treatments; such fractionation of treatment is referred to as conventionally fractionated irradiation. Such treatment may be alternatively given via a smaller number of treatments employing modestly higher individual doses. Such approach is referred to as moderately hypo fractionated irradiation. Employing advanced immobilization, image fusion, target definition and IGRT techniques treatment may be given via only a few i.e. 1-5 fractions in which the individual fractional dose may be 5-10 times that of conventional irradiation treatments. When such ultra hypo fractionated approach is employed in a single treatment, it is referred to as SRS; when 2-5 such treatments are used, it is referred to as SBRT.
This policy outlines guidelines, including but not limited to the frequency of use of some Current Procedural Terminology (CPT®) codes. Providers are requested to submit all services for the same service date as a single claim after services are provided.
Radiation therapy may be reimbursable or the management of many types of cancer when certain criteria are met. More specific guidelines may be reviewed in the medical policies.
Radiation Therapy
CPT 77338 Multi-leaf collimator (MLC) device for IMRT design/construction/plan reported once per IMRT plan. MLC is not appropriate to be reported in conjunction with compensator based IMRT (G6016).
Compensator based IMRT delivery code is used (G6016, 77334) should be used for blocking rather than CPT code 77338 for MLC.
For standard IMRT delivery (77385, 77386, G6015), only one unit of 77332, 77333 or 77334 may be billed during treatment and immobilization. Blocking is addressed with the MLC, so additional units are not needed.
Treatment Simulation CPTs 77280-77293
Standard courses of radiation therapy will require between one and three simulations. No more than one simulation should be reported per date of service. The plan will reimburse up to five simulations (77290, 77285) and five verifications of placement (77280) per course of treatment. The course of treatment is defined as 6 months. Verification simulations only use 77280 regardless of the code used for initial simulation.
Treatment Planning CPTs 77261-77263
Treatment planning should be billed by a qualified radiation oncologist with procedure codes 77261-77263. Only one treatment planning code is allowed per course of treatment (6-month period). The physician may report the appropriate CPT procedure code for installation/application of the radioelement (77761-77789) in addition to the treatment planning.
Radiotherapy Planning 77295
Only one teletherapy isodose plan (77306, 77307) is allowed per volume of interest (tumor area). 3D-CRT plan (CPT 77295) or IMRT plan (CPT 77301) are not separately reimbursable when billed on the same date of service as teletherapy isodose planning.
SRS Treatment Management (77432), IMRT planning (77301), 3D CRT Planning (77295), and SBRT Treatment Management (77435) are not reimbursable on the same date of service and should not be billed together.
Supervision/Handling
Procedure code 77790 may be reported only for brachytherapy techniques requiring manual loading (CCI). Supervision/handling (77790) is not separately reimbursable from application of radiation sources (77761, 77762, 77763, 77770, 77771, 77772, 77778).
Treatment Management
SBRT Treatment Management (77435) may be reported once per SBRT course.
SRS Treatment Management (77432) and SBRT Treatment Management (77435) stereotactic radiosurgery (61796, 61781) will not be reimbursable and should not be billed on the same date of service.
