Radiation Oncology

Policy No: 151
Date of Origin: 08/01/2024
Section: Administrative
Last Reviewed:
Last Revised:
Approved: 07/11/2024
Effective: 11/01/2024
Policy Applies To: Group and Individual & Medicare Advantage

This policy applies only to physicians and other qualified health care professionals.

3D CRT - Conventional three-dimensional conformal radiation therapy.

Contouring - Defining the target and avoidance of structures, a multiple step process.

IGRT - Image-guided radiation therapy, uses PET, MRI, and CT for accurate delivery.

IMRT -Intensity-modulated radiotherapy- varies the radiation intensity to expose tumor correctly and limit intensity to normal or critical structures.

PBT – photon-based radiotherapy

Respiratory motion management - treatment of certain thoracic, abdominal, and pelvic tumors pose challenges of respiratory motion.

SBRT - Stereotactic body radiation therapy, non-cranial.

Simulation - aided field setting- prior to the course of radiation, deciding location of ports.

SRS - Stereotactic radiation treatment, cranial

Treatment Planning - developing a plan to deliver treatment to the malignancy while dose blocking to normal tissue.

Radiation Oncology is the medical use of ionizing radiation and precise cancer treatment to control or kill malignant cells and certain non-malignant conditions. Radiation Oncology involves a multi-disciplinary specially trained team of professionals when providing services, including three-dimensional conformal (3D CRT or External Beam Radiation Therapy - EBRT), intensity modulated, stereotactic brain and body radiation therapy and brachytherapy. 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-leave collimater (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) and five verification 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.

Centers for Medicare & Medicaid Services (CMS), NCCI Procedure to Procedure (PTP) Edits

Centers for Medicare & Medicaid Services (CMS), NCCI Medically Unlikely Edits (MUEs)

Local Coverage Article A56874 Billing and Coding: Stereotactic Radiation Therapy: Stereotactic Radiosurgery(SRS) and Stereotactic Body Radiation Therapy (SBRT)

Intensity Modulated Radiotherapy (IMRT) Bundling