Radiation Therapy Services

Description

The American Society for Radiation Oncology (ASTRO) defines Intensity Modulated Radiation Therapy (IMRT) as a technology for delivering highly conformal external beam radiation to a well-defined treatment volume with radiation beams whose intensity varies across the beam. IMRT is particularly useful for delivering a highly conformal radiation dose to targets positioned near sensitive normal tissues.

Superficial Radiation Therapy (SRT) delivers radiation therapy using low energy x-rays. This technology avoids deep tissue damage by only penetrating the skin.

This reimbursement policy applies to professional and facility claims for radiation therapy services related to, or as part of, IMRT or SRT plan development.

Same group practice is defined as a physician and/or other qualified health care professional of the same specialty with the same Federal Tax ID number.

Policy

Blue Cross Blue Shield North Carolina (Blue Cross NC) will reimburse radiation therapy related services according to the criteria outlined in this policy.

Reimbursement Guidelines

IMRT/ Proton Beam Therapy (CPT® 77301)

CPT® codes 77280, 77285, 77290, 77295, 77306, 77307, 77321, 77331 and 77370 are not separately reimbursable when performed the day of or within 30 days (prior to, or after) CPT® code 77301 by the same group practice for the same member.

Modifier 59 is appropriate to represent a distinct procedural service for a different tumor on a different date of service, and unrelated to the IMRT plan.

Multi-lead collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction per IMRT plan (CPT® 77338) is reported once per IMRT plan and is limited to 3 units per 60 day treatment course.

SRT (CPT® 77401)

Simulation (CPT® 77280, 77285 or 77290) is only reimbursable once per 60 day course of treatment.

Basic radiation dosimetry calculation (CPT® 77300) is only reimbursable once per 60 day course of treatment.

Image guidance (HCPCS G6001) is not reimbursable when performed with SRT.

Radiology Maximum Units/Frequency

Stereotactic Radiosurgery (SRS) for cranial lesions (simple or complex) is reported once per course of treatment and is only reimbursable one unit per two weeks. Additional cranial lesions should not be reported more than four times for an entire course of treatment (two weeks) regardless of the number of lesions treated and may be reported only once per lesion.

SRS for spinal lesions is reported once per course of treatment and is only reimbursable one unit per two weeks. Additional spinal lesions should not be reported more than two times for the entire course of treatment (two weeks) regardless of the number of lesions treated and may be reported only once per lesion.

Stereotactic body radiation treatment (CPT® 77371-77373) and, stereotactic radiosurgery treatment (G0339, G0340) should not be reported more than five sessions for an entire course of treatment regardless of number of lesions treated. Since a treatment course is typically defined as two weeks, this combination of codes should only be reported up to five times per two weeks.

Additionally, stereotactic radiation treatment delivery (CPT® 77371, 77372) and stereotactic radiosurgery (G0339) represent a complete course of stereotactic radiosurgery treatment and should not be reported more than once for a single two-week course of treatment.

Radiation therapy management with complete course of therapy consisting of 1 or 2 fractions only will be limited to 1 session per 60 days.

Stereotactic radiation treatment management of cranial lesion(s), complete course of treatment consisting of 1 session should not be reported more than once in a two-week treatment course.

Treatment management for SBRT is limited to one visit per two-week treatment course.

Special treatment procedures (77470) should only be reported once per two-week treatment course.

Rationale

In line with the American Society for Radiation Oncology (ASTRO), CPT® 77301, which represents the IMRT also includes other related radiation therapy services performed as part of the development of the IMRT plan.

According to CMS, CPT® 77280, 77285, 77290, 77295, 77306, 77307, 77321, 77331 and 77370 may not be billed separately if they are performed as part of developing an IMRT treatment plan, regardless of whether they are billed on the same or a different date of service (CMS Manual, chapter 4, §§ 200.3.1 and 200.3.2).

Billing and Coding

Applicable codes are for reference only and may not be all inclusive. For further information on reimbursement guidelines, please see the Blue Cross NC web site at www.bcbsnc.com.

Related Policy

Bundling Guidelines

Outpatient Code Editor (OCE) Edits

Intensity Modulated Radiation Therapy (IMRT) of the Chest (Medical Policy)

Intensity Modulated Radiation Therapy (IMRT) for Sarcoma of the Extremities (Medical Policy)

Intensity-Modulated Radiation Therapy (IMRT) of the Prostate (Medical Policy)

Intensity Modulated Radiation Therapy (IMRT) of Head and Neck (Medical Policy)

Intensity Modulated Radiation Therapy for Tumors of the Central Nervous System (Medical Policy)

References 

ASTRO IMRP Planning American Society for Radiation Oncology

ASTRO Model Policies IMRT IMRTMP

Medicare Claims Processing Manual, Chapter 4 Medicare Claims Processing Manual (cms.gov)

ASTRO Basics of Coding American Society for Radiation Oncology (ASTRO)

History

4/20/2021 New policy developed. Notification on 4/20/2021 for effective date 7/1/2021. (eel)

10/1/2021 Policy renamed from “Intensity Modulated Radiation Therapy“ to “Radiation Therapy Services“. Policy expanded from IMRT to include SRT. Notification on 10/1/2021 for effective date 11/30/2021. (eel)

12/30/21 Routine policy review. Medical Director approved. (eel)

6/1/22 Policy language updated throughout. Multi-lead collimator added to Reimbursement Guidelines. Listing of “Radiology Maximum Units/Frequency” added to Reimbursement Guidelines. Medical Director approved. Notification on 3/31/2022 for effective date 6/1/2022. (eel)

12/31/2022 Routine policy review. Minor revisions only. (ckb)

1/1/2024 Routine policy review. Code 77301 and proton beam therapy clarified. Medical Director approved. (ss)

11/1/2024 Clarification to the definition of same group practice. No change to policy intent. (tlc)

Application

These reimbursement requirements apply to all commercial, Administrative Services Only (ASO), and Blue Card Inter-Plan Program Host members (other Plans members who seek care from the NC service area). This policy does not apply to Blue Cross NC members who seek care in other states.

This policy relates only to the services or supplies described herein. Please refer to the Member's Benefit Booklet for availability of benefits. Member's benefits may vary according to benefit design; therefore member benefit language should be reviewed before applying the terms of this policy.