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.

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® 77014, 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).

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

Brachytherapy

Brachytherapy element is not separately reimbursable when billed with remote after-loading high intensity brachytherapy. Brachytherapy isodose planning is limited to ten times per 60 days by any provider.

Dosimetry and Simulation

Basic radiation dosimetry calculation is limited to ten units per 60 days by any provider. Special dosimetry is limited to six units per 60 days by any provider.

Simulation reimbursement is limited to five units per 60 days.

For superficial radiation treatment (SRT), basic radiation dosimetry calculation and simulation are only reimbursable once per 60 days.

3-dimensional radiotherapy planning is limited to three times per 60 days.

Image guidance is not reimbursable when performed with SRT.

Intensity Modulated Radiotherapy Plan

Intensity modulated radiotherapy dose planning is only reimbursable once per 60 days.

Individual services performed as part of the development of intensity modulated radiotherapy dose planning are not separately reimbursable when performed the day of or within 30 days (prior to, or after) of a billed intensity modulated radiotherapy dose planning service 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 intensity modulated radiotherapy dose planning.

Design and construction of multi-lead collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT) is reported once per IMRT plan and is limited to 3 units per 60 days.

Radiation Therapy and Treatment Management Services

A radiation therapy management complete course that is 2 or less fractions is limited to 1 session per 60 days.

Radiation therapy treatment device reimbursement is limited to seven units per 60 days. An additional 5 units may be reimbursed for services with a head, neck or prostate cancer diagnosis or when performed within two weeks before or after IMRT or stereotactic body radiation treatment (SBRT).

Therapeutic radiology treatment planning is limited to one unit per 60 days when performed by any provider for the same course of treatment. Diagnostic professional radiology services (i.e., MRI and CT) are not separately reimbursable from complex therapeutic radiology treatment planning.

Radiation treatment management services should only be reported once per week by any provider. Services integral to radiation treatment management services and brachytherapy are not separately reimbursable.

Special treatment procedures are only reimbursable within two weeks of a complex therapy as defined by the American Society for Radiation Oncology (ASTRO).

Therapeutic port films are only reimbursable once per week.

Stereotactic Radiosurgery

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.

Treatment management for SBRT is limited to one visit per two weeks.

SBRT and stereotactic radiosurgery treatment 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 and stereotactic radiosurgery represent a complete course of stereotactic radiosurgery treatment and should not be reported more than once for a single two-week course of treatment.

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

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)

ASTRO 2024 Radiation Oncology Coding Resource

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)

2/01/2025 Maximum units and frequency language updated throughout policy. RPOC approved. Notification on 12/01/2024 for effective date 2/01/2025. (ss)

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.