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Radiation Therapy Services

Radiation oncology is the specialty of medicine that utilizes high-energy ionizing radiation in the treatment of malignant neoplasms and certain non-malignant conditions. It uses several distinct therapeutic modalities ­ teletherapy, brachytherapy, hyperthermia and stereotactic radiation. As a part of the consolidation of Local Coverage Determinations (LCDs) for the Jurisdiction 4 Medicare Administrative Contractor (MAC) region, TrailBlazer® inherited a number of LCDs. The LCD regarding external beam radiation therapy services was mainly a list of definitions and had few concepts related to "medically reasonable and necessary." Consequently, TrailBlazer retired the LCD ("Radiation Oncology: External Beam/Teletherapy ­ 4R-23AB" (L26839)) and replaced it with this article that includes selected coding guidelines and documentation requirements. This document addresses teletherapy for malignant and benign lesions. Other modalities have been or will be addressed in separate LCDs. Current active J4 LCDs dealing with radiation therapy include: "Brachytherapy: Non-Intracoronary ­ 4R-21AB (L26834)." "Grenz Ray Treatment - 4R-20AB (L26831)." "Intensity-Modulated Radiation Therapy (IMRT) ­ 4R-22AB (L26833)." "Stereotactic Body Radiation Therapy ­ 4R ­ 24AB (L26835)." "Stereotactic Radiosurgery ­ 4R-25AB (L26838)." CMS has issued requirements for radiation therapy services in the following documents: CCI ­ Correct Coding Initiative Medicare Contractor Beneficiary and Provider Communications Manual, Chapter 5. Medicare Claims Processing Manual (Pub.100-04): o Chapter 13, Section 70: "Radiation Oncology." o Chapter 13, Section 20.2.1: "Hospital and Skilled Nursing Facility (SNF) Patients." Medicare Benefit Policy Manual (Pub. 100-02): o Chapter 15, Section 90: "X-ray, Radium, and Radioactive Isotope Therapy." Definitions Since some words, (e.g., port and field) have been used interchangeably and because certain payments are based on these words, this document stipulates the following definitions. Bite Block: A restraining device generally used in the oral cavity often attached to an outside source for patient stability. Block: A device fabricated of an energy-absorbing material such as lead or Cerrobend (Wood's metal) to shape or delineate the treatment portal to match the configuration of the desired area and to shield or protect normal structures. Bolus: A tissue-equivalent material used to change the surface deposition of a radiation beam.

Published August 2011

© CPT codes, descriptions, and other data only are copyright 2010 American Medical Association. All rights reserved. Applicable FARS/DFARS clauses apply. © CDT codes and descriptions are copyright 2010 American Dental Association. All rights reserved. Applicable FARS/DFARS clauses apply.

Compensator: An irregularly shaped beam-modifying device utilized to reconfigure the beam intensity to match irregular tissue contours. Collimator: A beam-shaping device attached to the head of the treatment machine to define the initial configuration (the length and width) of the treatment portal. Dosimetry: The calculation of the radiation dose distribution within a treatment beam. Hyperfractionation: Radiation therapy delivered more than once per day. Isodose: A plotting of lines or a series of lines following paths of the same dose distribution within a treatment beam. Mold: A patient-restraining device usually constructed of plaster or thermosetting plastic that fits to the contour of the patient and restricts the motion of the patient during treatment. Port, Portal: These words are synonymous and refer to the site on the skin where the radiation beam enters the body. "Field," often used as a synonym for "port," will not be used in this policy. Portal Verification: Any means of verifying the placement and configuration of the treatment portal. Simulation: The use of a simulator, or other means, to determine the various treatment portal outlines and orientation to be used in the course of radiation therapy. Simulator: A radiation generator operating in the diagnostic X-ray range. A simulator has the mechanical capability to orient a radiation beam toward a patient with parameters imitating that of the proposed therapy while affording direct X-ray fluoroscopic visualization and roentgenographic images of the area. This machine is not capable of delivering radiation therapy. Stent: A splint-restraining device generally used in the oral cavity. The device is usually constructed of acrylic or some other dental material but may incorporate lead or other energy-absorbing material to protect some portion of the cavity from direct dose deposition. Stereotactic: A three-dimensional technique of intersecting multiple portals creating complex interaction of the treatment beams and resulting isodose plans. Teletherapy or External Beam Radiation Therapy (EBRT): The delivery of electromagnetic energy from a treatment machine at some distance from the treatment area. External beam radiation is commonly delivered by a linear accelerator, which can deliver photons (X-rays) or electrons to the targeted area. Volume of Interest: This phrase refers to that volume within the body to which the radiation therapy is directed. In this document, volume of interest is never synonymous with port and is preferred because it is the phrase most commonly used by radiation oncologists. Treatment volume is accurate but less often used. Area of interest, used in the American Medical Association's (AMA's) CPT book, suggests a two-dimensional configuration and is, in this geometric sense, inaccurate. Target site seems to point to just the tumor itself and excludes the surrounding volume of tissue that might be of interest. "Field" is used sometimes to mean volume of interest and other times to mean port and, therefore, can be confusing.

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Wedge: A treatment beam-modifying device acting to change the intensity of the treatment beam in a graduated fashion across the width or length of the treatment portal. For definitions of other terms, TrailBlazer will accept definitions published in the most current editions of standard coding references such as The ASTRO/ACR Guide to Radiation Oncology Coding or A User's Guide for Radiation Oncology Management and Billing Procedures (Cancer Care Network). Treatment Planning Clinical Treatment Planning (CPT Codes 77261­77263): Clinical treatment planning and tumor mapping is crucial to identifying the location, extent and volume of the tumor(s) to be treated and all of the critical structures surrounding it. Treatment planning is a one-time charge per course of therapy. Only one plan should be billed per treatment course. Billing multiple treatment plans for a single course of therapy is not allowed. The CCI bundles 77305, 77310 and 77315 into 77321 and does not allow payment for a combination of these CPT codes unless 77321 is for a different volume of interest than one for the other CPT codes. This is a professional service only and the physician is responsible for all of the technical aspects of the treatment planning process. Legible documentation will consist of a written treatment plan that has been dated and signed by the physician and includes the above criteria (special tests, modality, treatment time/dose considerations, ports and devices). Evidence of the planning process maintained in the patient's medical record includes, but is not limited to: Identification of the location, extent and volume of tumor(s) to be treated and the critical structure surrounding them. The physician's plans of appropriate course of therapy, including a plan(s) that may involve ordering and interpreting special tests surgical exploration with biopsy and placing markers for the purpose of treatment planning and tumor localization. Documentation that supports the use of each individual CPT code. Therapeutic Radiation Simulation-Aided Field Setting (CPT Codes 77280­77295): Radiation oncology simulation is defined as the process of determining and establishing the radiation therapy treatment portals to a specific treatment volume. Simulation is used to actually direct the treatment beams to the specific volumes of interest. Simulation may be carried out on a dedicated conventional simulator or CT scanner, radiation therapy treatment unit (e.g., linear accelerator), virtual reality-based 3-D simulation system or other diagnostic X-ray (including CT, MRI or PET scans), ultrasound, nuclear medicine equipment that has been modified to localize treatment volumes to define the area that requires treatment or diagnostic imaging equipment (e.g., fluoroscopy, CT, MRI). The complexity of simulation is based on the number of ports of entry, treatment volumes, and the inclusion and type of treatment devices. The number of films taken per treatment volume, the modality from which the images for simulation are obtained and the use of fluoroscopy are not determinants of complexity, however. Portal changes based on unsatisfactory initial simulation(s) are not reported as additional simulations. However, additional simulations may be required during treatment to account for changes in port size, boost dose or to account for changes in the treatment volume.

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Inclusion of treatment devices in the simulation process typically increases the complexity. Simulation without the inclusion of devices or with premade devices (e.g., blocks, immobilization) is considered simple. The typical course of radiation therapy may require between one and three simulations. Frequency in excess of three simulations may require additional documentation. However, no more than one simulation should be reported on any given day. Documentation of simulation requires a written record of the procedure and hard copy of electronic images and evidence of image review by physicians including signature or initials and date of review. 77295© Therapeutic radiology simulation-aided field setting; three-dimensional: Documentation must be a hard copy of computer-generated, three-dimensional tumor volume and critical structure or critical area reconstruction and three-dimensional representation of dose distribution in the form of dose clouds and/or Dose Volume Histograms (DVH) of volume of interest and critical structures with evidence of review by a physician. CPT code 77295 may be billed once per treatment course per treatment volume. Threedimensional simulation includes those activities necessary to perform a three-dimensional treatment plan, including digitally reconstructed radiographs of the beam's-eye view and either cross-sectional reconstructions of the dose distributions in three dimensions or a review of the dose-volume histograms of the resultant treatment. CPT code 77295 also includes the work done for teletherapy isodose plan (CPT codes 77305­ 77315), and accordingly, CPT codes 77305­77315 should not be billed separately. Further, the CCI has bundled CPT codes 77280, 77285 and 77290 so these CPT codes may not be billed in addition to 77295. In most circumstances, the anatomy and the planning tumor volume for the highest dose regions will not change throughout the treatment course. Therefore, in general, a single activity (CPT code 77295) and reimbursement shall suffice. If more than one set of beams utilizing different beam and gantry angles is used to treat a larger "nodal" volume and a smaller "conedown" volume, and both sets of treatments are planned off the same CT dataset, two sets of beam's-eye view portals can be generated. Only one set of dose-volume histograms is necessary for documentation in this case ­ the dose-volume histograms representing the cumulative dose distributions from the two plans. Therefore, only one 77295 charge is appropriate. In those uncommon circumstances where there is a substantial change in either patient anatomy or tumor conformation where a second CT dataset is required to produce an accurate, efficacious and safe "cone-down" plan, a second 77295 charge may be appropriate. When the physician deems this to be the case, the medical necessity for the second 77295 simulation must be documented. Dosimetry Basic Radiation Dosimetry Calculation (CPT Code 77300): This service is considered to be medically necessary for each treatment port and if a patient has off-axis calculations, calculations for different depth doses, different volumes of interest, secondary film dosimetry, abutting volumes of interest or any other situation requiring individual point calculations of radiation dosage.

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Changes in a patient's weight or girth during the course of radiation treatment may necessitate dosimetry recalculation. Basic dosimetry calculations may be reported as many times as necessary calculations are performed. The typical course of radiation therapy will require from one to six dosimetry calculations depending on the complexity of the case. However, radiation treatments to the head/neck, prostate or for Hodgkin's disease may require eight or more calculations. Frequent simulations will require supporting documentation with the medical record clearly addressing the need for the number of procedures. Both external beam and brachytherapy require specific calculations to be made and recorded before or during the course of therapy. For external beam, CPT code 77300 is used to report dosimetry calculations. However, multiple points of calculation within an isodose plan should not be reported independently or individually. For brachytherapy, CPT code 77300 may be reported when an independent calculation is performed exclusive of the isodose plan. Teletherapy/External Beam Isodose Plan (CPT Codes 77305­77315): Isodose plans are essential to ensure that the treatment volumes receive the prescribed dose of radiation. Teletherapy involves the use of external beam radiation. A teletherapy isodose plan determines the radiation dose within the target volume and to surrounding volumes of normal tissue. An isodose plan is calculated by the qualified medical physicist using computer-based measurements of radiation beams produced by the treatment unit and is reported under CPT codes 77305, 77310 or 77315, teletherapy isodose plan: simple, intermediate or complex, respectively. This service is considered medically necessary for a given course of radiation therapy to a specific volume of interest. The typical course of radiation therapy will require from one to six isodose plans. Frequency in excess of the upper end of this range will require supporting documentation. Usually only one plan per volume of interest will be sufficient even though some patients may require multiple teletherapy plans during the course of therapy. Situations that may require an extra teletherapy plan include the need to change the machine or the volume of interest. Toward the end of treatment, due to documented clinical variations of the patient, another plan may be required. Special Teletherapy Port Plan (CPT Code 77321): This CPT code is utilized when planning for any special beam consideration is required (e.g., electrons, heavy particles). Some examples include the use of electrons in total skin irradiation, photons for hemibody irradiation, and proton or neutron beam therapy planning. Note that an isodose plan is an integral piece of documentation for work effort on this planning CPT code. If a particle beam is planned for delivery without an isodose plan, 77300 should be assessed. An isodose plan need not be developed for hemibody, total body proton or total skin electron plans. The radiation oncologist must document his involvement in the planning and selection of the special beam parameters and must make the final selection and initiation of the treatment process. Special Dosimetry (CPT Code 77331): This CPT code is used to report the measurement of radiation dose at a given point using special radiation monitoring and measuring devices such as thermoluminescent dosimeters, solid state diode probes, special dosimetry probes, other dosimetry probes or film dosimetry.

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This procedure is not to be routinely performed each time the patient is treated. It would be expected that the utilization of this procedure would correspond with the level of complexity of the clinical treatment planning services provided for the patient. This service is typically billed once per port when the physician determines that it is necessary to have a measurement of the amount of radiation that a patient has actually received at a given point, with the final results being utilized to accept or modify the current treatment plan. The monitoring devices utilized for measuring and monitoring can include Thermoluminescent Dosimeters (TLD), solid state diode probes, special dosimetry probes or film dosimetry. The physician must specify the type of special dosimetry. Basic Radiation Dosimetry Calculation (CPT Code 77300): Documentation requires that the calculation(s) be reviewed, signed and dated by a physician. The necessity of any repeated dosimetry must be clearly documented. Teletherapy/External Beam Isodose Plan (CPT Codes 77305­77315): The physician's documentation must be specific to the number of volumes of interest. The specific location of the tumor(s) to be treated must be documented as well as the specific number of ports involved with each volume of interest treated. All isodose plans must be checked and signed by the medical radiological physicist and the radiation oncologist. Special Teletherapy Port Plan (CPT Code 77321): Documentation requires that the special teletherapy port plan be reviewed, signed and dated by the radiation oncologist. Special Dosimetry (CPT Code 77331): Documentation of special dosimetry requires a physician order for the procedure including clear documentation of the necessity for the procedure and that the work product is reviewed, signed and dated by the physician. Treatment Devices Treatment Device Design and Construction (CPT Codes 77332­77334): Many different types of treatment devices are used in the successful delivery of radiation oncology treatments. Examples include beam-shaping devices, custom-fabricated patient-immobilization devices, beam-modification devices and equipment used to shield critical structures. Their use is determined by the clinical judgment of the radiation oncologist based on patient anatomy and disease state. They are fabricated as the direct result of physician work and supervision. During the course of fractionated radiation therapy, the accuracy of their daily use is the direct responsibility of the treating physician. In all levels of complexity, the physician must be directly involved in the design, selection and placement of any of the devices. Providers should bill for devices at the beginning of the treatment course and then may bill again later in the course of treatment when additional or new devices are required. Payment for one set of treatment devices may be allowed per separate port when radiation therapy is started. The number of charges for treatment devices will depend on the individual patient's needs. However, according to the 2005 ASTRO/ACR Radiation Oncology User's Guide: "The typical course of radiation

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therapy may consist of up to five professional charges for devices. (Prostate, head/neck and Hodgkin's disease treatments may require eight devices.) Frequency in excess of the upper end of this range may require supporting documentation." The number of sets is equal to the number of different anatomic sites or ports involved, except that opposing ports (such as AP/PA) represent one set. Refer to the table below for a list of treatment devices and their associated complexity levels: Treatment Device Alpha Cradle Aquaplast Asymmetric Jaws 77334 ­ Complex 77334 ­ Complex 77332 ­ Simple for two separate portals (x2 unless mirror image) 77334 ­ Complex IF, used with other complex device 77333 ­ Intermediate 77333 ­ Intermediate N/A 77333 ­ Intermediate 77332 ­ Simple 77333 ­ Intermediate 77334 ­ Complex 77334 ­ Complex 77334 ­ Complex 77334 ­ Complex per port 77333 ­ Intermediate 77334 ­ Complex 77332 ­ Simple 77334 ­ Complex 77332 ­ Simple 77332 ­ Simple Eye Blocks 77334 ­ Complex 77332 ­ Simple for 1­2 77333 ­ Intermediate 3+ N/A 77334 ­ Complex per field 77334 ­ Complex 77333 ­ Intermediate

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CPT Code

Beam Splitter Blocks Bite Blocks, Stent, Mouthbite Blue Prone Pillow Bolus ­ Special Bolus ­ Simple Breast Board Cerrobend Clam Shells Compensators Conformal Blocking Cord Blocks Dental Mold ­ Custom Electronic Cone for IMRT Electron Cut-Out Custom Electron Cut-Out Non-Custom Eye Shields External or Non-Custom Eye Blocks Internal Hand Blocks Leg Immobilizer Multi-Leaf Collimator (MLC) Nose Shield Pituitary Headholder

Treatment Device Rings Shoulder Retractor Stereotactic Headframe Superflab Cut Superflab ­ Uncut T-Bar Testicle Shields Reusable Customized Non-Reusable TBI Beam Compensator Timo Vacloc (Vaculoc), Vacuplast Wedges only when used separate from other Devices/Wingboard

CPT Code N/A N/A 77333 ­ Intermediate 77334 ­ Complex (if no other devices billed) 77332 ­ Simple 77333 ­ Intermediate 77333 ­ Intermediate 77334 ­ Complex 77334 ­ Complex N/A 77334 ­ Complex 77334 ­ Complex N/A

Providers should bill for devices at the beginning of the treatment course and may bill again in the course of treatment when additional or new devices are required. Payment for one set of devices (CPT codes 77332­77334) will be allowed for each port. A pair of devices for opposing ports (e.g., left and right lateral, AP and PA) constructed from a single film is considered one port for billing purposes. However, if each member of the pair required a separate film for its construction (two films used), then one Professional Component (PC) and two Technical Components (TCs) are billed separately. When the patient has a combination of a wedge, a compensator, a bolus or a port block covering the same treatment port, this would be billed as a single complex treatment device rather than a separate charge being rendered for each of the individual items. Products used for patient comfort (e.g., pillows, pads, cushions) should not be charged as treatment devices. The need for each device and the physician's participation in its design, supervision and construction must be documented in the medical record. The physician's participation in this aspect of the process of care must include the physician's signature and date on simulation images and port images.

77520­77523 and 77525 Proton Beam Delivery: Because proton beam therapy is relatively new and available in only a few locations, the provider/physician will need to contact Medicare to discuss indications and payment. Each claim will be individually reviewed. These are technical CPT codes only. 77417© Portal Verification Film(s): These films should agree with the original simulation films and dosimetry. This procedure may not be quantity billed. It is a technical component only procedure; it does not carry a professional physician component and does not require a modifier. The review and interpretation of port films is considered part of the weekly clinical treatment management by the physician. Portal verification films should be reported as one charge per five fractions of therapy,

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regardless of the number of films required during this time interval and may be obtained via electronic imaging. Radiation Treatment Management (CPT Codes 77427, 77431): Radiation treatment management is reported in units of five fractions or treatment sessions, regardless of the actual time period in which the services are furnished. The services need not be furnished on consecutive days. Multiple fractions (hyperfractionation) representing two or more treatment sessions furnished on the same day may be counted separately and may be considered for payment as long as there has been a distinct break in therapy sessions and the fractions are of the character usually furnished on different days. The only instance appropriate for billing CPT code 77427 for less than five fractions is if there are three or four fractions beyond a multiple of five at the end of a course of treatment or when the full course of treatment is three or four fractions. One or two fractions beyond a multiple of five at the end of the course of treatment are not reported separately. The professional services furnished during treatment management typically consist of: Review of port films. Review of dosimetry, dose delivery and treatment parameters. Review of patient treatment set-up. Examination of patient for medical evaluation and management (e.g., assessment of the patient's response to treatment, coordination of care and treatment, review of imaging and/or lab test results). If a patient's entire treatment course consists of only one or two fractions, the physician should bill with CPT code 77431 and report the individual dates of service in the appropriate comment field on the claim. Do not use CPT code 77431 for reimbursement for the remaining treatments at the end of a long course of therapy. CMS requires that providers indicate the number of radiation treatments on each claim when seeking reimbursement for radiation therapy management as follows: Each radiation therapy management service should be billed on a separate detail line. The date of service should be the beginning date for each set of five treatments delivered. Payment will only be made after the fifth treatment has been delivered or for the last three or four fractions at the end of the treatment course. Radiation therapy management must be submitted along with the specific number of fractions (number of fractions is to be noted in the appropriate claim comment field with the individual dates of radiation treatment). Claims must clearly document when a new course of therapy begins or they will be processed as a continuation of therapy resulting in incorrect payment. Documentation should include the date and current treatment dose on the day of the weekly management note, although the individual components of the service may occur throughout the reporting period. A radiation oncologist must evaluate the clinical and technical aspects of the treatment and document that evaluation and the resulting management decisions. Place of Service: Payment is limited to services furnished in the office (POS 11), inpatient hospital (POS 21), outpatient hospital (POS 22) and a freestanding radiation therapy center (POS 99).

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Note: All documentation must be specific to the patient being treated or the claim may be denied or rejected. Documentation must include the planned course of therapy, type and delivery of treatment, level of clinical management involved, and ongoing documentation of any changes in the course of treatment. Failure to provide documentation for all additional devices may result in a denial or rejection of the claim. Appeals for denied claims must be accompanied by that portion of the patient's medical record that documents the reason for the additional sets or the physician's involvement in designing the devices or positioning the patient. It is not necessary to provide the complete medical record. A patient referral with diagnostic information and request for consultation for radiation oncology should be maintained in the patient's record and made available to Medicare on request. If a patient is a hospital inpatient or Skilled Nursing Facility (SNF) patient in a covered Part A stay and is transported to a freestanding facility for therapy, the technical component of the radiation oncology services cannot be paid to the freestanding facility (according to Internet-Only Manual (IOM), Pub 100-04, Chapter 13, Section 20.2.1). The patient will need to be discharged and readmitted or the freestanding facility can receive payment from the hospital or SNF through prior arrangements with the hospital or SNF. Medical Physics Consultation (CPT Codes 77336, 77370): CPT codes 77336 and 77370 are technical services only and are payable by Medicare Part B only in settings in which the technical component is payable, i.e., in the freestanding radiation oncology center that employs its own radiation physicist. These services require full documentation to include, but not be limited to, specifications of the prescribing physician, which include: Review of patient's treatment chart and record. Justification of prescribed radiation dosage. Appropriate positioning. Beam orientation. Radiation safety. 77336© Continuing Medical Physics Consultation: This service ensures the treatment administered conforms to the specifications of the prescribing physician. This service includes a documented review of the patient's treatment chart and record to verify that the patient received the prescribed radiation dosage, appropriate positioning and beam orientation, and radiation safety. CPT code 77336 is a "weekly CPT code" and is reported once for each week of external beam radiation treatments in which at least three fractions have been given or once for each five fractions in the event that more than one fraction is given per day. For radiation therapy treatment that is not administered in five weekly fractions (such as brachytherapy or stereotacticradiosurgery) or for a course of radiation therapy consisting of one or two fractions, CPT code 77336 may be reported. 77370© Special Medical Physics Consultation: The special medical radiation physics consultation CPT code is used when the radiation oncologist makes a direct request to the qualified medical physicist for a special consultative report or for specific physics services on an individual patient. Such a request may be made when the complexity of the treatment plan is of such magnitude that a

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thorough written analysis is necessary to address a specific problem or when the service to be performed requires the expertise of a qualified medical physicist. The clinical indication that justified the request for the special physics consultation should also be documented. Examples of problems that might justify the use of this CPT code include: Complex interrelationships of electron and photon ports and complex dosimetric considerations in brachytherapy, including high-dose-rate remote afterloader applications, intravascular brachytherapy treatments, and interstitial radioactive seed implantation. Analysis of customized beam-modification devices and special blocking procedures (and their dosimetric evaluation) to protect critical organs during treatment. Analysis of the effects of previous radiation therapy with assessment of cumulative radiation dose to critical organs. Computation of dose to the fetus in a pregnant patient undergoing radiation therapy. Special brachytherapy equipment developed by the qualified medical physicist to treat a particular patient. The qualified medical physicist will spend a considerable amount of time and effort on behalf of a specific patient and will render a customized written report (which will form part of the patient's chart) to the radiation oncologist in reference to the problem or service being addressed. CPT code 77370 must be used for consultative purposes when a problem or special situation arises during radiation therapy. This CPT code requires a detailed written report describing the problem to be given to the requesting physician. Radiation Treatment Delivery (CPT Codes 77401­77416): These CPT codes recognize the technical component and the various energy levels administered. It is important to code according to the level of service and the energy used. The physician's documentation within the patient's medical record must support the specific energy levels reported to Medicare. Two factors determine which treatment delivery CPT code to choose: Energy level used in treatment, in megavolts (MV). Complexity of treatment (defined as number of treatment sites, port and devices). Two Separate Treatment Areas 77407 up to 5 MeV 77408 6­10 MeV 77409 11­19 MeV 77411 20 MeV or greater Three or More Separate Treatment Areas 77412 up to 5 MeV 77413 6­10 MeV 77414 11­19 MeV 77416 20 MeV or greater

Superficial 77401

Single 77402 up to 5 MeV 77403 6­10 MeV 77404 11­19 MeV 77406 20 MeV or greater

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Simple Treatment Delivery (77401, 77402, 77403, 77404, 77406) Single port. Parallel ports. No devices. Simple devices.

Intermediate Treatment Delivery (77407, 77408, 77409, 77411) Two separate areas. Three or more ports. Multiple non-complex devices.

Complex Treatment Delivery (77412, 77413, 77414, 77416) Three or more areas treated. Custom devices. Rotational beam. Compensator. Special particle beam (i.e., electrons, neutrons). Tangential ports. Wedges

When billing for multiple treatments on the same day, the claim must document that there has been a distinct break between therapies. Statements such as "a.m. and p.m. treatments" placed in Item 19 on the CMS-1500 claim form or electronic equivalent will suffice. CPT codes 77401­77416 recognize the technical component and the various energy levels administered. It is important to code according to the level of service and the energy used. When two different energy levels are given in the same session, bill the CPT code (77401­ 77416) for the highest energy level only. When more than one treatment (CPT codes 77401­77416) is performed on the same day, e.g., hyperfractionation, each treatment should be billed on a separate detail line, appending modifier 59 to the additional treatment session. Multiple treatment sessions (CPT codes 77401­77416) on the same day are payable as long as there has been a distinct break in therapy services and the individual sessions are of the character usually furnished on different days. When billing for multiple treatments on the same day, the claim must document that there has been a distinct break between therapies. Radiation treatment delivery CPT codes (77401­77416) can be billed using a date range if the treatments are performed on consecutive days and the energy and level of service are the same, the total number being indicated in the CMS-1500 claim form day or unit field or electronic equivalent. If the dates of service are not consecutive or the energy or level of service is not the same, each date of service must be billed on a separate detail line. Multiple treatment sessions (CPT codes 77401­77416) on the same day are payable as long as there has been a distinct break in therapy services and the individual sessions are of the character usually furnished on different days. When billing for multiple treatments on the same day, the claim must document that there has been a distinct break between therapies. Stereoscopic X-ray guidance for localization of target volume (CPT code 77421): This is an alternative means of ensuring accurate 3-D positioning. When performed, port verification films (77417) should not be separately reported for these sessions. The record should clearly reflect that this was performed and recorded for any session billed.

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Special Treatment Procedures (CPT code 77470): Additional physician effort and work required for special radiation treatment procedures is reported with CPT code 77470. These include: Hyperfractionation. Total body irradiation per oral or vaginal cone use. Hemibody irradiation. Intracavity cone use. Brachytherapy (other than coronary). Hyperthermia. Concurrent chemotherapy. Radiation response modifiers. Stereotactic radiosurgery (single fraction or fractionated). Intra-operative radiation therapy. Heavy particles (e.g., protons/neutrons). 3-D CRT. IMRT. Other time-consuming or complex treatment procedures. This CPT code is not intended for use when the patient has another ongoing medical diagnosis such as diabetes, COPD, or hypertension. A brief written statement is appropriate for this CPT code. It is considered an acceptable standard of practice for CPT code 77470 to be reported only once during a treatment course and it may be billed in addition to the weekly management CPT code. For the remaining treatment course, a physician should use the appropriate weekly radiation therapy management CPT codes (77427 and 77431) for management of the patient.

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Radiation Therapy Services

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