SUPERSEDED LCD Reference Article Billing and Coding Article

Billing and Coding: Stereotactic Radiation Therapy: Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT)

A56874

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Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.
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Document Note

Posted: 3/12/2020
The “ICD-10 Codes that Support Medical Necessity” section has been revised to correct the ICD-10 code range C79.32-C79.52 to include ICD-10 code C79.31 under section “Group 1 Medical Necessity ICD-10 Codes Asterisk Explanation” and to correct the ICD-10 code range C00.1-C10.9 to include ICD-10 code C00.0 under “Group 2 Medical Necessity ICD-10 Codes Asterisk Explanation” section.

Note History

Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A56874
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Stereotactic Radiation Therapy: Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT)
Article Type
Billing and Coding
Original Effective Date
08/22/2019
Revision Effective Date
04/01/2020
Revision Ending Date
N/A
Retirement Date
N/A
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Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

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CMS National Coverage Policy

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Article Guidance

Article Text

This article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Stereotactic Radiation and Therapy: Stereotactic Radiosurgery (SRS) and Stereotactic Body Radiation Therapy (SBRT).

Coding Information:

Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.

A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.

The diagnosis code(s) must best describe the patient's condition for which the service was performed.

SRS is typically performed in a single session. If more than one session is required, SBRT codes must be used.

Documentation Requirements:

All documentation must be available upon request of the Medicare contractor.

The patient's record must support the necessity and frequency of treatment. The medical record must clearly indicate the critical nature of the anatomy or other circumstances necessitating the services, the patient's functional status and a description of current performance status (Karnofsky Performance Status).

Documentation should include the date and the current treatment dose.

Coverage may be considered at the Redetermination (Appeal) level on an individual basis for lesions when documentation clearly supports the necessity for high radiation dose per fraction and the necessity to avoid surrounding tissue exposure. When requesting an individual consideration through the written redetermination (formerly appeal) process, providers must include all relevant medical records and literature that supports the request. At a minimum two (2) Phase II studies (human feasibility studies suggesting efficacy, pilots) or one (1) Phase III study (primary evidence of safety and efficacy, pivotal) must be submitted for the Contractor Medical Director’s review.

Treatment devices, complex (CPT code 77334) is limited to one unit for each collimator in a linear accelerator system or one for each helmet in a cobalt-60 system. If the total number of units exceeds six (6) or the number of isocenters plus three (3) when multiple isocenters are necessary, a detailed explanation of medical necessity must be documented in the medical record. Documentation must specify factors, such as, multiple isocenters, irregularity of target volume(s), proximity of critical structures or other reasons which justify the units of service for dosimetry or treatment devices.

Utilization Guidelines:

Codes 77373, G0339 and G0340 will pay only once per day of treatment regardless of the number of sessions or lesions. CPT code 77435 code will pay only once per course of therapy.

Response To Comments

Number Comment Response
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Coding Information

Bill Type Codes

Code Description
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Revenue Codes

Code Description
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CPT/HCPCS Codes

Group 1

(14 Codes)
Group 1 Paragraph

Stereotactic Radiosurgery (SRS)/SBRT (for Cranial Lesions only) Services

Group 1 Codes
Code Description
61796 STEREOTACTIC RADIOSURGERY (PARTICLE BEAM, GAMMA RAY, OR LINEAR ACCELERATOR); 1 SIMPLE CRANIAL LESION
61797 STEREOTACTIC RADIOSURGERY (PARTICLE BEAM, GAMMA RAY, OR LINEAR ACCELERATOR); EACH ADDITIONAL CRANIAL LESION, SIMPLE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
61798 STEREOTACTIC RADIOSURGERY (PARTICLE BEAM, GAMMA RAY, OR LINEAR ACCELERATOR); 1 COMPLEX CRANIAL LESION
61799 STEREOTACTIC RADIOSURGERY (PARTICLE BEAM, GAMMA RAY, OR LINEAR ACCELERATOR); EACH ADDITIONAL CRANIAL LESION, COMPLEX (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
61800 APPLICATION OF STEREOTACTIC HEADFRAME FOR STEREOTACTIC RADIOSURGERY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
63620 STEREOTACTIC RADIOSURGERY (PARTICLE BEAM, GAMMA RAY, OR LINEAR ACCELERATOR); 1 SPINAL LESION
63621 STEREOTACTIC RADIOSURGERY (PARTICLE BEAM, GAMMA RAY, OR LINEAR ACCELERATOR); EACH ADDITIONAL SPINAL LESION (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
77371 RADIATION TREATMENT DELIVERY, STEREOTACTIC RADIOSURGERY (SRS), COMPLETE COURSE OF TREATMENT OF CRANIAL LESION(S) CONSISTING OF 1 SESSION; MULTI-SOURCE COBALT 60 BASED
77372 RADIATION TREATMENT DELIVERY, STEREOTACTIC RADIOSURGERY (SRS), COMPLETE COURSE OF TREATMENT OF CRANIAL LESION(S) CONSISTING OF 1 SESSION; LINEAR ACCELERATOR BASED
77373 STEREOTACTIC BODY RADIATION THERAPY, TREATMENT DELIVERY, PER FRACTION TO 1 OR MORE LESIONS, INCLUDING IMAGE GUIDANCE, ENTIRE COURSE NOT TO EXCEED 5 FRACTIONS
77432 STEREOTACTIC RADIATION TREATMENT MANAGEMENT OF CRANIAL LESION(S) (COMPLETE COURSE OF TREATMENT CONSISTING OF 1 SESSION)
77435 STEREOTACTIC BODY RADIATION THERAPY, TREATMENT MANAGEMENT, PER TREATMENT COURSE, TO 1 OR MORE LESIONS, INCLUDING IMAGE GUIDANCE, ENTIRE COURSE NOT TO EXCEED 5 FRACTIONS
G0339 IMAGE-GUIDED ROBOTIC LINEAR ACCELERATOR-BASED STEREOTACTIC RADIOSURGERY, COMPLETE COURSE OF THERAPY IN ONE SESSION OR FIRST SESSION OF FRACTIONATED TREATMENT
G0340 IMAGE-GUIDED ROBOTIC LINEAR ACCELERATOR-BASED STEREOTACTIC RADIOSURGERY, DELIVERY INCLUDING COLLIMATOR CHANGES AND CUSTOM PLUGGING, FRACTIONATED TREATMENT, ALL LESIONS, PER SESSION, SECOND THROUGH FIFTH SESSIONS, MAXIMUM FIVE SESSIONS PER COURSE OF TREATMENT

Group 2

(4 Codes)
Group 2 Paragraph

Stereotactic Body Radiation Therapy (SBRT) Services

 

Group 2 Codes
Code Description
77373 STEREOTACTIC BODY RADIATION THERAPY, TREATMENT DELIVERY, PER FRACTION TO 1 OR MORE LESIONS, INCLUDING IMAGE GUIDANCE, ENTIRE COURSE NOT TO EXCEED 5 FRACTIONS
77435 STEREOTACTIC BODY RADIATION THERAPY, TREATMENT MANAGEMENT, PER TREATMENT COURSE, TO 1 OR MORE LESIONS, INCLUDING IMAGE GUIDANCE, ENTIRE COURSE NOT TO EXCEED 5 FRACTIONS
G0339 IMAGE-GUIDED ROBOTIC LINEAR ACCELERATOR-BASED STEREOTACTIC RADIOSURGERY, COMPLETE COURSE OF THERAPY IN ONE SESSION OR FIRST SESSION OF FRACTIONATED TREATMENT
G0340 IMAGE-GUIDED ROBOTIC LINEAR ACCELERATOR-BASED STEREOTACTIC RADIOSURGERY, DELIVERY INCLUDING COLLIMATOR CHANGES AND CUSTOM PLUGGING, FRACTIONATED TREATMENT, ALL LESIONS, PER SESSION, SECOND THROUGH FIFTH SESSIONS, MAXIMUM FIVE SESSIONS PER COURSE OF TREATMENT
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CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

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Group 1 Codes

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ICD-10-CM Codes that Support Medical Necessity

Group 1

(116 Codes)
Group 1 Paragraph

Stereotactic Radiosurgery Services and Stereotactic Body Radiation Therapy (for Cranial Lesions only) - (Codes 61796, 61797, 61798, 61799, 61800, 63620, 63621, 77371, 77372, 77373, 77432, 77435, G0339, and G0340):

 

Group 1 Codes
Code Description
C11.0 Malignant neoplasm of superior wall of nasopharynx
C11.1 Malignant neoplasm of posterior wall of nasopharynx
C11.2 Malignant neoplasm of lateral wall of nasopharynx
C11.3 Malignant neoplasm of anterior wall of nasopharynx
C11.8 Malignant neoplasm of overlapping sites of nasopharynx
C11.9 Malignant neoplasm of nasopharynx, unspecified
C30.0 Malignant neoplasm of nasal cavity
C30.1 Malignant neoplasm of middle ear
C31.0 Malignant neoplasm of maxillary sinus
C31.1 Malignant neoplasm of ethmoidal sinus
C31.2 Malignant neoplasm of frontal sinus
C31.3 Malignant neoplasm of sphenoid sinus
C31.8 Malignant neoplasm of overlapping sites of accessory sinuses
C31.9 Malignant neoplasm of accessory sinus, unspecified
C69.31 Malignant neoplasm of right choroid
C69.32 Malignant neoplasm of left choroid
C70.0 Malignant neoplasm of cerebral meninges
C70.9 Malignant neoplasm of meninges, unspecified
C71.0 Malignant neoplasm of cerebrum, except lobes and ventricles
C71.1 Malignant neoplasm of frontal lobe
C71.2 Malignant neoplasm of temporal lobe
C71.3 Malignant neoplasm of parietal lobe
C71.4 Malignant neoplasm of occipital lobe
C71.5 Malignant neoplasm of cerebral ventricle
C71.6 Malignant neoplasm of cerebellum
C71.7 Malignant neoplasm of brain stem
C71.8 Malignant neoplasm of overlapping sites of brain
C71.9 Malignant neoplasm of brain, unspecified
C72.20 Malignant neoplasm of unspecified olfactory nerve
C72.21 Malignant neoplasm of right olfactory nerve
C72.22 Malignant neoplasm of left olfactory nerve
C72.30 Malignant neoplasm of unspecified optic nerve
C72.31 Malignant neoplasm of right optic nerve
C72.32 Malignant neoplasm of left optic nerve
C72.40 Malignant neoplasm of unspecified acoustic nerve
C72.41 Malignant neoplasm of right acoustic nerve
C72.42 Malignant neoplasm of left acoustic nerve
C72.50 Malignant neoplasm of unspecified cranial nerve
C72.59 Malignant neoplasm of other cranial nerves
C75.1 Malignant neoplasm of pituitary gland
C75.2 Malignant neoplasm of craniopharyngeal duct
C75.3 Malignant neoplasm of pineal gland
C75.5 Malignant neoplasm of aortic body and other paraganglia
C7B.03* Secondary carcinoid tumors of bone
C7B.8* Other secondary neuroendocrine tumors
C79.31* Secondary malignant neoplasm of brain
C79.32* Secondary malignant neoplasm of cerebral meninges
C79.40* Secondary malignant neoplasm of unspecified part of nervous system
C79.49* Secondary malignant neoplasm of other parts of nervous system
C79.51* Secondary malignant neoplasm of bone
C79.52* Secondary malignant neoplasm of bone marrow
C79.89* Secondary malignant neoplasm of other specified sites
C79.9* Secondary malignant neoplasm of unspecified site
D18.02 Hemangioma of intracranial structures
D32.0 Benign neoplasm of cerebral meninges
D32.9 Benign neoplasm of meninges, unspecified
D33.0 Benign neoplasm of brain, supratentorial
D33.1 Benign neoplasm of brain, infratentorial
D33.2 Benign neoplasm of brain, unspecified
D33.3 Benign neoplasm of cranial nerves
D35.2 Benign neoplasm of pituitary gland
D35.3 Benign neoplasm of craniopharyngeal duct
D35.4 Benign neoplasm of pineal gland
D35.5 Benign neoplasm of carotid body
D35.6* Benign neoplasm of aortic body and other paraganglia
D42.0* Neoplasm of uncertain behavior of cerebral meninges
D42.1* Neoplasm of uncertain behavior of spinal meninges
D42.9* Neoplasm of uncertain behavior of meninges, unspecified
D43.0* Neoplasm of uncertain behavior of brain, supratentorial
D43.1* Neoplasm of uncertain behavior of brain, infratentorial
D43.2* Neoplasm of uncertain behavior of brain, unspecified
D43.4* Neoplasm of uncertain behavior of spinal cord
D44.3 Neoplasm of uncertain behavior of pituitary gland
D44.4 Neoplasm of uncertain behavior of craniopharyngeal duct
D44.5 Neoplasm of uncertain behavior of pineal gland
D44.6* Neoplasm of uncertain behavior of carotid body
D44.7* Neoplasm of uncertain behavior of aortic body and other paraganglia
D49.6* Neoplasm of unspecified behavior of brain
D49.7* Neoplasm of unspecified behavior of endocrine glands and other parts of nervous system
G20* Parkinson's disease
G25.0* Essential tremor
G25.1* Drug-induced tremor
G25.2* Other specified forms of tremor
G40.301 Generalized idiopathic epilepsy and epileptic syndromes, not intractable, with status epilepticus
G40.311 Generalized idiopathic epilepsy and epileptic syndromes, intractable, with status epilepticus
G40.319 Generalized idiopathic epilepsy and epileptic syndromes, intractable, without status epilepticus
G40.411 Other generalized epilepsy and epileptic syndromes, intractable, with status epilepticus
G40.419 Other generalized epilepsy and epileptic syndromes, intractable, without status epilepticus
G40.911 Epilepsy, unspecified, intractable, with status epilepticus
G40.919 Epilepsy, unspecified, intractable, without status epilepticus
G50.0 Trigeminal neuralgia
G50.8 Other disorders of trigeminal nerve
G50.9 Disorder of trigeminal nerve, unspecified
G51.1 Geniculate ganglionitis
G51.2 Melkersson's syndrome
G51.31 Clonic hemifacial spasm, right
G51.32 Clonic hemifacial spasm, left
G51.33 Clonic hemifacial spasm, bilateral
G51.39 Clonic hemifacial spasm, unspecified
G51.4 Facial myokymia
G51.8 Other disorders of facial nerve
G51.9 Disorder of facial nerve, unspecified
G52.0* Disorders of olfactory nerve
G52.1* Disorders of glossopharyngeal nerve
G52.2* Disorders of vagus nerve
G52.3* Disorders of hypoglossal nerve
G52.7* Disorders of multiple cranial nerves
G52.8* Disorders of other specified cranial nerves
G52.9* Cranial nerve disorder, unspecified
G53* Cranial nerve disorders in diseases classified elsewhere
Q28.2* Arteriovenous malformation of cerebral vessels
Q28.3* Other malformations of cerebral vessels
T66.XXXA* Radiation sickness, unspecified, initial encounter
T66.XXXD* Radiation sickness, unspecified, subsequent encounter
T66.XXXS* Radiation sickness, unspecified, sequela
Z92.3 Personal history of irradiation
Group 1 Medical Necessity ICD-10-CM Codes Asterisk Explanation

*ICD-10-CM codes C7B.03, C7B.8, C79.31-C79.52, C79.89-C79.9, D35.6, D42.0-D43.2, D43.4, D44.6-D44.7, D49.6-D49.7, G52.0-G53, Q28.2-Q28.3, are all limited to use for lesions occurring either above the neck or in the spine.

*ICD-10-CM codes G20, G25.0, G25.1 and G25.2 are limited to a patient who cannot be controlled with medication, has major systemic disease or coagulopathy, and who is unwilling or unsuited for open surgery.

*ICD-10-CM code T66.XXXA, T66.XXXD, and T66.XXXS may only be used where prior radiation therapy to the site is the governing factor necessitating SRS in lieu of other radiotherapy. An ICD-10-CM code for the anatomic diagnosis must also be used.

Group 2

(115 Codes)
Group 2 Paragraph

Stereotactic Body Radiation Therapy (SBRT) Services (Codes 77373, 77435, G0339, and G0340):

Group 2 Codes
Code Description
C00.0* Malignant neoplasm of external upper lip
C00.1* Malignant neoplasm of external lower lip
C00.2* Malignant neoplasm of external lip, unspecified
C00.3* Malignant neoplasm of upper lip, inner aspect
C00.4* Malignant neoplasm of lower lip, inner aspect
C00.5* Malignant neoplasm of lip, unspecified, inner aspect
C00.6* Malignant neoplasm of commissure of lip, unspecified
C00.8* Malignant neoplasm of overlapping sites of lip
C00.9* Malignant neoplasm of lip, unspecified
C01* Malignant neoplasm of base of tongue
C02.0* Malignant neoplasm of dorsal surface of tongue
C02.1* Malignant neoplasm of border of tongue
C02.2* Malignant neoplasm of ventral surface of tongue
C02.3* Malignant neoplasm of anterior two-thirds of tongue, part unspecified
C02.4* Malignant neoplasm of lingual tonsil
C02.8* Malignant neoplasm of overlapping sites of tongue
C02.9* Malignant neoplasm of tongue, unspecified
C03.0* Malignant neoplasm of upper gum
C03.1* Malignant neoplasm of lower gum
C03.9* Malignant neoplasm of gum, unspecified
C04.0* Malignant neoplasm of anterior floor of mouth
C04.1* Malignant neoplasm of lateral floor of mouth
C04.8* Malignant neoplasm of overlapping sites of floor of mouth
C04.9* Malignant neoplasm of floor of mouth, unspecified
C05.0* Malignant neoplasm of hard palate
C05.1* Malignant neoplasm of soft palate
C05.2* Malignant neoplasm of uvula
C05.8* Malignant neoplasm of overlapping sites of palate
C05.9* Malignant neoplasm of palate, unspecified
C06.0* Malignant neoplasm of cheek mucosa
C06.1* Malignant neoplasm of vestibule of mouth
C06.2* Malignant neoplasm of retromolar area
C06.80* Malignant neoplasm of overlapping sites of unspecified parts of mouth
C06.89* Malignant neoplasm of overlapping sites of other parts of mouth
C06.9* Malignant neoplasm of mouth, unspecified
C07* Malignant neoplasm of parotid gland
C08.0* Malignant neoplasm of submandibular gland
C08.1* Malignant neoplasm of sublingual gland
C08.9* Malignant neoplasm of major salivary gland, unspecified
C09.0* Malignant neoplasm of tonsillar fossa
C09.1* Malignant neoplasm of tonsillar pillar (anterior) (posterior)
C09.8* Malignant neoplasm of overlapping sites of tonsil
C09.9* Malignant neoplasm of tonsil, unspecified
C10.0* Malignant neoplasm of vallecula
C10.1* Malignant neoplasm of anterior surface of epiglottis
C10.2* Malignant neoplasm of lateral wall of oropharynx
C10.3* Malignant neoplasm of posterior wall of oropharynx
C10.4* Malignant neoplasm of branchial cleft
C10.8* Malignant neoplasm of overlapping sites of oropharynx
C10.9* Malignant neoplasm of oropharynx, unspecified
C22.0 Liver cell carcinoma
C22.1 Intrahepatic bile duct carcinoma
C22.2 Hepatoblastoma
C22.3 Angiosarcoma of liver
C22.4 Other sarcomas of liver
C22.7 Other specified carcinomas of liver
C22.8 Malignant neoplasm of liver, primary, unspecified as to type
C22.9 Malignant neoplasm of liver, not specified as primary or secondary
C25.0 Malignant neoplasm of head of pancreas
C25.1 Malignant neoplasm of body of pancreas
C25.2 Malignant neoplasm of tail of pancreas
C25.3 Malignant neoplasm of pancreatic duct
C25.4 Malignant neoplasm of endocrine pancreas
C25.7 Malignant neoplasm of other parts of pancreas
C25.8 Malignant neoplasm of overlapping sites of pancreas
C25.9 Malignant neoplasm of pancreas, unspecified
C34.00 Malignant neoplasm of unspecified main bronchus
C34.01 Malignant neoplasm of right main bronchus
C34.02 Malignant neoplasm of left main bronchus
C34.10 Malignant neoplasm of upper lobe, unspecified bronchus or lung
C34.11 Malignant neoplasm of upper lobe, right bronchus or lung
C34.12 Malignant neoplasm of upper lobe, left bronchus or lung
C34.2 Malignant neoplasm of middle lobe, bronchus or lung
C34.30 Malignant neoplasm of lower lobe, unspecified bronchus or lung
C34.31 Malignant neoplasm of lower lobe, right bronchus or lung
C34.32 Malignant neoplasm of lower lobe, left bronchus or lung
C34.80 Malignant neoplasm of overlapping sites of unspecified bronchus and lung
C34.81 Malignant neoplasm of overlapping sites of right bronchus and lung
C34.82 Malignant neoplasm of overlapping sites of left bronchus and lung
C34.90 Malignant neoplasm of unspecified part of unspecified bronchus or lung
C34.91 Malignant neoplasm of unspecified part of right bronchus or lung
C34.92 Malignant neoplasm of unspecified part of left bronchus or lung
C61 Malignant neoplasm of prostate
C64.1 Malignant neoplasm of right kidney, except renal pelvis
C64.2 Malignant neoplasm of left kidney, except renal pelvis
C64.9 Malignant neoplasm of unspecified kidney, except renal pelvis
C65.1 Malignant neoplasm of right renal pelvis
C65.2 Malignant neoplasm of left renal pelvis
C65.9 Malignant neoplasm of unspecified renal pelvis
C74.00 Malignant neoplasm of cortex of unspecified adrenal gland
C74.01 Malignant neoplasm of cortex of right adrenal gland
C74.02 Malignant neoplasm of cortex of left adrenal gland
C74.10 Malignant neoplasm of medulla of unspecified adrenal gland
C74.11 Malignant neoplasm of medulla of right adrenal gland
C74.12 Malignant neoplasm of medulla of left adrenal gland
C74.90 Malignant neoplasm of unspecified part of unspecified adrenal gland
C74.91 Malignant neoplasm of unspecified part of right adrenal gland
C74.92 Malignant neoplasm of unspecified part of left adrenal gland
C75.5 Malignant neoplasm of aortic body and other paraganglia
C77.1 Secondary and unspecified malignant neoplasm of intrathoracic lymph nodes
C78.00 Secondary malignant neoplasm of unspecified lung
C78.01 Secondary malignant neoplasm of right lung
C78.02 Secondary malignant neoplasm of left lung
C78.7 Secondary malignant neoplasm of liver and intrahepatic bile duct
C78.89 Secondary malignant neoplasm of other digestive organs
C79.00 Secondary malignant neoplasm of unspecified kidney and renal pelvis
C79.01 Secondary malignant neoplasm of right kidney and renal pelvis
C79.02 Secondary malignant neoplasm of left kidney and renal pelvis
C79.70 Secondary malignant neoplasm of unspecified adrenal gland
C79.71 Secondary malignant neoplasm of right adrenal gland
C79.72 Secondary malignant neoplasm of left adrenal gland
T66.XXXA* Radiation sickness, unspecified, initial encounter
T66.XXXD* Radiation sickness, unspecified, subsequent encounter
T66.XXXS* Radiation sickness, unspecified, sequela
Z92.3 Personal history of irradiation
Group 2 Medical Necessity ICD-10-CM Codes Asterisk Explanation

*ICD-10-CM codes C00.0-C10.9 should be used for recurrence after prior conventional fractionated RT.

*ICD-10-CM code T66.XXXA, T66.XXXD, and T66.XXXS may only be used where prior radiation therapy to the site is the governing factor necessitating SBRT in lieu of other radiotherapy. An ICD-10-CM code for the anatomic diagnosis must also be used.

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ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

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Group 1 Codes

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ICD-10-PCS Codes

Group 1

Group 1 Paragraph

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Group 1 Codes

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Additional ICD-10 Information

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Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description
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Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Code Description
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Other Coding Information

Group 1

Group 1 Paragraph

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Group 1 Codes

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Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
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Revision History Information

Revision History Date Revision History Number Revision History Explanation
04/01/2020 R3

The “ICD-10 Codes that Support Medical Necessity” section has been revised to correct the ICD-10 code range C79.32-C79.52 to include ICD-10 code C79.31 under section “Group 1 Medical Necessity ICD-10 Codes Asterisk Explanation” and to correct the ICD-10 code range C00.1-C10.9 to include ICD-10 code C00.0 under “Group 2 Medical Necessity ICD-10 Codes Asterisk Explanation” section.

 

 

04/01/2020 R2

Based on a reconsideration request, the following diagnosis codes have been added to Group 1 in the "ICD-10 Codes that support medical necessity" section: C69.31 and C69.32.

Added CPT codes: 61796, 61797, 61798, 61799, 61800, 63620 and 63621 to Group 1 in the "CPT/HCPCs Codes" section.

10/24/2019 R1

This Article has been converted to the new Billing and Coding Article type.

Bill types and Revenue codes have been removed from this article. Guidance on these codes is available in the Bill type and Revenue code sections.

Asterisks have been added to ICD-10 codes in Group 1 and Group 2 in ICD-10 Codes that support Medical Necessity section. Language was removed from the Group 1 and Group 2 paragraphs and added to the Group 1 and Group 2 Medical Necessity ICD-10 Asterisk Explanation.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
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