LCD Reference Article Billing and Coding Article

Billing and Coding: Proton Beam Radiotherapy

A57669

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Draft Article
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.

Document Note

Note History

Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A57669
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Proton Beam Radiotherapy
Article Type
Billing and Coding
Original Effective Date
10/03/2018
Revision Effective Date
10/01/2021
Revision Ending Date
N/A
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

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.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

Copyright © 2023, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

Internet Only Manuals (IOMs):

  • CMS IOM Publication 100-08, Medicare Program Integrity Manual,
    • Chapter 13, Section 13.5.4 Reasonable and Necessary Provision in an LCD

Social Security Act (Title XVIII) Standard References:

  • Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.
  • Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.

Article Guidance

Article Text

This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L33937 Proton Beam Radiotherapy. Please refer to the LCD for reasonable and necessary requirements.

Coding Guidance

Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.

Documentation Requirements

  1. All documentation must be maintained in the patient's medical record and made available to the contractor upon request.
  2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.
  3. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.

Utilization Guidelines

In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.

Compliance with the provisions in LCD L33937, Proton Beam Radiotherapy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description
999x Not Applicable
N/A

Revenue Codes

Code Description
99999 Not Applicable
N/A

CPT/HCPCS Codes

Group 1

(4 Codes)
Group 1 Paragraph

Note: Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book.

Group 1 Codes
Code Description
77520 Proton trmt simple w/o comp
77522 Proton trmt simple w/comp
77523 Proton trmt intermediate
77525 Proton treatment complex
N/A

CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(61 Codes)
Group 1 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT codes: 77520, 77522, 77523, and 77525.

Group 1 Codes
Code Description
C41.0 Malignant neoplasm of bones of skull and face
C41.1 Malignant neoplasm of mandible
C41.2 Malignant neoplasm of vertebral column
C41.3 Malignant neoplasm of ribs, sternum and clavicle
C41.4 Malignant neoplasm of pelvic bones, sacrum and coccyx
C69.21 Malignant neoplasm of right retina
C69.22 Malignant neoplasm of left retina
C69.31 Malignant neoplasm of right choroid
C69.32 Malignant neoplasm of left choroid
C69.41 Malignant neoplasm of right ciliary body
C69.42 Malignant neoplasm of left ciliary body
C69.61 Malignant neoplasm of right orbit
C69.62 Malignant neoplasm of left orbit
C69.81 Malignant neoplasm of overlapping sites of right eye and adnexa
C69.82 Malignant neoplasm of overlapping sites of left eye and adnexa
C70.0 Malignant neoplasm of cerebral meninges
C70.1 Malignant neoplasm of spinal meninges
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
C72.0 Malignant neoplasm of spinal cord
C72.1 Malignant neoplasm of cauda equina
C72.21 Malignant neoplasm of right olfactory nerve
C72.22 Malignant neoplasm of left olfactory nerve
C72.31 Malignant neoplasm of right optic nerve
C72.32 Malignant neoplasm of left optic nerve
C72.41 Malignant neoplasm of right acoustic nerve
C72.42 Malignant neoplasm of left acoustic 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
C79.31 Secondary malignant neoplasm of brain
C79.49 Secondary malignant neoplasm of other parts of nervous system
D32.0 Benign neoplasm of cerebral meninges
D32.1 Benign neoplasm of spinal meninges
D33.0 Benign neoplasm of brain, supratentorial
D33.1 Benign neoplasm of brain, infratentorial
D33.3 Benign neoplasm of cranial nerves
D33.4 Benign neoplasm of spinal cord
D33.7 Benign neoplasm of other specified parts of central nervous system
D35.2 Benign neoplasm of pituitary gland
D35.3 Benign neoplasm of craniopharyngeal duct
D35.4 Benign neoplasm of pineal gland
D42.0 Neoplasm of uncertain behavior of cerebral meninges
D42.1 Neoplasm of uncertain behavior of spinal meninges
D43.0 Neoplasm of uncertain behavior of brain, supratentorial
D43.1 Neoplasm of uncertain behavior of brain, infratentorial
D43.3 Neoplasm of uncertain behavior of cranial nerves
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
Q28.2 Arteriovenous malformation of cerebral vessels
Q28.3 Other malformations of cerebral vessels

Group 2

(247 Codes)
Group 2 Paragraph

It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM code book appropriate to the year in which the service is rendered for the claim(s) submitted.

The following ICD-10-CM codes support medical necessity and provide coverage for CPT codes: 77520, 77522, 77523, and 77525.

Group 2 Codes
Code Description
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
C02.4 Malignant neoplasm of lingual tonsil
C02.8 Malignant neoplasm of overlapping sites of tongue
C03.0 Malignant neoplasm of upper gum
C03.1 Malignant neoplasm of lower gum
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
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
C06.0 Malignant neoplasm of cheek mucosa
C06.1 Malignant neoplasm of vestibule of mouth
C06.2 Malignant neoplasm of retromolar area
C06.89 Malignant neoplasm of overlapping sites of other parts of mouth
C07 Malignant neoplasm of parotid gland
C08.0 Malignant neoplasm of submandibular gland
C08.1 Malignant neoplasm of sublingual gland
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
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
C12 Malignant neoplasm of pyriform sinus
C13.0 Malignant neoplasm of postcricoid region
C13.1 Malignant neoplasm of aryepiglottic fold, hypopharyngeal aspect
C13.2 Malignant neoplasm of posterior wall of hypopharynx
C13.8 Malignant neoplasm of overlapping sites of hypopharynx
C14.2 Malignant neoplasm of Waldeyer's ring
C14.8 Malignant neoplasm of overlapping sites of lip, oral cavity and pharynx
C15.5 Malignant neoplasm of lower third of esophagus
C16.0 Malignant neoplasm of cardia
C16.1 Malignant neoplasm of fundus of stomach
C16.2 Malignant neoplasm of body of stomach
C16.3 Malignant neoplasm of pyloric antrum
C16.4 Malignant neoplasm of pylorus
C16.8 Malignant neoplasm of overlapping sites of stomach
C19 Malignant neoplasm of rectosigmoid junction
C20 Malignant neoplasm of rectum
C21.1 Malignant neoplasm of anal canal
C21.2 Malignant neoplasm of cloacogenic zone
C21.8 Malignant neoplasm of overlapping sites of rectum, anus and anal canal
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
C26.1 Malignant neoplasm of spleen
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
C32.0 Malignant neoplasm of glottis
C32.1 Malignant neoplasm of supraglottis
C32.2 Malignant neoplasm of subglottis
C32.3 Malignant neoplasm of laryngeal cartilage
C32.8 Malignant neoplasm of overlapping sites of larynx
C33 Malignant neoplasm of trachea
C34.01 Malignant neoplasm of right main bronchus
C34.02 Malignant neoplasm of left main bronchus
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
C34.31 Malignant neoplasm of lower lobe, right bronchus or lung
C34.32 Malignant neoplasm of lower lobe, left bronchus or 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
C37 Malignant neoplasm of thymus
C38.0 Malignant neoplasm of heart
C38.1 Malignant neoplasm of anterior mediastinum
C38.2 Malignant neoplasm of posterior mediastinum
C40.01 Malignant neoplasm of scapula and long bones of right upper limb
C40.02 Malignant neoplasm of scapula and long bones of left upper limb
C40.11 Malignant neoplasm of short bones of right upper limb
C40.12 Malignant neoplasm of short bones of left upper limb
C40.21 Malignant neoplasm of long bones of right lower limb
C40.22 Malignant neoplasm of long bones of left lower limb
C40.31 Malignant neoplasm of short bones of right lower limb
C40.32 Malignant neoplasm of short bones of left lower limb
C40.81 Malignant neoplasm of overlapping sites of bone and articular cartilage of right limb
C40.82 Malignant neoplasm of overlapping sites of bone and articular cartilage of left limb
C44.01* Basal cell carcinoma of skin of lip
C44.02* Squamous cell carcinoma of skin of lip
C44.09* Other specified malignant neoplasm of skin of lip
C44.1121* Basal cell carcinoma of skin of right upper eyelid, including canthus
C44.1122* Basal cell carcinoma of skin of right lower eyelid, including canthus
C44.1191* Basal cell carcinoma of skin of left upper eyelid, including canthus
C44.1192* Basal cell carcinoma of skin of left lower eyelid, including canthus
C44.1221* Squamous cell carcinoma of skin of right upper eyelid, including canthus
C44.1222* Squamous cell carcinoma of skin of right lower eyelid, including canthus
C44.1291* Squamous cell carcinoma of skin of left upper eyelid, including canthus
C44.1292* Squamous cell carcinoma of skin of left lower eyelid, including canthus
C44.1321* Sebaceous cell carcinoma of skin of right upper eyelid, including canthus
C44.1322* Sebaceous cell carcinoma of skin of right lower eyelid, including canthus
C44.1391* Sebaceous cell carcinoma of skin of left upper eyelid, including canthus
C44.1392* Sebaceous cell carcinoma of skin of left lower eyelid, including canthus
C44.1921* Other specified malignant neoplasm of skin of right upper eyelid, including canthus
C44.1922* Other specified malignant neoplasm of skin of right lower eyelid, including canthus
C44.1991* Other specified malignant neoplasm of skin of left upper eyelid, including canthus
C44.1992* Other specified malignant neoplasm of skin of left lower eyelid, including canthus
C44.212* Basal cell carcinoma of skin of right ear and external auricular canal
C44.219* Basal cell carcinoma of skin of left ear and external auricular canal
C44.222* Squamous cell carcinoma of skin of right ear and external auricular canal
C44.229* Squamous cell carcinoma of skin of left ear and external auricular canal
C44.292* Other specified malignant neoplasm of skin of right ear and external auricular canal
C44.299* Other specified malignant neoplasm of skin of left ear and external auricular canal
C44.311* Basal cell carcinoma of skin of nose
C44.319* Basal cell carcinoma of skin of other parts of face
C44.321* Squamous cell carcinoma of skin of nose
C44.329* Squamous cell carcinoma of skin of other parts of face
C44.391* Other specified malignant neoplasm of skin of nose
C44.399* Other specified malignant neoplasm of skin of other parts of face
C44.41* Basal cell carcinoma of skin of scalp and neck
C44.42* Squamous cell carcinoma of skin of scalp and neck
C44.49* Other specified malignant neoplasm of skin of scalp and neck
C44.510* Basal cell carcinoma of anal skin
C44.511* Basal cell carcinoma of skin of breast
C44.519* Basal cell carcinoma of skin of other part of trunk
C44.520* Squamous cell carcinoma of anal skin
C44.521* Squamous cell carcinoma of skin of breast
C44.529* Squamous cell carcinoma of skin of other part of trunk
C44.590* Other specified malignant neoplasm of anal skin
C44.591* Other specified malignant neoplasm of skin of breast
C44.599* Other specified malignant neoplasm of skin of other part of trunk
C44.612* Basal cell carcinoma of skin of right upper limb, including shoulder
C44.619* Basal cell carcinoma of skin of left upper limb, including shoulder
C44.622* Squamous cell carcinoma of skin of right upper limb, including shoulder
C44.629* Squamous cell carcinoma of skin of left upper limb, including shoulder
C44.692* Other specified malignant neoplasm of skin of right upper limb, including shoulder
C44.699* Other specified malignant neoplasm of skin of left upper limb, including shoulder
C44.712* Basal cell carcinoma of skin of right lower limb, including hip
C44.719* Basal cell carcinoma of skin of left lower limb, including hip
C44.722* Squamous cell carcinoma of skin of right lower limb, including hip
C44.729* Squamous cell carcinoma of skin of left lower limb, including hip
C44.792* Other specified malignant neoplasm of skin of right lower limb, including hip
C44.799* Other specified malignant neoplasm of skin of left lower limb, including hip
C44.81* Basal cell carcinoma of overlapping sites of skin
C44.82* Squamous cell carcinoma of overlapping sites of skin
C44.89* Other specified malignant neoplasm of overlapping sites of skin
C47.0 Malignant neoplasm of peripheral nerves of head, face and neck
C47.11 Malignant neoplasm of peripheral nerves of right upper limb, including shoulder
C47.12 Malignant neoplasm of peripheral nerves of left upper limb, including shoulder
C47.21 Malignant neoplasm of peripheral nerves of right lower limb, including hip
C47.22 Malignant neoplasm of peripheral nerves of left lower limb, including hip
C47.3 Malignant neoplasm of peripheral nerves of thorax
C47.4 Malignant neoplasm of peripheral nerves of abdomen
C47.5 Malignant neoplasm of peripheral nerves of pelvis
C48.0 Malignant neoplasm of retroperitoneum
C49.0 Malignant neoplasm of connective and soft tissue of head, face and neck
C49.11 Malignant neoplasm of connective and soft tissue of right upper limb, including shoulder
C49.12 Malignant neoplasm of connective and soft tissue of left upper limb, including shoulder
C49.21 Malignant neoplasm of connective and soft tissue of right lower limb, including hip
C49.22 Malignant neoplasm of connective and soft tissue of left lower limb, including hip
C49.3 Malignant neoplasm of connective and soft tissue of thorax
C49.4 Malignant neoplasm of connective and soft tissue of abdomen
C49.5 Malignant neoplasm of connective and soft tissue of pelvis
C49.8 Malignant neoplasm of overlapping sites of connective and soft tissue
C50.012 Malignant neoplasm of nipple and areola, left female breast
C50.022 Malignant neoplasm of nipple and areola, left male breast
C50.112 Malignant neoplasm of central portion of left female breast
C50.122 Malignant neoplasm of central portion of left male breast
C50.212 Malignant neoplasm of upper-inner quadrant of left female breast
C50.222 Malignant neoplasm of upper-inner quadrant of left male breast
C50.312 Malignant neoplasm of lower-inner quadrant of left female breast
C50.322 Malignant neoplasm of lower-inner quadrant of left male breast
C50.412 Malignant neoplasm of upper-outer quadrant of left female breast
C50.422 Malignant neoplasm of upper-outer quadrant of left male breast
C50.512 Malignant neoplasm of lower-outer quadrant of left female breast
C50.522 Malignant neoplasm of lower-outer quadrant of left male breast
C50.612 Malignant neoplasm of axillary tail of left female breast
C50.622 Malignant neoplasm of axillary tail of left male breast
C50.812 Malignant neoplasm of overlapping sites of left female breast
C50.822 Malignant neoplasm of overlapping sites of left male breast
C52 Malignant neoplasm of vagina
C53.0 Malignant neoplasm of endocervix
C53.1 Malignant neoplasm of exocervix
C53.8 Malignant neoplasm of overlapping sites of cervix uteri
C54.0 Malignant neoplasm of isthmus uteri
C54.1 Malignant neoplasm of endometrium
C54.2 Malignant neoplasm of myometrium
C54.3 Malignant neoplasm of fundus uteri
C54.8 Malignant neoplasm of overlapping sites of corpus uteri
C56.1 Malignant neoplasm of right ovary
C56.2 Malignant neoplasm of left ovary
C56.3 Malignant neoplasm of bilateral ovaries
C57.01 Malignant neoplasm of right fallopian tube
C57.02 Malignant neoplasm of left fallopian tube
C57.11 Malignant neoplasm of right broad ligament
C57.12 Malignant neoplasm of left broad ligament
C57.21 Malignant neoplasm of right round ligament
C57.22 Malignant neoplasm of left round ligament
C57.3 Malignant neoplasm of parametrium
C57.7 Malignant neoplasm of other specified female genital organs
C57.8 Malignant neoplasm of overlapping sites of female genital organs
C61 Malignant neoplasm of prostate
C67.0 Malignant neoplasm of trigone of bladder
C67.1 Malignant neoplasm of dome of bladder
C67.2 Malignant neoplasm of lateral wall of bladder
C67.3 Malignant neoplasm of anterior wall of bladder
C67.4 Malignant neoplasm of posterior wall of bladder
C67.5 Malignant neoplasm of bladder neck
C67.6 Malignant neoplasm of ureteric orifice
C67.7 Malignant neoplasm of urachus
C67.8 Malignant neoplasm of overlapping sites of bladder
C73 Malignant neoplasm of thyroid gland
C74.01 Malignant neoplasm of cortex of right adrenal gland
C74.02 Malignant neoplasm of cortex of left adrenal gland
C74.11 Malignant neoplasm of medulla of right adrenal gland
C74.12 Malignant neoplasm of medulla of left adrenal gland
C75.0 Malignant neoplasm of parathyroid gland
C7A.026 Malignant carcinoid tumor of the rectum
C7A.090 Malignant carcinoid tumor of the bronchus and lung
C7B.02 Secondary carcinoid tumors of liver
C76.3 Malignant neoplasm of pelvis
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
C79.49* Secondary malignant neoplasm of other parts of nervous system
C79.71 Secondary malignant neoplasm of right adrenal gland
C79.72 Secondary malignant neoplasm of left adrenal gland
Group 2 Medical Necessity ICD-10-CM Codes Asterisk Explanation

Dual diagnosis requirement:

*ICD-10-CM codes C44.01, C44.02, C44.09, C44.1121, C44.1122, C44.1191, C44.1192, C44.1221, C44.1222, C44.1291, C44.1292, C44.1321, C44.1322, C44.1391, C44.1392, C44.1921, C44.1922, C44.1991, C44.1992, C44.212, C44.219, C44.222, C44.229, C44.292, C44.299, C44.311, C44.319, C44.321, C44.329, C44.391, C44.399, C44.41, C44.42, C44.49, C44.510, C44.511, C44.519, C44.520, C44.521, C44.529, C44.590, C44.591, C44.599, C44.612, C44.619, C44.622, C44.629, C44.692, C44.699, C44.712, C44.719, C44.722, C44.729, C44.792, C44.799, C44.81, C44.82, and C44.89 are all limited to use for skin cancer with perineural/cranial nerve invasion and must be billed with C79.49 as a dual diagnosis.

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

Group 1

(1 Code)
Group 1 Paragraph

All those not listed under the “ICD-10 Codes that Support Medical Necessity” section of this article.

Group 1 Codes
Code Description
XX000 Not Applicable
N/A

ICD-10-PCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Additional ICD-10 Information

N/A

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
999x Not Applicable
N/A

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
99999 Not Applicable
N/A

Other Coding Information

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

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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
N/A N/A
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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
N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation
10/01/2021 R1

Article revised and published on 10/14/2021 effective for dates of service on and after 10/01/2021 to reflect the Annual HCPCS Code Updates. The following ICD-10-CM code has been added to the Article: C56.3 to Group 2 Codes. Minor formatting changes have been made throughout the coding section.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
Articles
A57671 - (MCD Archive Site)
LCDs
L33937 - Proton Beam Radiotherapy
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Keywords

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