Billing and Coding: Radiation Therapies

Title XVIII of the Social Security Act, §1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 13, §70.5 Radiation Physics Services (CPT Codes 77300 – 77399)

CMS Internet-Only Manual, Pub. 100-04, Medicare Claims Processing Manual, Chapter 4, §200.3 Billing Codes for Intensity Modulated Radiation Therapy (IMRT) and Stereotactic Radiosurgery (SRS), §200.3.1 Billing Instructions for IMRT Planning and Delivery, §200.3.2 Billing for Multi-Source Photon (Cobalt 60-Based) Stereotactic Radiosurgery (SRS) Planning and Delivery

MLN Matters Number: SE18013. Intensity-Modulated Radiation Therapy (IMRT) Planning Services Editing. September 11, 2018.

CR9658, July 2016 Update of the Hospital Outpatient Prospective Payment System (OPPS)

OIG Report, Audit (A-09-16-02033), 08-15-2018

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Radiation Therapies L39553.

Documentation Requirements

• All documentation must be maintained in the patient's medical record. The documentation must support the medical necessity of the services as specified in this article and it must be made available to the contractor upon request.
  
  
• 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 and credentials of the physician, non-physician practitioner, dosimetrist, physicist or radiation therapist responsible for and providing the described care for the patient.
  
  
• The submitted medical record must support the use of the selected ICD-10-CM diagnosis code(s). The submitted CPT^®/HCPCS code(s) must describe the service performed. It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM and CPT^® code books appropriate to the year in which the service is rendered for the claim(s) submitted.

• For all radiation therapy, the medical record must include the patient’s primary diagnosis for which the prescribed radiation therapy is needed, the patient’s history for this illness as well as active co-morbid medical conditions, the patient’s performance status when applicable and as required by the LCD, any relevant imaging reports, the proposed treatment plan, the number and location and size of tumors that are present, the stage of disease, and the anatomic site of the radiation delivery.

• For any type of radiation therapy for non-cancer diagnosis coverage (such as, but not limited to epilepsy, trigeminal/facial nerve applications, movement disorders, Parkinson’s disease, tremor conditions), it is important to clearly and very specifically document to the prior therapies tried and failed. Names of therapies and durations given and whether improvement or worsening occurred is crucial to support a decision to proceed with aggressive radiation therapy. Failure to document with specificity and precision related to the past diagnostic and attempted treatment for a condition as it relates to a unique beneficiary may well result in a non-coverage decision due to lack of reasonable and necessary standards having been met.

• For Stereotactic Body Radiation Therapy (SBRT) and Stereotactic Radiosurgery (SRS), the patient’s record must support the medical necessity of treatment. Supporting clinical records must include not only the patient’s medical history and physical examination findings, but also the patient’s current functional status, as described by an overall performance status score (e.g., Karnofsky Performance Status (KPS) or Eastern Cooperative Oncology Group (ECOG) Performance Status score). A radiation oncologist must evaluate the clinical and technical aspects of the treatment and document this evaluation as well as the resulting management decision. Justification for aggressive local therapy to 1 or more deposits of metastatic cancer for either total disease clearance in the setting of oligometastatic disease or to reduce overall burden of systemic disease for a specifically defined clinical benefit must be documented. In the case of recurrent disease requiring palliation or when tumor cannot be treated as effectively or safely by other radiotherapy methods due to proximity of previously irradiated volumes, documentation to those beneficiary unique facts must be documented in the medical record.

• Medical record documentation maintained by the provider must indicate the medical necessity for radiation oncology procedure as outlined in the LCD L39553 and must include ALL of the following for a radiation oncology procedure which employs inverse planning:

• • The type of radiation therapy that will be delivered must be precisely documented and cannot be inferred from the equipment or technology or computerized optimization being utilized.

• • The type of radiation therapy planning that was ultimately used must be precisely documented and cannot be inferred from the equipment or technology or computerized optimization being utilized.

• • A treatment plan/prescription must be present and must define the goals and requirements of the treatment, including the specific dose constraints for the target(s) and nearby critical structures.

• • A statement by the treating physician documenting the special advantages and genuine need for performing the specified radiation therapy delivery type and planning type on the patient in question, especially in comparison to conventional forward treatment planning and/or delivery. With IMRT planning and delivery documentation, the physician must address the other organs at risk (OAR) or adjacent critical structures.

• • Review by the radiation oncologist of the radiologic images of the target and all critical structures with representative isodose distributions that characterize the three-dimensional (3D) dose. The document containing this review must be signed with credentials and dated.

• • Radiation oncologist review of dose-volume histograms for all targets and critical structures specifically documented as reviewed or authenticated via signature with credentials and date.

• • Description of the number and location of each treatment step/rotation or portal to accomplish the treatment plan.

• • Documentation of dosimetric verification of treatment setup and delivery, signed by both the radiation oncologist and the medical physicist with a legible signature and credentials and date.

• • For compensator-based radiation therapy delivery, the unique compensator design should be documented for each step or portal.

• • Documentation of fluence distributions recomputed in a phantom, or an equivalent methodology consistent with patient specific treatment verification.

• • Target verification methodology documentation to include documentation of the clinical treatment volume (CTV) and the planning target volume (PTV); documentation of immobilization/patient positioning, and means of dose verification and secondary means of verification.

• • Other procedures performed during the episode of care must have documentation that supports the professional and technical components by identifying the place of service, the date of service, the supervising physician, and proof of work provided.

• • If applicable, when billing for respiratory management simulation, documentation must be present that identifies structures that move between high- and low-dose regions due to respiration. The documentation must include the medical necessity of this service. This is more extensive documentation than what would occur with just a simulation note since it is part of the isodose planning process. Since the work occurs over several days and involves the therapists, the dosimetrist, the physicist and the physician, the narrative supporting this service would and should appear in several documents. The simulation note should document the physician review of respiratory motion management set-up and use at the time of simulation. The treatment plan document must indicate that the physician created and intended to cover the target volume in all phases of respiratory motion.

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.

CPT^®/HCPCS code(s) may be subject to National Correct Coding Initiative (NCCI) edits. This information does not supersede NCCI edits. Please refer to NCCI for correct coding guidelines and specific applicable code combinations prior to billing Medicare.

• IMRT planning is paid by Medicare under the OPPS as a bundled payment. The bundled payment covers a range of services that may be performed as part of developing an IMRT treatment plan. The bundled payment covers these services regardless of when they are billed.

• CT guidance with CPT^®code 77014 should not be separately reported with simulation service codes 77280-77290 and code 77295 (Therapeutic radiology simulation-aided field setting; 3-dimensional). The use of CT guidance is integral to the simulation procedure and the value of the professional and technical components of CT guidance is now captured within the simulation service. This guidance applies to the freestanding and hospital-based settings.

• CPT^® code 77301 is used for development of an IMRT plan. Per CMS, payment for CPT^® codes 77014, 77280, 77285, 77290, 77295, 77306, 77307, 77321, and 77331 are included in the payment for CPT^® code 77301. These codes should not be reported in addition to 77301 even if provided prior to or as part of the IMRT plan. They can be reported as needed during the course of IMRT treatment delivery (with CPT^® codes 77385, 77386). This guidance applies to CPT^® code 77301 in both the hospital and in a freestanding facility.

• 77370 cannot be used for quality assurance or development of the treatment plan. There may be certain clinical scenarios where the radiation oncologist will need a special physics consult after the development of the plan. That circumstance and rationale would need to be documented in the medical record by the radiation oncologist.

• Special dosimetry (77331), for example TLD or microdosimetry, would only be reported and potentially covered if the medical record demonstrates a specific prescription for this service by the treating physician and an explanation of medical necessity for it exists. As noted above, it is not covered before or during an IMRT plan.

• 77372 is never to be used for the first fraction or any other fraction of a fractionated SRS treatment. It is only to be used for single session cranial linac-based SRS.

• For SRS and SBRT with forward planning, it is appropriate to bill CPT^® codes 77290 (simulation), 77295 (planning), and CPT^® either 77371/77372 (single fraction delivery) or 77373 (multifraction delivery). For SRS and SBRT with inverse planning, it is appropriate to bill CPT^® codes 77301 (both simulation and planning) and either 77371/77372 (single fraction delivery) or 77373 (multifraction delivery).

• CPT^® code 77373 (SBRT treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions) includes the possibility of treating multiple sites of disease in 1 treatment course. Therefore, if the sum of the treatment days for all of the sites treated during a single course of therapy exceeds 5; it is not appropriate to charge CPT^® code 77373 for SBRT delivery.

• For all spinal radiosurgery (1 to 5 fractions), use CPT^® code 77435 once for the entire course of treatment. CPT^® code 77432 and 77435 cannot be billed for the same patient for the same episode of care. It is not appropriate to bill CPT^® code 77432 with CPT^® code 77470, 77427, 77431, and 77435 on the same date of service.

• A prolonged (4 to 6 weeks) course of cranial radiation therapy should be billed using appropriate codes for conventionally fractionated radiotherapy. Fractionated stereotactic cranial and body radiotherapy codes apply only to hypofractionated (1 to 5 fractions) radiosurgery using large doses per fraction.

• Usually, a radiation oncologist will work with a neurosurgeon to perform SRS. Radiation oncologists and neurosurgeons have separate CPT^® codes for SRS. CPT^® codes 61796 – 61800 are reported for the work attributed to the neurosurgeon. These codes are mutually exclusive with the radiation oncology CPT^® codes 77432 and 77435; therefore, the same physician should not bill for both these codes.

• CPT^® codes 77280-77290 Simulation aided field settings should not be reported for verification of the treatment field during the course of IMRT.

• The respiratory motion management simulation CPT^® code 77293 is an add-on code and cannot be billed on its own. This code describes the physician work and resources involved in acquiring a respiratory correlated or ‘4D’ CT simulation study for conformal planning. It should be billed, as applicable, with either CPT^® code 77295 or 77301 on the same date of service, even though the work may take place over many days. The work involved in +77293 includes physicians, therapists, dosimetrists and physicists and has both a professional and a technical component. The work is performed both in the simulator and in dosimetry. The add-on code +77293 is part of the simulation and isodose planning process, not part of treatment delivery. This code is only charged once per 3D or IMRT plan. Medicare does not provide separate technical payment for this service in the hospital outpatient environment.

• Basic radiation dosimetry 77300 (Basic radiation dosimetry calculation central axis depth dose calculation, TDF, NSD, gap calculation, off axis factor, tissue inhomogeneity factors, calculation of non-ionizing radiation surface and depth dose, as required during course of treatment, only when prescribed by the treating physician) is a separate and distinct service from IMRT planning and should be reported accordingly. The radiation dose delivered by each IMRT beam must be individually calculated and verified before the course of radiation treatment begins. 77300 is billed once for each IMRT beam or arc up to a limit of 10. This code is used to report dosimetry calculations that arrive at the relationship between monitor units (or time) and dose, and the physician’s verification, review and approval. The documentation must contain the independent check of each field, separate from the computer-generated IMRT plan.) In “step and shoot” or compensator based IMRT treatment courses, 1 unit of 77300 can be charged per gantry angle. Therefore, the units of 77300 charged would correspond to the number of gantry angles in the IMRT plan, frequently up to 10 units. In volumetric modulation arc radiotherapy (VMAT) treatment courses, a patient is usually treated with 1 or 2 arcs; some brain treatments require a third arc. Therefore, there are 1 to 3 charges of 77300 for a typical VMAT plan. Supporting documentation should accompany a claim for more than 10 calculations on a single day.

• CPT^® code 77338 was established to report multi-leaf collimator (MLC) design and construction for IMRT. It captures the radiation oncologist work of designing and fabricating the device, the practice expense of physicist and dosimetrist staff, and the equipment that is used for this design and fabrication. This code is reported only once per IMRT plan. There is no separate accounting for gantry angles or other beam arrangements. Additional IMRT plans during a course of care would warrant additional reporting of 77338. 77334, in IMRT, would be used to report an immobilization device constructed at the time of simulation.

• Image-guided radiation therapy (IGRT) services should not be billed with SRS or SBRT services (77371, 77372, 77373, 77432, 77435) as they are already bundled into these codes.

• CPT^® code 77387, guidance for localization of target volume for delivery of radiation treatment delivery, includes intrafraction tracking when performed. This CPT^® code, however, was not assigned a reimbursement value in the Medicare Physician Fee Schedule. Instead, providers are instructed to report IGRT services using the following HCPCS G-codes and CPT^® code as appropriate:

G6001

G6002

G6017

77014

These codes can also be used to report the professional component of IGRT services for providers in a hospital setting by attaching the -26 modifier to the codes.

Hospitals do use CPT^® code 77387 per the Hospital Outpatient Prospective Payment System (HOPPS). This technical component is reported with the -TC modifier. However, the technical component of IGRT code 77387 is bundled into IMRT delivery codes 77385 and 77386.

77387-TC should always be reported when image guidance is performed with conventional (non-IMRT, non-SRS/SBRT) CPT^® codes 77402, 77407, and 77412. However, 77387-TC is not reimbursed separately in the hospital setting because it is packaged into the Ambulatory Payment Classification with the treatment delivery service with which it is performed. Reporting the service is still important as the data is collected by CMS and might be utilized in future HOPPS rate-setting.

Most freestanding centers will report claims under the Medicare Physician Fee Schedule, and therefore, will report G-codes for treatment delivery and IGRT to the Medicare payer.

The 2020 HOPPS final rule lowered the supervision level required for hospital-based therapeutic services, including radiation therapy services, from direct to general supervision.

However:

This general supervision policy does NOT apply when:

• Radiation therapy is delivered in a freestanding center;
• The work of radiation treatment management is performed;
• Brachytherapy (CPT^® codes 77770-77772), stereotactic radiation therapy (CPT^® codes 77371-77373) and other services described by CPT^® codes requiring that the radiation oncologist personally provide the services are performed;
• Diagnostic services, such as image guidance, are performed; or
• A hospital determines that radiation therapy services require direct supervision.

“Direct supervision” requires that the physician be immediately available to provide assistance throughout the duration of the procedure. “General supervision” means the procedure is furnished under the physician’s overall direction and control, but the physician’s presence is not required during the performance of the procedure. This contractor will take this opportunity to interpret “immediate availability” within the context of direct supervision since clarification is often requested. The provision of direct supervision means that the provider must be able to be physically present and able to furnish assistance and direction throughout the performance of the procedure. In turn, the physician must only be doing work that is immediately interruptible and furthermore, “immediacy” is clarified as meaning the provider can be at bedside within 1-2 minutes. Any interval longer than that is simply not judged to be immediate by this A/B MAC.

Recall that regardless of supervision requirements, many CPT^® codes describe specific work. As an example, the work described by CPT^® codes 77427, 77431, 77432, 77435, and 77469, radiation treatment management, must be provided personally by the radiation oncologist, who is ultimately responsible for the entirety of patient care. Thus, the weekly management of patients receiving radiation therapy, which involves all technical and medical aspects of managing the patient through a treatment course, is always conducted under the direct supervision of a radiation oncologist, who must continue to independently document her or his involvement in the process. Additionally, direct supervision associated with the delivery of brachytherapy and stereotactic radiation therapy remains.

If state scope of practice requirements do not prevent advance practice providers from supervising the delivery of radiation therapy services, then it is up to the discretion of the hospital or organization to determine appropriate supervisory requirements based on a general supervision requirement. But again, the work described by CPT^® codes 77427, 77431, 77432, 77435 and 77469 must be provided personally by the radiation oncologist, who is ultimately responsible for the entirety of patient care. Thus, the weekly management of patients receiving radiation therapy, which involves all technical and medical aspects of managing the patient through a treatment course, is always conducted under the supervision of a radiation oncologist, who must continue to independently document her or his involvement in the process.

If occurring, the radiation oncology physician’s treatment protocol must indicate parameters under which treatment may proceed at the discretion of the qualified technical personnel, and clearly indicate situations under which the qualified radiation oncology physician must be contacted before treatment is provided. Again, such discretion cannot supersede federal or state regulations.

The qualified radiation oncology physician must review and approve guidance images that were produced prior to each daily treatment within 24 hours or prior to the next treatment delivery.

• IMRT
• SRS
• SBRT
• SABR