The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Superficial Radiation Therapy (SRT) for the Treatment of Nonmelanoma Skin Cancers (NMSC) DL40176.
Please refer to the LCD for reasonable and necessary requirements.
Coding Guidance
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. For Part B, use the GY or GZ modifier.
Per the Current Procedural Terminology (CPT®) codebook definition, the use of the correct CPT codes for the simulation of radiation, SRTs, delivery of radiation treatments and uses of image guidance (IG) requires consistency with ASTRO and CMS guidelines for radiation services.
For purposes of this LCD, SRT is only payable in a non-facility setting. As defined by Section 3(b) of the Patient Access and Medicare Protection Act (PAMPA), the following settings would be allowable: The term “non-facility settings” refers to freestanding radiation therapy centers, which are treated like physicians’ offices for Medicare payment and billing purposes and are paid under the Medicare Physician Fee Schedule (MPFS). In contrast, the term “facility settings” refers to hospitals, which provide radiation therapy (RT) in their hospital outpatient departments. Physician offices if allowed by their local state requirements as meeting these requirements would also fall under the rubric of a freestanding RT center for Medicare payment and billing purposes for the delivery of SRT.
A course of RT usually includes a clearly defined set of services such as RT consultation, treatment planning, certain technical preparation and special services (e.g., medical radiation physics, dosimetry, treatment devices, treatment delivery, and treatment management).
Pre-Treatment Documentation Requirements
Documentation must support medical necessity for the use of SRT over other conventional treatment modalities and include the following:
- A statement by the provider why the patient is a nonsurgical candidate AND
- Appropriate documentation of the discussion with the patient why SRT is preferred for the treatment of their NMSC(s) and include a discussion of present and future risks of RT treatment(s).
General Documentation Requirements
- Documentation must support medical necessity for the simulation, fractionation regimen, dosing, dosimetry, medical physics evaluation and any needed changes in ongoing treatment regimens.
- 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 SRT , the medical record must include the patient’s primary diagnosis for which the prescribed SRT 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, location and size of tumor(s) that are present, the stage of disease, and the anatomic site of the radiation delivery.
- Medical record documentation maintained by the provider must indicate the medical necessity as outlined in the LCD and must include ALL of the following for a radiation oncology procedure which employs radiation treatment planning:
- The type of SRT planning that was ultimately used must be precisely documented and cannot be inferred from the equipment or technology or computerized optimization being utilized.
- The type of SRT that will be delivered 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 SRT delivery type and planning type on the patient in question, especially in comparison to conventional forward treatment planning and/or delivery; the physician must address the other organs at risk (OAR) or adjacent critical structures.
- Radiation oncologist or other qualified physician 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 treating physician and the medical physicist with a legible signature, credentials and date.
- 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.
