Intensity Modulated Radiation Therapy (IMRT) Billing
IMRT is a computer-based method of planning for, and delivery of, generally narrow, patient specific, spatially and often temporally modulated beams of radiation to solid tumors within a patient. The computer-generated images show the size and shape of the tumor. Thin beams of radiation, of different intensities, are then aimed at the tumor from many angles. Blocks may be set in place which ensure that the beams do not scatter, but rather, focus directly on the tumor.
- IMRT Planning
- Simulation-Aided Field Setting
- Technical Component
- Special Medical Radiation Physics Consultation
- Multi-Leaf Collimator
- Treatment Devices
Payment amounts for the services identified by CPT codes 77014, 77280, 77285, 77290, 77295, 77305 through 77321, 77331, and 77370 are included in the Ambulatory Payment Classification (APC) payment for CPT 77301 (intensity modulated radiotherapy plan, including dose volume histograms for target and critical structure partial tolerance specifications). These codes should not be reported in addition to CPT 77301 when provided prior to, or as part of, the development of the IMRT plan.
Simulation-Aided Field Setting
CPT codes 77280, 77285, and 77290 describe the process of defining relevant normal and abnormal target anatomy and acquiring the images and data necessary to develop the optimal radiation treatment process for the patient. These codes may be billed separately if they are not a part of the IMRT treatment plan and may not be billed with CPT 77301.
CPT 77385 is often appropriate for breast or prostate cancer diagnoses because critical structures are not in the immediate area.
CPT 77386 may be appropriate for the left breast, depending on the location of the tumor and what tissues may be impacted. If billing CPT 77386 for the left breast, ensure the documentation supports the complex level of IMRT treatment delivery. Pancreatic cancer is an example where the complex delivery may be reasonable and necessary due to the other vital organs and tissues surrounding that area.
CPT codes 77385 and 77386 should not be billed in conjunction with CPT codes 77371-77373; these codes are for billing multi-source photon (cobalt 60-based) Stereotactic Radiosurgery (SRS) planning and delivery.
Special Medical Radiation Physics Consultation
CPT 77370 may be billed separately, for example, when a special physics assessment is needed during the course of therapy. A medical physics consultation could also be appropriate where it applies to another modality (e.g., an accompanying "boost" with external beam) but it may not be billed with CPT 77301 if it is part of the plan development.
Multi-Leaf Collimator (MLC)
Do not bill CPT 77338 with CPT 77385; also, do not bill CPT 77338 more than once per IMRT plan, unless an exceptional circumstance should arise; for example, if the beneficiary was in a car accident after the device was designed, and as a result, suffered injuries that may impact the construction of the device, a subsequent billing of CPT 77338 may be appropriate for the same treatment plan. If this, or any other situation were to occur, Noridian does expect to see it thoroughly documented in the medical record to support the medical necessity of a second occurrence of CPT 77338.
When a provider designs and constructs a treatment or immobilization device that is separate and distinct from the "device" derived from the computerized IMRT plan, the provider may then report CPT codes 77332-77334, as appropriate, with modifier 59. The medical record must have documentation to support this use of modifier 59.
A treatment device could also be appropriate where it applies to another modality (e.g., an accompanying "boost" with external beam).
- CMS Change Request (CR)9549, April 2016 Update of the Hospital Outpatient Prospective Payment System (OPPS)
- CMS CR9930, January 2017 Update of the Hospital Outpatient Prospective Payment System (OPPS)
- CMS Internet Only Manual (IOM), Medicare Claims Processing Manual, Chapter 4, Section 200.3
- CMS Medicare Learning Network (MLN) Matters (MM)8853, Revised Modification to the Medically Unlikely Edit (MUE) Program
- MLN MM Special Edition (SE)18013, Intensity-Modulated Radiation Therapy (IMRT) Planning Services Editing
- CMS National Correct Coding Initiative (NCCI) MUE Manual
- American Society for Radiation Oncology (ASTRO) Radiation Oncology Coding Resource
Last Updated Sep 25, 2018