Radiation Oncology - JF Part B
Radiation Oncology
Radiation Oncology is the medical use of ionizing radiation and part of a precise cancer treatment to control or kill malignant cells and certain non-malignant conditions. It involves a specially-trained team of professionals performing everything from Evaluation and Management (E/M) visits to weekly Radiation Treatments. Radiation therapy, radiotherapy, or radiation oncology is often abbreviated RT, RTx, or XRT. The treatment goal is to deliver the patient their prescribed amount of radiation to the cancerous tumor; while limiting the amount absorbed by the surrounding healthy and critical organs.
Access the information below by clicking into the title:
- General Coverage
- Intensity Modulated Radiation Therapy (IMRT)
- Stereotactic Radiosurgery (SRS)
- Stereotactic Body Radiation Therapy (SBRT)
- Bundling and Other Special Services
- Comprehensive Error Rate Testing (CERT) Errors and Compliance Risk Areas
- Billing Tips
- Resources
General Coverage
A patient must have an E/M office visit or hospital consultation (CPTs 99202-99233) to prepare for treatment; clinical planning and simulation (CPTs 77261-77290). There are many treatment devices and special services (CPTs 77295-77370), along with NEW placement guidance codes (CPTs 77402, 77407, and 77412) and radiation treatment delivery codes (CPTs 77437-77438). Then, the weekly radiation therapy management (CPTs 77427-77432), and any follow-up or special services.
Covered in many place of service (POS) areas
- Office, Freestanding Radiation Oncology Center, or Radiation Therapy Center (RTC) (POS 11)
- Outpatient hospital - off campus (POS 19)
- Inpatient hospital (POS 21)
- Outpatient hospital - on campus (POS 22)
- Ambulatory Surgical Center (ASC) (POS 24)
National Correct Coding Initiative (NCCI) is important to know and Noridian advises checking all codes billed on the same day, against the CCI edits. If the second column code is bundled into the first column with a zero (0) indicator, providers cannot bill Medicare or the patient. Watch Medically Unlikely Edits (MUEs) with MUE Adjustment Indicator (MAI); e.g., MAI-two (2) = Date of Service Edit: Policy Code Descriptor / CPT Instruction
Covered Providers
Specially trained team of professionals; based on their state scope of license, include:
- Radiation Oncologist or Neurosurgeon (specially trained physician to treat cancer), who oversees care and writes course of treatment
- Radiation oncologists must evaluate treatment clinical and technical aspects, document evaluation and resulting management decisions
- If there's no radiation oncologist in area, radiation physicist charges not recognized under "incident to"
- Physician supervision includes radiation oncologist evaluating clinical and technical treatment aspects; documenting results of management decisions
- Medical physicists ensure accuracy of precise radiation dose and accurate computerized calculations
- Dosimetrists collaborate with medical physicists to calculate beam configurations and IMRT exposures
- Radiation therapist operates machine and positioning patient on treatment table
- Radiation therapy nurses collaborate with physician and assists with side effects and/or reactions from treatment
- Non-physician practitioners (NPPs) not eligible to supervise radiation therapy services in office setting
| CPT | Description |
|---|---|
| 77261 | Simple planning requires a single treatment area of interest encompassed in a single port or simple parallel opposed ports with simple or no blocking |
| 77262 | Intermediate planning requires 3 or more converging ports, 2 separate treatment areas, multiple blocks, or special time dose constraints |
| 77263 | Complex planning requires highly complex blocking, custom shielding blocks, tangential ports, special wedges or compensators, 3 or more separate treatment areas, rotational or special beam considerations, combination of therapeutic modalities |
- Typical course of radiation therapy will require between one and three simulations
- No more than one simulation reported any given day
- Treatment area(s) simulation-aided field settings following planning
- Not for treatment field verification or billed as sole modality
- Directs treatment beams with diagnostic imaging (e.g., MRI), radiation therapy (linear accelerator), or CT scanner
- Allowed globally, technical (TC), or professional (26)
| CPT | Description |
|---|---|
| 77280 | Simple - single treatment with either a single port or parallel opposed ports |
| 77285 | Intermediate - 2 treatment areas, 3 or more converging ports, multiple blocks |
| 77290 | Complex - 3 or more treatment areas simulation of tangential portals, 3 or more treatment areas, rotation or arc therapy, complex blocking, custom shielding blocks, brachytherapy source verification, hyperthermia probe verification, any use of contrast materials |
| +77293 | Add on code for respiratory motion management simulation-physician work |
- CPT 77295 - 3D radiotherapy plan with high dose-volume histogram
- Billed only once per treatment course
- Includes teletherapy isodose plan with CPTs 77306-77307; not billed separately
- CPTs 77280, 77285, and 77290 not separately payable on same date
- Includes both professional (-26) and technical (-TC) components
- Radiation dosimetry calculations allowed if physician personally performs service or participated
- E.g., review/validate physicist's calculation
- 77261-77334 performed before treatment starts
- 77316-77318 Brachytherapy Isodose Plan
- Simple, intermediate, and complex dosimetry calculations; 1-4 radiation sources or single channel for remote after loading brachytherapy
- Allowed globally, technical (TC), or professional (26)
- CERT Special Study on CPT 77300 (Dosimetry) where signed radiation oncology consultation report received and missing:
- IMRT order and/or prescription
- Planning notes including treatment fields, physics, and dosimetry calculations signed by radiation oncologist or medical physicist
- Documentation to support review of CT or MRI based images of target and all critical structures
- Weekly physics consult review w/calculations for treatment
- As required during course of treatment; only when prescribed by treating physician
- Unique/distinct/basic dosimetry calculations reported one (1) - six (6) times
- 8 or more for head/neck, Hodgkin's, prostate, etc.
- Separate claim for basic dosimetry (CPT 77300) when distinct service, prescribed by treating physician, over/above part of IMRT 77301 plan, and outside parameters
- Separate step in process of care for IMRT
- Allowed globally, technical (TC), or professional (26)
- If anatomy changes (e.g., tumor shrinkage), another IMRT may be charged
- If advanced imaging (PET, MRI, CT) used
| CPT | Description |
|---|---|
| 77300 | Basic radiation dosimetry calculation |
| 77301 | IMRT plan, including dose-volume histograms for target and critical structure partial tolerance specifications |
| 77331 | Special dosimetry within treatment field using special radiation equipment with specific physician order |
- Dose calculations (77300) cannot be charged with these plans
| CPT | Description |
|---|---|
| 77306 | Simple plan; one or two unmodified ports; includes basic dosimetry calculations |
| 77307 | Complex plan; multiple treatment areas (including tangential ports, the use of wedges, blocking, rotational beams, or special beam considerations) used and includes basic dosimetry calculations |
| 77321 | Special teletherapy port plan, particles, hemi- or total body with only one plan billed per treatment course |
- May include metal or electronic inserts, wedges, or casts
- Use of passive restraints such as straps, pillows, sandbags, etc., not billable
- May be known as "treatment aids"
- Allowed globally, technical (TC), or professional (26)
| CPT | Description |
|---|---|
| 77332 | Treatment devices, design, and construction; simple (simple block, simple bolus) E.g., Pre-made electron block, Breast board, "Standard" bolus (simple beam modification device |
| 77333 | Treatment devices, design, and construction; intermediate (multiple blocks, stents, bite blocks, special bolus) E.g., Bite block, Customized bolus |
| 77334 | Treatment devices, design, and construction; complex (irregular blocks, special shields, compensators, etc.) E.g., Alpha cradles, Vac-Lok™, Aquaplast Mask, or any of the MLCs or both custom shields or custom molds |
- Represents physician's (e.g., radiation oncologist, radiologist) care involvement
- Specific to weekly radiation treatment plan review
- Weekly physics before radiation treatment
- CPTs 77336 and 77370 are technical services only; payable only in freestanding clinic settings
| CPT | Description |
|---|---|
| 77336 | Continuing medical physics consult once per one (1) - five (5) fractions of external beam |
| 77338 | Multi-leaf collimator (MLC) device for IMRT design/construction/plan - reported once per IMRT plan |
| 77370 | Special medical physics consult once per treatment course |
- Deleted 2026 CPT 77417 (therapeutic radiology port images or port films); bundled CPT 77387
- CPT 77427 weekly units of five fractions or treatment sessions regardless of actual time furnished; don't need billing on consecutive days
- Timeframe usually five - seven days and reflected in comment or narrative field of claim
- CPT 77431 covers entire treatment course, if only one or two fractions; physician reports in narrative
| CPT | Description |
|---|---|
| 77427 | Treatment management, 1-5 fractions |
| 77431 | Treatment management, 1-2 fractions |
Effective January 1, 2026, radiation oncology introduced new CPTs for superficial and orthovoltage, and updates within the 2026 CPT® book (pages 562-565) with detailed instructions with new, revised, and deleted CPTs.
New CPTS:
- 77436 - surface radiation therapy planning for superficial or orthovoltage treatments, including simulation-aided field setting for cutaneous targets (global, TC or 26)
- 77437 - superficial radiation treatment delivery up to 150 kV per fraction (only global)
- 77438 - orthovoltage radiation treatment delivery greater than 150 kV and up to 500 kV per fraction (only global)
- +77439 - add-on code for ultrasound image guidance used to place superficial or orthovoltage treatment fields for cutaneous tumors (global or 26 only) and report only once per course with 77437 or 77438
Deleted G codes (G6001-G6017), CPTs 77014, 77401, and Category III CPT 0394T after 12/31/2025
Revised CPTs via hierarchy levels by differentiating work and complexity guidance; including Isocenter focus with high precision cancer treatment with IMRT and SRS categorized; including technical guidance, regardless of planning methods
- 77402 - Radiation treatment delivery; Level 1 (e.g., single-electron field, multiple-electron fields, or 2D photons), including imaging guidance, when performed
- 77407 - Radiation treatment delivery; Level 2, single isocenter (e.g., 3D or IMRT), photons, including image guidance, when performed
- 77412 - Radiation treatment delivery; Level 3, multiple isocenters with photon therapy (e.g., 2D, 3D, or IMRT), or single-isocenter photon therapy, (e.g., 3D or IMRT) with active motion management, or total skin electrons, or mixed-electron/photon field(s), including imaging guidance when performed
- All documentation must support the medical necessity and claims submitted without such evidence denied or monies recouped post-pay
- Treatment goal must be documented (curative, palliative, or tumor control) in medical records
- Record must contain patient's informed consent to treatment
- Medical records are logical and clear (recommend flow charts, where helpful)
- Prescription or treatment plan designed by radiation oncologist must be on file and signed
- Treated illness/clinical management level
- Treatment type, delivery, changes
- Designation - treatment site and isotope
- Designation - number of source positions
- Planned dose to each point
- Reports
- Simulation, physicist, dosimetry, radiological, etc.
- Any patient referrals/consultations
- Records or pictures may use colored lines for film-based and black to show calculated dose distribution
- Follow Radiation Therapy Documentation Requirements Checklist
Intensity Modulation Radiation Therapy (IMRT) CPTs 77385, 77386
- Minimizing healthy tissue damage, this radiotherapy technique matches tumor size, position, strength, and shape
- Involves planning (77301), simulation (77280, 77285, 77290), etc.
- Deleted 2026 77014 (CT image guidance)
- Deleted 2026 77385 (simple delivery for prostate, breast, plus sites using physical compensator-based IMRT and 77386-complex delivery at any energy level)
- Work now captured in revised delivery family
IMRT-specific documentation must support:
- Reasonable and necessary requirements and must be available to Medicare for review upon request
- Prescription must define goals and requirements of treatment plan, including specific dose constraints for target(s) and nearby critical structures
- Statement by treating physician documenting special need for performing IMRT on patient in question, rather than performing conventional or 3-dimensional treatment planning and delivery
- Signed and dated IMRT inverse plan that meets prescribed dose constraints for planning target volume (PTV) and surrounding normal tissue using either:
- Dynamic multi-leaf collimator (DMLC) or segmented multi-leaf collimator (SMLC) (average number of "steps" required to meet IMRT delivery is 5), or
- Inverse planned IMRT solid compensators to achieve intensity modulation radiation delivery
- Target verification methodology includes:
- Both PTV or Planning treatment volume and Clinical treatment volume (CTV)
- Immobilization and patient positioning
- Means of dose verification and secondary means of verification
- Before patient's first treatment, monitor units (MUs)
- Generated by IMRT treatment plan and must be independently checked
- Documenting fluence distributions; meaning fluence map from treatment planning system (TPS) from electronic portal imaging device (EPID) images must be validated for 10 head and neck IMRT cases
- Documentation must reflect those structures moving in and out of high and low dose regions created by respiration
- Voluntary breath holding not considered appropriate and solution for movement that can best be accomplished with gating technology
Stereotactic Radiosurgery (SRS) CPTs 77371, 77372
- Distinct discipline as high-resolution imaging
- Uses externally generated ionizing radiation
- Inactivate or eradicate defined target(s)
- Head or spine and without incision
- Cranial lesions one treatment only
- Computer-assisted, three-dimensional planning
- E.g., Gamma Knife®, XKnife®, CyberKnife®, etc.
- # of treatment sessions brief as 15 mins or few hours
- Depends on individual treatment plan
- Multidisciplinary team of Neurosurgeon-Radiation Oncologist-Medical Physicist
- Radiation oncologists/neurosurgeons separately bill
- CPT 77372 SRS treatment code
Stereotactic Body Radiation Therapy (SBRT) CPTs 77373, 77432, 77435
Stereotactic body radiation therapy (SBRT) is a treatment that couples a high degree of anatomic targeting accuracy with very high doses of extremely precise, externally generated, ionizing radiation; thereby, maximizing the cell-killing effect on the target(s), while minimizing radiation-related injury in adjacent normal tissues.
- SBRT treatment delivery per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions)
- Also method of delivering high doses of ionizing radiation to small intra-cranial targets when applied "cranial lesions only."
All SBRT is performed with at least one form of image guidance to confirm proper patient positioning and tumor localization (CT/MR/PET imaging-based systems or advanced imaging). Since the goal of SBRT is to intensify the potency of the radiotherapy by completing an entire course of treatment within an extremely accelerated time frame, any course of radiation treatment extending beyond five fractions is not considered SBRT and is not to be billed.
When billing for SBRT delivery, it is not appropriate to bill more than one treatment delivery code on the same day of service, even though some types of delivery may have elements of several modalities (e.g., IMRT stereotactic approach). Only one delivery code is to be billed and this includes image guidance. During SBRT, the physicist must be available onsite during the patient imaging and treatment to provide personal supervision.
- CPT 77373 paid only once per day of treatment regardless of number of sessions or lesions
- CPT 77432 weekly management code per treatment allowed once per course of treatment regardless of number of cranial (and spinal) lesions
- CPT 77435 paid only once per course of treatment of SBRT and cannot be billed during the same course of therapy
- Medical records must clearly document need
SBRT/SRS Documentation Requirements
- Support medical necessity and frequency
- Patient history/physical
- Functional status
- Karnofsky Status or Eastern Cooperative Oncology Group (ECOG) Performance
- Measures patient's ability to survive chemotherapy, with performance scales of 100-0 and grades from 0-5. SBRT is not considered medical necessary for patients with poor performance status of Karnofsky (less than 40 or ECOG-3 or worse)
- Date and current treatment dose
- Radiation oncologist E/M decisions
- Document and sign
Bundling and Other Special Services
Radiation Therapy Treatment bundles the following services: Anesthesia, infected skin care, checking treatment charts, dosage verification, final physical exam, nutritional counseling, pain management, review/revision of treatment plan, routine medical management unrelated, special ostomy care, written reports, progress note, follow-up exam/care for 90-days, etc. CPT codes include (not all inclusive):
- 11920-11922, 16000-16030, 36425, 53670, 53675, 90780-90781, 90847, 99211-99285, 99050-99080, and 99371-99373
Miscellaneous bundling also includes CPTs 77014 (deleted 2026), 77280, 77285, 77290, 77295, 77306-77321, 77331, and 77370 and not reported on the same date of service (DOS); as IMRT planning or when CPT 77301 provided prior to or as a part of the IMRT plan development. CPTs 77306, 77307, and 77321 bills only when applying to another modality (e.g., accompanying boost with external beam).
Image-Guided Radiation Therapy (IGRT) CPT 77387
- CPT 77387 - professional image review and physician interpretation; includes intrafraction tracking
- Cannot bill 77387 with -TC modifier (tracking purposes only and not separately payable)
- Modifies treatment delivery for intended target position changes - distinct service
- Report image guidance and tracking reporting
- Consist of technical and professional components (PC)
- Reported according to practice setting
- For tracking purposes and not separately reimbursable with Non-Hospital Outpatient Prospective Payment System (HOPPS)
- Billed with treatment delivery CPTs 77402, 77407, or 77412 (conventional treatment delivery without IGRT)
- Hospital bills for treatment delivery codes 77402, 77407 or 77412
Intraoperative Radiation Treatment Delivery (IORT) CPTs 77424, 77425, 77469
- 77424 - Intraoperative radiation treatment delivery, X-ray, single treatment session; TC only
- 77425 - Intraoperative radiation treatment delivery, electrons, single treatment session; TC only
- 77469 - Intraoperative radiation treatment management; physician work for either photon or electron-based IORT treatment delivery
Miscellaneous Codes
- 77422-77423 - Neutron beam treatment delivery
- 77520-77525 - Proton treatment delivery
- 77778 - Low Dose Rate (LDR) Brachytherapy
- 77770-77772 - High Dose Rate (HDR) Brachytherapy
- 77790 - Supervision, handling, loading of radioelement
- 0394T-0395T - Electronic Brachytherapy
Comprehensive Error Rate Testing (CERT) Errors and Compliance Risk Areas
When a specific, required documentation element is missing, such as a physician's order signature or a form required to be completed; Comprehensive Error Rate Testing (CERT) may recoup the monies previously paid. The medical record missing one or more of the following:
- No radiation therapy plan submitted
- Documentation submitted did not adequately describe service
- Incorrect date of service
- Physician's signature missing or signature log and/or attestation for illegible signature
Billing Tips
- No modifiers between physician supervisory levels
- Date of Service (DOS) or date range (Item 24A of CMS-1500 claim form)
- Date range billed variety of ways and fractions reflected in narrative
- Item 19 of CMS-1500 claim form or electronic NTE 02
- First or last treatment date
- If either radiation oncologist or neurosurgeon not fully participating in patient's care
- One physician indicates 54 modifier (surgical care only) and another bills with 55 modifier (postoperative management only) for global days and date span in Item 19 narrative
- Number of service (NOS) = 1 (up to 5 fractions)
- More than one set of treatments per day? NOS = 2 and narrative reflects one of the following:
- AM/PM treatments
- Eight (8), nine (9), or 10 fractions
- BID or twice a day
- Treatment course end? List final three (3) or final four (4) fractions in narrative
- Six (6) or seven (7) fractions NOT common; however, allowed
- If billing E/M visits or the weekly radiation codes the same day; never append modifier 59
