Radiation oncology services, Medicare

Applies to: 

Commercial, Medicaid and Medicare plans

Definition

Radiation therapy uses high-energy radiation to shrink tumors and kill cancer cells. X-rays, gamma rays, and charged particles are types of radiation used for cancer treatment. The radiation may be delivered by a machine outside the body (external-beam radiation therapy), or it may come from radioactive material placed in the body near cancer cells (internal radiation therapy, also called brachytherapy). - from cancer.gov

A course of radiation follows a process of care which can include the following:

  • Clinical treatment planning, CPT 77261-77263
  • Simulation, CPT 77280-77290
  • Treatment planning (codes vary depending on the type of radiation; ex: brachytherapy, IMRT) - codes are outlined below
  • Medical radiation physics, dosimetry, treatment devices and special services
  • Radiation treatment management

Clinical treatment planning

77261

Therapeutic radiology treatment planning; simple. Consists of a single area of malignancy with a single port or opposing ports parallel to each other and basic or no blocking.

77262

Therapeutic radiology treatment planning; intermediate. Consists of two separate areas of malignancy with three or more ports that converge, multiple blocks, or time or dosage considerations.

77263

Therapeutic radiology treatment planning; complex. Consists of three or more separate areas of malignancy with tangential ports, wedges or compensators, complex blocking, a combination of two or more modes of treatment, or rotating or other beam considerations.

Treatment stimulation

77280

Therapeutic radiology simulation-aided field setting; simple. Done for a single area of malignancy with a single port or opposing ports parallel to each other and basic or no blocking.

77285

Therapeutic radiology simulation-aided field setting; intermediate. Done for two separate areas of malignancy with three or more ports and multiple blocks.

77290

Therapeutic radiology simulation-aided field setting; complex. Done for three or more areas of malignancy with tangential ports and complex blocking that may require customized shielding blocks, rotation or arc therapy, brachytherapy source and hyperthermia probe verification, and use of contrast materials.

77293

Respiratory motion management simulation (List separately in addition to code for primary procedure)

  • Typical course of radiation therapy will require between one and three simulations. No more than one simulation may be reported on any given day.
  • Treatment area(s) simulation-aided field settings following planning. Not for treatment field verification or billed as sole modality.
  • Verification simulations (77280) for IMRT are not billable with IMRT courses of therapy

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

  • Only one calculation is billable per port/beam angle or arc for 3D and IMRT external beam treatments.
  • Multiple calculations per beam angle, when billable, are not allowed due to linear accelerator limitations (e.g. split carriage fields).
  • Monitor unit calculations (CPT® 77300) are considered bundled into brachytherapy isodose planning codes (CPT® 77316, 77317, 77318)

77331

Special dosimetry (i.e., TLD, microdosimetry) (specify), only when prescribed by the treating physician. Special dosimetry uses measuring and monitoring devices when the physician deems it necessary to calculate the total amount of radiation that a patient has received at any given point. The results determine whether to uphold or alter the current treatment plan.

  • This type of dosimetry is mainly used as a source of independent dose verification and can be performed using film, diodes or TLDs, among other tools.
  • If performed, special dosimetry measurements may occur only once per port/field, when supported by medical necessity, and should not be performed as a routine procedure.
  • CPT 77331 is not billable for QA or output measurements associated with IMRT or stereotactic procedures.
  • To support a claim for CPT 77331, the healthcare provider must document the following information:
    - The prescription from the treating physician for special dosimetry
    - The type of dosimetry used, such as TLD or microdosimetry
    - The date and time of the dosimetry procedure
    - The results of the dosimetry measurements
    - Any adjustments made to the treatment plan based on the dosimetry results
    - Signature of the healthcare provider performing the dosimetry procedure

77399

Unlisted procedure, medical radiation physics, dosimetry and treatment devices, and special services

  • When requested, rationale and documentation must be submitted for review.
  • Unlisted services should not be used for a service that is packaged or bundled into other services.

Isodose and port plans

77306

Teletherapy isodose plan; simple (1 or 2 unmodified ports directed to a single area of interest), includes basic dosimetry calculation(s)

77307

Teletherapy isodose plan; complex (multiple treatment areas, tangential ports, the use of wedges, blocking, rotational beam, or special beam considerations), includes basic dosimetry calculation(s)

77321

Special teletherapy port plan, particles, hemibody, total body. A special teletherapy port plan calculates the dosage level of the treatment portal for the use of electrons or heavy particles when used in a portion of or as the main mode of treatment for the field of interest.

Dosimetry calculations (77300) are inclusive of the above plans and not separately reportable.

Treatment devices

77332

Treatment devices, design and construction; simple (simple block, simple bolus)

77333

Treatment devices, design and construction; intermediate (multiple blocks, stents, bite blocks, special bolus)

77334

Treatment devices, design and construction; complex (irregular blocks, special shields, compensators, wedges, molds or casts)

77338

Multi-leaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction per IMRT plan

  • Treatment device services contain a professional and technical component.
  • The professional component is based upon the physician's participation in the actual design of the block.
  • The technical component is based on each individual block requiring time and materials to be fabricated.

Additional notes

  • There are 2 types of treatment devices - immobilization and beam-modifying:
    - Immobilization devices assist in establishing and maintaining a reproducible treatment position for the patient to undergo treatments.
    - Beam-modifying devices assist in creating the shape of the treatment portal and also protects critical structures near or inside the area receiving radiation.
    - Simple blocks are considered pre-made electron block, breast board or a standard bolus.
    - Intermediate blocks are considered bite blocks or a customized bolus.
    - Complex blocks are considered Alpha cradles, Vac-locks, Aquaplast mask, MLCs or both custom shields and custom molds. These devices are any item molded or created for a particular patient and cannot be used for another patient’s treatment but have the ability to be re-designed for another patient at a later time.
  • Use of passive restraints such as straps, pillows, sandbags, etc., not billable
  • Only one beam-modifying device is billable per port/field
  • A mirrored pair of devices is billable as one professional and one technical device between the two ports. Mirrored devices are treatment fields are parallel opposed in which the devices are a mirror image of each other.
  • 77338 is only billed once per MLC-based IMRT plan, regardless of the number of ports constructed for the plan.
  • 77338 may be allowed for a boost plan

Medical physics consults

77336

Continuing medical physics consultation, including assessment of treatment parameters, quality assurance of dose delivery and review of patient treatment documentation in support of the radiation oncologist, reported per week of therapy

  • May be reported after every 5 radiation treatments. Complete, short courses of therapy (1-2 fractions), 77336 may be billed for a quantity of 1
  • Review of the medical record by the physicist well after the treatment has been finalized is not billable.

77370

Special medical radiation physics consultation required under special circumstances (e.g., radiation to a pregnant patient); technical component only.

  • Done at direct request of the radiation oncologist when the complexity of the treatment plan is great.
  • Requires a written analysis on the course of treatment.
  • Allowed 1 time per course of therapy.
  • 77370 is not reportable for IMRT QA as the QA is a necessary and required function of the IMRT planning.
  • To support a claim for CPT code 77370, the following documentation is required:
    - A request from the treating physician to the physicist for a written analysis of how to deal with the specific treatment problem
    - A customized written report from the physicist, including details such as dose calculation, blocking, and other necessary information for delivering treatment
    - Inclusion of the report in the patient’s chart
  • CPT code 77370 should be reported once under the following circumstances: brachytherapy, stereotactic radiosurgery (SRS) or stereotactic body radiation therapy (SBRT), use of radioisotopes, patient has an implanted cardiac devices, reconstruction of previous radiation therapy plan, pregnant patient undergoing radiation therapy, or fusion of three-dimensional image sets such as positron emission tomography (PET) scan or magnetic resonance imaging (MRI) scan. IMRT planning (77301) includes fusion of three-dimensional image sets such as PET scan or MRI scan. (ASTRO, 2023)

Special / associated services

77470

Special treatment procedure (e.g., total body irradiation, hemibody radiation, per oral or endocavitary irradiation)

This code covers circumstances requiring extra and inordinate amounts of time and effort, managed throughout the course of treatment. These special circumstances are not considered routine for the service being performed.

The maximum quantity of special treatment procedures (77470) allowed per course of treatment is one (1).

To support a claim for CPT 77470, the following information should be documented:

  • Request from the provider
  • Patient’s medical history and diagnosis, indicating the need for a special treatment procedure.
  • Detailed treatment plan, including advanced radiation physics, medical imaging, and special dose calculations.
  • Procedure notes, describing the steps taken during the special treatment procedure and any complications or issues encountered.
  • Post-procedure assessment and follow-up care plan, if applicable.

Circumstances where CPT 77470 is not appropriately reported:

  • CPT is not intended to report IMRT, 3-D conformal radiotherapy treatment planning or contouring, or due to co-morbidities.
  • Receipt only of concurrent or recently completed chemotherapy. In order to report 77470, documentation must include the extensive work done for the management of concurrent chemotherapy in combination with radiation therapy.

77399

Unlisted procedure, medical radiation physics, dosimetry and treatment devices, and special services

CPT code 77399 should only be reported if no other code adequately describes the procedure or service in question. Click here for additional requirements for billing unlisted procedure codes.

Member cost-sharing for weekly radiation oncology services

Many providers and members confuse the daily copayments applied to weekly radiation oncology services with the 20% coinsurance applied by Original Medicare to total amount billed. They believe members are paying more in copayments than they would under Original Medicare.

However, the member's out-of-pocket maximum protects the member from paying out more than he/she would have paid under Original Medicare. Once a member reaches his/her out-of-pocket maximum, services are covered at 100% by Priority Health.

77261, 77262, 77263, Tumor mapping and clinical treatment planning:

One time only charge. Radiation copay applies.

77280 - 77295, Therapeutic radiology stimulation:

Radiation copay applies.

77427, Weekly physician management services:

One copay per day. Specialist copay applies.

77425 and 77431, Weekly therapeutic services:

One copay per day. Radiation copay applies.

77300-77399, Radiation physics:

One copay per day. Radiation copayapplies.

77014, Profesional component, modifier 26:

Not billable. No copay applies.

77014 and 77336, CT guidance:

Not billable. No copay applies.

77241, Steroscopic X-ray:

Not billable. No copay applies.

Billing for weekly radiation services

The Centers for Medicare and Medicaid Services (CMS) require that weekly billing for radiation services for physician management (77427) and therapeutic (77425 and 77431) services be billed with a unit of 1.

Billing by fractions of a week

One weekly unit of treatment management is equal to five fractions or treatment sessions. The unit of 1 represents one week's service.

If, at the final billing of the treatment course, there are fractions beyond the multiples of five that equal treatment weeks: 

  • Three or four fractions are paid for as a full week unit of 1.
  • One or two fractions are considered as having been paid through prior payments.

For more information see the Medicare Claims Processing Manual, Chapter 13, Radiology Services and Other Diagnostic Procedures.