Billing Guidelines for Intensity Modulated Radiation Therapy (IMRT)
Provider Administrative Policy
DisclaimerOur provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts.
This policy serves to document the guidelines we adopted during a recent audit after soliciting feedback from the provider community.
Intensity Modulated Radiation Therapy (IMRT) is a form of radiotherapy that delivers a precise dose of radiation to targeted areas with minimal exposure or damage to surrounding healthy tissue. With IMRT, a computer controls the size and intensity of the radiation beams as they enter a patient's body from various angles. While IMRT is a technique for delivering radiation doses, it is not clinically indicated for treatment of all cancers. It has proven to be most effective in treating cancers of the head, neck and prostate where the site of the tumor can be stationary during treatment, making it easier to target the treatment beams and protect surrounding tissue. Please refer to our medical policies 8.01.46, 8.01.47, 8.01.48, 8.01.49 for an explanation on what types of cancers IMRT is indicated.
Please refer to these guidelines to understand how we may edit your IMRT claims once submitted to Blue Cross of Idaho.
|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 reported once per every dosimetry calculation. Blue Cross of Idaho may investigate occurrences of CPT 77300 with more than ten billing units per course of therapy.|
|77301||(Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specifications) - is reported once per course of therapy to a specific area.|
|77334||(Treatment devices, design and construction; complex) - is only reported once per treatment device per course of therapy used in IMRT delivery. Treatment devices used in radiation oncology are customized blocks or shields to protect healthy tissue surrounding the treatment area and are made from energy-absorbing material. Blue Cross of Idaho may investigate occurrences of CPT 77334 with more than ten billing units per course of therapy.|
|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) - is only reported once per week of therapy; preferably at the end of each week.|
|77338||(Multi-leaf collimator device(s) for intensity modulated radiation therapy design and construction per IMRT plan) - is reported once per course of therapy.|
|77418||(Intensity modulated treatment delivery, single or multiple fields/arcs, via narrow spatially and temporally modulated beams, binary, dynamic MLC, per treatment session) - is reported once per IMRT treatment session.|
|77427||(Radiation treatment management, 5 treatments) - is only reported once per every five treatment sessions; preferably at the conclusion of those five treatment sessions, or in the event the entire course of treatment is complete, it may be used for three or more sessions.|
National Correct Coding Initiative (NCCI) bundling edits will occur for all same day services billed in conjunction with CPT codes 77301, 77338 and 77418 for both professional and facility claims. Additionally, we will edit facility claims containing CPT 77301 against CMS guidelines that package a number of CPT codes with IMRT planning because we consider them a part of planning, whether or not they occur on the same day.
IMRT delivery should be preceded by IMRT planning. To mix standard radiation planning and treatment with IMRT planning and treatment is incorrect billing.
|June 2012||Revised||Linked Medical Policies and put CPT Codes in numerical order|
|September 2011||Revision||Removed "IMRT services require prior authorization."|