Reimbursement Guidelines
Brachytherapy
Brachytherapy element is not separately reimbursable when billed with remote after-loading high intensity brachytherapy. Brachytherapy isodose planning is limited to ten times per 60 days by any provider.
Dosimetry and Simulation
Basic radiation dosimetry calculation is limited to ten units per 60 days by any provider. Special dosimetry is limited to six units per 60 days by any provider.
Simulation reimbursement is limited to five units per 60 days.
For superficial radiation treatment (SRT), basic radiation dosimetry calculation and simulation are only reimbursable once per 60 days.
3-dimensional radiotherapy planning is limited to three times per 60 days.
Image guidance is not reimbursable when performed with SRT.
Intensity Modulated Radiotherapy Plan
Intensity modulated radiotherapy dose planning is only reimbursable once per 60 days.
Individual services performed as part of the development of intensity modulated radiotherapy dose planning are not separately reimbursable when performed the day of or within 30 days (prior to, or after) of a billed intensity modulated radiotherapy dose planning service by the same group practice for the same member.
Modifier 59 is appropriate to represent a distinct procedural service for a different tumor on a different date of service, and unrelated to the intensity modulated radiotherapy dose planning.
Design and construction of multi-lead collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT) is reported once per IMRT plan and is limited to 3 units per 60 days.
Radiation Therapy and Treatment Management Services
A radiation therapy management complete course that is 2 or less fractions is limited to 1 session per 60 days.
Radiation therapy treatment device reimbursement is limited to seven units per 60 days. An additional 5 units may be reimbursed for services with a head, neck or prostate cancer diagnosis or when performed within two weeks before or after IMRT or stereotactic body radiation treatment (SBRT).
Therapeutic radiology treatment planning is limited to one unit per 60 days when performed by any provider for the same course of treatment. Diagnostic professional radiology services (i.e., MRI and CT) are not separately reimbursable from complex therapeutic radiology treatment planning.
Radiation treatment management services should only be reported once per week by any provider. Services integral to radiation treatment management services and brachytherapy are not separately reimbursable.
Special treatment procedures are only reimbursable within two weeks of a complex therapy as defined by the American Society for Radiation Oncology (ASTRO).
Therapeutic port films are only reimbursable once per week.
Stereotactic Radiosurgery
Stereotactic Radiosurgery (SRS) for cranial lesions (simple or complex) is reported once per course of treatment and is only reimbursable one unit per two weeks. Additional cranial lesions should not be reported more than four times for an entire course of treatment (two weeks) regardless of the number of lesions treated and may be reported only once per lesion.
SRS for spinal lesions is reported once per course of treatment and is only reimbursable one unit per two weeks. Additional spinal lesions should not be reported more than two times for the entire course of treatment (two weeks) regardless of the number of lesions treated and may be reported only once per lesion.
Treatment management for SBRT is limited to one visit per two weeks.
SBRT and stereotactic radiosurgery treatment should not be reported more than five sessions for an entire course of treatment regardless of number of lesions treated. Since a treatment course is typically defined as two weeks, this combination of codes should only be reported up to five times per two weeks.
Additionally, stereotactic radiation treatment delivery and stereotactic radiosurgery represent a complete course of stereotactic radiosurgery treatment and should not be reported more than once for a single two-week course of treatment.
Stereotactic radiation treatment management of cranial lesion(s), complete course of treatment consisting of 1 session should not be reported more than once in two weeks.