Description:
Radiation oncology is a specialty of medicine that utilizes high-energy ionizing radiation in the treatment of malignant neoplasms and certain types of non-malignant conditions. A course of radiation therapy consists of 5 stages and utilizes several therapeutic modalities that include: teletherapy, brachytherapy, hyperthermia and stereotactic radiation.

Policy Statement:
Radiation oncology services are reimbursable and considered medically reasonable and necessary when the following conditions are documented and indicated in the client’s medical chart:

TUMOR MAPPING AND CLINICAL TREATMENT PLANNING (77261 – 77263)

Clinical treatment management and tumor mapping is crucial to identifying the location, extent, and volume of tumor(s) to be treated and all critical structure surrounding them. A physician plans the appropriate course of radiation therapy that will allow for maximal benefits while protecting the structures and tissues. Clinical treatment planning may include the ordering and interpreting of multiple tests (i.e., CT scans, MR scans, lymphangiography, surgical exploration with biopsy and markers placed for the purpose of treatment planning and localization. There are three (3) categories of treatment planning as listed below:

• 77261 Simple Treatement Planning:
  Used when the area or volume that is to be treated is clearly defined and easily encompasses the tumor while excluding normal tissue and structures. This planning requires no interpretation of tests and involves no more than one critical structure. Typically these will be with patient with solitary bony metastases, metastatic tumors to the brain, palliative lung cancer, and other palliative situations.
• 77262 Intermediate Treatment Planning:
  Used when there are two (2) separate treatment areas involved, most commonly in situations of metastatic disease. This would include patients with bone metastasis in different sites, bone and brain metastasis, uncomplicated lung cancer, whole pelvis irradiation for pre-operative, post-operative, or curative situations, etc. Critical or sensitive organs that need protection are usually involved. Interpretation of special tests, localization of tumor volume are involved in this planning.
• 77263 Complex Treatment Planning:
  Used when complex treatment planning is needed. Three or more areas may require treatment. The patient may have early or advanced disease, which is complex in its distribution. Special planning and mapping is required to protect sensitive, normal structures. Combined therapies, such as brachytherapy, surgery or chemotherapy, may be required for optimum benefits.

**Treatment planning is a one time charge per course of therapy. Multiple treatment plans for a single course of treatment are not allowed.**

THERAPEUTIC RADIOLOGY SIMULATION-AIDED FIELD SETTING (77280 – 77295)

Following treatment planning, simulation is used to actually direct the treatment beams to the specific volume of interest. This may be carried out on a dedicated conventional simulator or CT scanner, radiation therapy treatment unit (linear accelerator) or using diagnostic imaging equipment (flouroscopy, CT, MR). The number and arrangements of portals will determine the level of complexity of simulation. The number of films taken per treatment and the use of fluoroscopy are not determinants of complexity.

Portal changes based on unsatisfactory initial simulation (s) are not reportable as additional simulations. Minor changes in port size without changes in beam or clinical justification do not warrant an additional charge or a higher level of complexity.

• 77280 Simple Simulation:
  Simulation is considered simple when there is a single area being treated and no more than two ports, parallel opposed, will be simulated. Only one or two films, often without fluoroscopy. If any of the following factors are present, the simulation is simple:

  • Verification simulation
  • Open PA spine
  • Open AP/PA field
  • Set up simulation requiring no custom complex immobilization
• 77285 Intermediate Simulation:
  Simulation is considered to be intermediate when three or more portals converge on a single or when two separate areas are being simulated, such as two areas of metastatic disease to bone. Blocking, utilizing more than a single block, will also cause the simulation to become intermediate. If any of the following factors are present, the simulation is intermediate:

  • T-spine and L-spine separate fields; no blocks or simple hand blocks
  • Hip and shoulder; no blocks or hand blocks
  • Four field open box
• 77290 Complex Simulation:
  Simulation is considered to be complex when there are three or more volumes of interest, rotation or arc therapy. Complex blocking or custom made shielding blocks when clinically necessary to define anatomic structures and the volume of interest. Tangential ports with multiple devices. If any of the following factors are present, the simulation is complex:

  • Breast Tangents
  • Three field esophagus with wedges
  • H/N with Aquaplast Mask
  • Electron field … should be documented on setup sheet/or with photo images with appropriate date of service, if clinical
  • Prostate with customized blocking
  • Virtual simulations that document the creation of custom complex blocking
  • Field placement for any brachytherapy procedure
• 77295 Therapeutic Radiology Simulation-Aided Field Setting:
  Three dimensional simulation and treatment is clinically warranted when one or more of the following conditions exist:

  1. The tumor volume is irregular and in close opposition to normal or critical structures that must be protected.
  2. The target tumor volume is in such a location that it cannot be clearly identified under conventional fluoroscopic guidance.
  3. The final boost field must be constructed to the exact tumor volume with its irregular configuration.
  4. Multiple conformed portals are necessary to cover the tumor volume with close margins and protect immediately adjacent normal structures.
  5. "Beam’s eye view" of multiple portals must be established for conformal treatment delivery.
  6. Multiple arcs in true three dimension must be established for stereotactic radiosurgery of the CNS lesions.
  7. An immediately adjacent area has been previously irradiated and abutting portals must be established with high precision.

**Code 77295 also includes the work done for a teletherapy isodose plan (codes 77306 – 77307) and, accordingly, codes 77306 – 77307 should not be billed separately. Detailed documentation by the physician is required for reporting this procedure.**

**The typical course of radiation therapy will require between one (1) and three (3) simulations. No more than one simulation should be reported on any given day.**

BASIC RADIATION DOSIMETRY CALCULATIONS (77300)

Dosimetry is a calculation of the radiation dose distribution within an area of interest requested by the radiation oncologist. This is done initially either by the medical radiological physicist or the medical treatment planning dosimetrist. This is considered medically necessary for each treatment field (port) and if the patient has off-axis calculations; calculations for different depth doses, different target areas, secondary firm dosimetry, abutting fields, or any other situation requiring individual point calculations of radiation dosage.

**The typical course of radiation therapy may require between one and six dosimetry calculations, depending on the complexity of the patient’s problem. Frequency in excess of the upper limits of this range will require supporting documentation**

TELETHERAPY ISODOSE PLAN(S)

Teletherapy involves the use of external beam radiation. It is considered medically necessary for a given course of radiation therapy to a specific area. 

• 77306 Simple Isodose Plan:
  One or two ports of interest are directed at one area.
• 77307 Complex Isodose Plan:
  Multiple treatment areas, tangential ports, use of wedges, blocking, rotational beam or special beam considerations, includes basic dosimetry calculation.

   

  **Only one Teletherapy Isodose Plan may be reported for a given course of therapy to a specific treatment area. Repeat Isodose Plans necessitated because of field corrections should not be charged separately. Additional Plans will require supporting documentation. The physician’s documentation must be specific to the number of areas as well as the specific location of tumor (s) and the specific number of ports involved with each area treated.

All isodose plans must be checked and signed by the medical radiological physicist and the radiation oncologist.

SPECIAL TELETHERAPY PORT PLAN (77321)

• 77321 Special Teletherapy Beam Consideration:

**This code may be billed only one (1) time for the course of treatment, regardless of the number of times that the special beam is utilized.**

BRACHYTHERAPY ISODOSE CALCULATIONS (77316 – 77318)

Brachytherapy is used to improve control of local disease, treat areas at high risk for recurrence of malignancy, preserve vital organ function and minimize normal surrounding tissue damage. The levels of complexity of conventional clinical brachytherapy relates directly to the number of sources or ribbons utilized in the procedure.

• 77316 Simple Brachytherapy:
   One to four sources/ribbon application; remote after loading brachytherapy, 1 – 4 sources, 1 channel
• 77317 Intermediate Brachytherapy:
  Multiplane dosage calculations, application involves five to ten source/ribbons, remote after loading brachytherapy, 5 – 10 sources, 2 – 12 channels
• 77318 Complex Brachytherapy:
  Multiplane isodose plan, volume implant calculation, over ten sources/ribbons used, remote afterloading brachytherapy, over 12 channels

**This code is generally billed one per treatment course. This procedure may be repeated only if a new implant is inserted.**

SPECIAL DOSIMETRY (77331)

Special/microdosimetry consists of the use of special radiation measuring and monitoring devices for determining the specific dosage of radiation at a given point. Not all patients require Special Dosimetry Calculations, therefore medical necessity must be documented. It is considered medically necessary once per treatment port, when the physician determines that it is necessary to have a measurement of the amount of radiation that a patient has actually received at a given point with the final results being utilized to accept or modify the current treatment plan. This procedure is NOT to be routinely performed each time the patient is treated. 

TREATMENT DEVICES, DESIGNS & CONSTRUCTION (77332 – 77334)

The purposes of the device (s) and the risks involved by their use or non-use, as well as the complexity of their design, determines the Complexity Level. The choice to custom make a device for a given patient is justified only for clinical necessity and must be documented for patients treated with palliative intent. Treatment devices are utilized for beam shaping, patient immobilization, shielding of critical structures and beam modification. 

• 77332 Simple Blocking:
  A simple block covers only a portion of a single port. This is generally used only for palliative cases where the blocking of a given area is important, but not critical. A minimal amount of time and effort is required on the part of the physician to design simple blocking.
• 77333 Intermediate Blocking:
  Multiple areas of a port are blocked and are utilized when more than one segment or area of a portal requires protection. The design of the blocking is still minimal in terms of skill, and effort but, the physician must indicate all of the areas to be protected and appropriate blocking must be fabricated.
• 77334 Custom Blocking:
  Custom blocking is usually reserved for curative cases. This follows physiologic volumetric boundaries of the cancer and normal tissues. Blocking is generally designed on the simulation films but, may be done on treatment portal films, computer designed or topographically drawn on the patient.

** The typical course of radiation therapy will justify from one to five charges for devices.

MEDICAL RADIATION PHYSICS CONSULTATION

• 77336 Continuing Medical Physics Services:

This code is used to describe ongoing medical physics service for every patient receiving radiation therapy. It includes documented weekly checking of the patient’s treatment chart by or under the supervision of a medical radiological physicist to assure that the treatment administered conforms to that prescribed by the radiation oncologist. It includes the verification of accurate dose calculations, accurate data entry in the patient’s chart, proper patient positioning and beam orientation, patient radiation safety, and dose summation at the conclusion of treatment. This service is an integral component of an ongoing patient quality assurance program.

• 77370 Special Medical Physics Consult:

This code is used in a consultative situation describing a very specific procedure that is carried out by the medical radiological physicist at the direct request of the radiation oncologist. It is used when there is a problem or special situation that arises during radiation therapy. This code requires a detailed WRITTEN report describing the problem to be given to the requesting physician.

**The technical relative values for 77336 and 77370 are also the global RVU. This is true regardless of the place of service (i.e., hospital or freestanding center). Code 77336 is reported once for every week (five fractions) of external beam treatment. Code 77370 is typically only reported once per course of radiation therapy.**

MEDICAL PHYSICS DOSE EVALUATION FOR RADIATION

• 76145 Medical physics dose evaluation for radiation exposure that exceeds institutional review threshold, including report

RADIATION TREATMENT DELIVERY (77401 – 77412)

Treatment management and delivery may be reported with codes 77401 – 77470. It is the responsibility of the physician to check the accuracy of the treatment delivery and to document the accuracy of the treatment as it relates to planning and setup. Ongoing patient examinations are performed as necessary. This should be reported using treatment management codes NOT evaluation and management codes. 

PORTAL VERIFICATION FILM(S) (77417)

Code 77417 is used to report port verification films. These films should agree with the original simulation films and dosimetry. The review and interpretation of port films is considered part of the weekly clinical treatment management by the physician.

IMRT is addressed in the following policies:

SPECIAL TREATMENT PROCEDURE (77470)

This procedure code covers the additional physician effort and work required while performing and/or managing special treatment situations. The use of this code covers the additional time and effort required of the physician and the hospital/freestanding staff to care for patients undergoing a very complex course of radiation therapy.

**This code should only be reported one time per course of treatment. It is not intended to be used for other ongoing medical problems the patient may have such as diabetes, hypertension or chronic obstructive pulmonary disease.**

References:

1. Guerrero Urbano MT, Nutting CM. Clinical use of intensity-modulated radiotherapy: Part II. Brit J Radiol. 2004b; 77:177-182.
2. Rudat V, Munter M, Rades D, et al. The effect of amifostine or IMRT to preserve the parotid function after radiotherapy of the head and neck region. Proc of ASCO. 2005; Suppl. Abstract No. 5502.
3. Ting JY, Scarbrough TJ. Intensity-modulated radiation therapy and image-guided radiation therapy: small clinic implementation. Hematol Oncol Clin N Am. 2006; 20:63-86.
4. Zietman AL, DeSilvio M, Slater JD, et al. A randomized trial comparing conventional dose (70.2 GyE) and high dose (79.2 GyE) conformal radiation in early stage adenocarcinoma of the prostate: results of an interim analysis of PROG 95-09. Int J Radiat Oncol Biol Phys. 2004; 60(1 Suppl):S131-S132. 
5. Ben-Josef E, Shields AF, Vaishampayan U, et al. Intensity-modulated radiotherapy (IMRT) and concurrent capecitabine for pancreatic cancer. Int J Radiat Oncol Biol Phys. 2004;59(2):454-459.
6. American Society for Therapeutic Radiology and Oncology (ASTRO). Reimbursement of intensity modulated radiation therapy. Policy and Practice. Fairfax, VA: ASTRO; 2002.
7. Bogardus CR. A User's Guide for Radiation Oncology Management & Billing Procedures. 7th ed. Oklahome City, OK:Cancer Care Network; 2006
8. American Society for Therapeutic Radiation and Oncology (ASTRO). the ASTRO/ACR Guide to Radiation Oncology Coding 2007. Fairfax, VA: ASTRO; 2007.

This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies and accredited national guidelines.

"Current Procedural Terminology © American Medical Association. All Rights Reserved" 

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