Brachytherapy (L30320)
Contractor Information
|
Contractor Name Wisconsin Physicians Service Insurance Corporation |
Contractor Number 00951, 00952, 00953, 00954, 52280, 05101, 05201, 05301, 05401, 05102, 05202, 05302, 05402 |
Contractor Type Carrier - FI - MAC |
LCD Information
Document Information
L30320 LCD Title Brachytherapy Contractor's Determination Number RAD-036 AMA CPT/ADA CDT Copyright Statement CPT codes, descriptions and other data only are copyright 2011 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. |
Primary Geographic Jurisdiction
Oversight Region Original Determination Effective Date For services performed on or after 08/16/2009 Original Determination Ending Date Revision Effective Date For services performed on or after 10/01/2011 Revision Ending Date |
CMS National Coverage Policy
Medicare Claims Processing Manual
Chapter 13 - Radiology Services and Other Diagnostic Procedures
70 - Radiation Oncology (Therapeutic Radiology)
70.1 - Weekly Radiation Therapy Management (CPT 77419 - 77430)
70.2 - Services Bundled Into Treatment Management Codes
70.3 - Radiation Treatment Delivery (CPT 77401 - 77417)
70.4 - Clinical Brachytherapy (CPT Codes 77750 - 77799)
70.5 - Radiation Physics Services (CPT Codes 77300 - 77399)
Formerly:
MCM 15021 Transmittal 1787, 01/24/2003
MCM 15022 Payment Conditions for Radiology Services.
MCM 5262 Payments Under the Fee Schedule for Radiologist Services.
Chapter 13 - Radiology Services and Other Diagnostic Procedures
70 - Radiation Oncology (Therapeutic Radiology)
70.1 - Weekly Radiation Therapy Management (CPT 77419 - 77430)
70.2 - Services Bundled Into Treatment Management Codes
70.3 - Radiation Treatment Delivery (CPT 77401 - 77417)
70.4 - Clinical Brachytherapy (CPT Codes 77750 - 77799)
70.5 - Radiation Physics Services (CPT Codes 77300 - 77399)
Formerly:
MCM 15021 Transmittal 1787, 01/24/2003
MCM 15022 Payment Conditions for Radiology Services.
MCM 5262 Payments Under the Fee Schedule for Radiologist Services.
Indications and Limitations of Coverage and/or Medical Necessity
Description:
Radiation oncology consists of two primary treatment modalities: external beam radiation therapy (EBRT) and brachytherapy. Brachytherapy is a type of radiation therapy that utilizes natural or manufactured radioactive isotopes or radionuclides that are temporarily or permanently implanted to treat malignancies or certain benign conditions and derives a physical advantage based upon the inverse square law of physics. This is achieved by implanting a radioactive source in the form of wires or seeds, close to or into the tumor or treatment site. There are currently three basic clinical brachytherapy formats: interstitial, intracavitary or intraluminal therapy. Brachytherapy may use a solid radioactive source, such as a 'seed' or liquid colloid isotopes, and may be either temporary or permanent. Further, brachytherapy may be called high dose rate or low dose rate.
Brachytherapy may be used independently as the sole treatment or as an adjunctive treatment in combination with external beam therapy and other modalities such as surgery or chemotherapy.
Brachytherapy may be performed concomitantly with surgical resection or in conjunction with procedures such as endoscopy or angioplasty, which are required to achieve access to the site of the disease. There are two distinct phases required to complete the process known as brachytherapy:
1. the insertion or placement of non-radioactive applicators or conduits that receive or transmit the radioactive material into the body, and
2. the loading of the radioactive material (the active or therapeutic agent) into the conduits or directly into tissue.
Low-dose rate (LDR) Brachytherapy - Rate of dose delivery is low (10-100 cGy per HOUR).
LDR is usually delivered over several days in a hospital setting; however, LDR may consist of permanently implanted sources and be performed as either an ambulatory or in-patient procedure. Radiation therapy is delivered as the isotope decays.
Low-dose-rate brachytherapy is of two types:
1. Permanently inserted sources or temporarily inserted sources. Common permanent sources are Palladium 103, Iodine 125, Cesium 131 and Gold198 that are usually used for treatment of prostate cancer.
2. Common temporarily inserted seeds/sources are Iridium 192 and Cesium 137. Iridium is physically smaller and can be used for interstitial implants (breast, head and neck, complex gynecological, sarcomas and others). The Cesium is contained in a larger tube and is used mostly for intracavitary gynecological implants. Temporary (LDR) implants usually are in place 1 to 3 days and patients are admitted and must be kept under radiation safety conditions in isolation on the wards to protect medical personnel from low level exposure to radiation
Description of a Prostate Brachytherapy Low-Dose-Rate Procedure
Patients with prostate cancers that are eligible for seed implantation fall within a set of guidelines established by the treating radiation oncologist and urologist. These guidelines determine candidates for the procedure versus those patients who may be best suited for an alternative therapy. The physicians present the recommendations to the patient.
Prior to the permanent seed implant, a transrectal ultrasound, CT scan or MRI examination is done to determine the shape and size of the prostate and technical feasibility of prostate brachytherapy.
After the urology diagnostic work-up and low dose rate brachytherapy has been chosen by the patient, there are several aspects to the episode of care including preplan, implant, and post implant (post plan). The prostate is "mapped" to determine the number of seeds required. Some centers may perform a pre-plan calculation to determine which holes in the template the needles need to be inserted and how many seeds to deposit through each needle in order to adequately irradiate the prostate. Other centers are performing the planning in the operating room at the time of the implant. Preplan tumor mapping and simulations done prior to the implant should not be billed again at the time of the implant. Conversely, simulations done on the day of implant (real time) should not be billed a second time on a day prior to the implant. The implant is generally done on an outpatient basis without an overnight hospital stay at an outpatient hospital facility or an ASC. A radiation oncologist and urologist may be both present for the case, and work as a team along with other specialized staff or the radiation oncologist or surgeon may perform the procedure alone.
In the operating room, the patient is placed under anesthesia, general, spinal or local. The ultrasound probe, is attached to the "stepper" assembly that also holds the square grid template against the perineum. The physician pushes stainless steel needles through the holes in the template, into the perineum and then the prostate, guided by the images seen on the ultrasound.
The physician may be performing a real-time plan with computers assessing the prostate gland and needle placement, or they may be following the pre-plan blueprint. Throughout the procedure
there is an assessment of the implant and the prostate. This is done to assure an adequate placement is taking place to deliver sufficient radiation dose. This is done in 3D fashion with available technology.
The number of seeds used depends on the volume of the prostate.
Fifty to 150 seeds are inserted using 15-40 needles (Most prostate implants require 60 to 120 seeds). This varies with the size and shape of the prostate and other factors (e.g. seed activity). There are three types of radioactive material (radioisotopes) that can be implanted into the prostate: iodine (I-125); palladium (Pd-103); and cesium (Cs-131).
Post implant, a second dataset is done to produce an accurate and safe plan (post plan). The documentation should support the simulation done. This can be done on the day of the procedure or up to 4 weeks following the procedure. This allows for review of the plan and true delivery compared with the dose planned.
High-dose rate (HDR) brachytherapy - Treatment delivery is at higher dose rates (10-100 cGy per MINUTE).
HDR is performed by using a remote afterloading device to deliver the radioactive source(s). HDR allows the dose to be delivered customarily in minutes and usually on an outpatient basis and is often given in a series of multiple fractions.
High-dose-rate brachytherapy involves the use of a high activity radiation source with source radioactivity and energy far too great to allow manual handling. HDR may be used for virtually any site in the body that is suitable for brachytherapy.
Description of a High-Dose-Rate Procedure
The HDR brachytherapy system uses a single, tiny (1mm by 3 mm) source that contains a highly radioactive source of Iridium-192 that is laser welded to the end of a thin, flexible stainless steel cable. The HDR machine, called a remote afterloader, safely stores the radiation source between treatments and delivers the source directly into the patient during therapy. The first step in the HDR brachytherapy process is the placement of the brachytherapy catheters, needles or other treatment applicators into the patient.
Then, following localization radiographs or scans (simulation) and related computer based treatment planning calculations (treatment planning/dosimetry), HDR treatment is administered to the patient in a shielded vault. The computer-guided remote afterloader is used to direct the source with millimeter precision into the applicator system. The source moves in 5mm steps to specific locations within the hollow conduits implanted in the target volume. It stops at designated positions called "dwell" positions. The distribution of radiation dose is determined by the dwell position location and how long the source remains at each of the many potential sites. HDR brachytherapy treatment courses may vary from 1 to 12 or more treatments (also known as fractions), depending on the type of cancer being treated, the prescribed dose, whether external radiation is also being administered and many other factors.
Pulsed Dose Rate (PDR) Brachytherapy: Uses sources of intermediate strength and delivers a series of doses on a 1-2 hourly schedule over a 1-2 day treatment period. It is also a form of remote afterloading.
Indications
Brachytherapy may be indicated as a primary or adjunctive therapy in a variety of tumors. A dose rate is selected based on the individual needs of the patient. LDR (low dose rate) and HDR (high dose rate) brachytherapy are two delivery systems for brachytherapy that use radioactive material to deliver a dose of intensive radiation therapy to a specific well-defined local site (treatment volume). In both LDR and HDR the treatment site should be defined and accessible to the applicators that are the delivery medium for the radioactive sources. Brachytherapy is done to treat a primary or metastatic neoplasm, while sparing sensitive, normal tissues that may be nearby. LDR and HDR procedures may be given with intent to cure, intent to palliate, or to obtain local control (either cure or palliation). Both may be given in conjunction with a course of external beam radiation therapy, or as single modalities.
The typical requirements of brachytherapy may involve:
1. Treatment planning (77263)
Brachytherapy is routinely designated complex (CPT code 77263) because it requires complex treatment volume design, dose levels near normal tissue tolerance, analysis or special tests, complex fractionation, or delivery concurrent with other therapeutic modalities or treatment of previously irradiated tissues.
2. Dosimetry (77300)
Brachytherapy requires certain calculations to be made throughout the course of treatment. Each basic dosimetry calculation may be submitted when performed for brachytherapy treatment.
3. Radiation treatment management (77427 - three or more treatments a week) or (77431- one treatment a week) Special treatment procedure (77470)
Brachytherapy management requires an understanding of the process of treatment delivery. There is a completely different process for patient management. Treatment is done weekly, 2 or more times a week and occasionally twice per day.
The management of brachytherapy includes overall management of the patient during the course of radiation therapy. It includes review of the treatment record to assure that the therapy is proceeding according to the radiation plan and dose prescription, medical evaluation of the patient during the course of treatment, making the necessary adjustments to the applicator during the course of treatment, and any other modifications or clinical interventions needed to assure safe and effective treatment during the clinical course of therapy.
Special treatment procedure (77470):
The delivery of brachytherapy often requires special arrangements with the operating room and radiation safe ward, coordination of the applicator insertion process with other specialists, preparation and provision of the applicators and related equipment, scheduling and integration of required physics support, and acquisition and preparation of the radiation sources. Brachytherapy is often delivered in conjunction with external radiation, chemotherapy, or surgery. Integration of these processes makes brachytherapy a special treatment procedure.
The regulation reads:
Weekly Radiation Therapy Management (CPT 77427). Pay for a physician's weekly treatment management services under code 77427. Instruct billing entities to indicate on each claim the number of fractions for which payment is sought.
A weekly unit of treatment management is equal to five fractions or treatment sessions. A week for the purpose of making payments under these codes is comprised of five fractions regardless of the actual time period in which the services are furnished. It is not necessary that the radiation therapist personally examine the patient during each fraction for the weekly treatment management code to be payable.
Multiple fractions representing two or more treatment sessions furnished on the same day may be counted as long as there has been a distinct break in therapy sessions, and the fractions are of the character usually furnished on different days.
Code 77427 is also reported if there are three or four fractions beyond a multiple of five at the end of a course of treatment; one or two fractions beyond a multiple of five at the end of a course of treatment are not reported separately. The professional services furnished during treatment management typically consist of:
review of port films;
review of dosimetry, dose delivery, and treatment parameters;
review of patient treatment set-ups;
examination of patient for medical evaluation and management, (e.g., assessment of the patient's response to treatment, coordination of care and treatment, review of imaging and/or lab test results).
EXAMPLE:
18 fractions = 4 weekly services
62 fractions = 12 weekly services
8 fractions = 2 weekly services
6 fractions = 1 weekly service
If billings have occurred which indicate that the treatment course has ended (and, therefore, the number of residual fractions has been determined), but treatments resume, adjust your payments for the additional services consistent with the above policy.
EXAMPLE:
8 fractions = payment for 2 weeks
2 additional fractions are furnished by the same physician. No additional Medicare payment is made for the 2 additional fractions.
Please note that the management code should be used mainly if there will be more than one fraction of HDR or LDR
4. Simulation (77280-77295)
For brachytherapy, simulation may require the use of imaging examinations of the implanted sources or applicator(s) containing dummy sources. These films of the implanted sources are used to develop isodose curves and other dosimetry, and may be billed separately, when appropriate.
Brachytherapy simulation CPT code 77290 is the complex process of obtaining images of the implanted region for purposes of making position adjustments and for performing dose calculations. Non-radioactive "dummy" sources are used to geographically define the "eventual position" of the radioactive sources in temporary implant devices, whereas permanently implanted sources are imaged directly. Contrast may be utilized to delineate adjacent normal tissues and organs.
Subsequent "check" verification simulations during the course of temporary implants to confirm or correct applicator position are reported as simple CPT code 77280.
CPT code 77295 may be billed as part of the brachytherapy process when the needed parameters are included (i.e. 3D volume reconstruction with DVH for target and normal tissues, etc. This information can be obtained from CT, U/S or MRI.).
5. Isodose planning (77326-77328)
Brachytherapy requires an isodose plan. This plan determines the dose at each implanted source and throughout the treatment volume and doses to surrounding normal tissue.
6. Handling and Loading of Radioelement (77790)
Where brachytherapy techniques require the manual loading of an isotope (LDR), the supervision, loading and handling of the isotope may be separately reported.
7. Source Application/Placement (77750, 77761-77763, 77776-77778, 77781-77784, and 77789)
Selection and placement of after-loading applicators and the loading and unloading of radioactive sources may be performed by the radiation oncologist alone or in collaboration with another physician.
8. Applicator placement
The choice of applicators and the actual placement of the after-loading device may be performed by the radiation oncologist alone or in collaboration with another physician (e.g., gynecologist, urologist, pulmonologist, gastroenterologist, thoracic surgeon).
9. Treatment devices (77332-77334)
Treatment devices (e.g., blocks, shields and wedges) may include the use of certain templates, molds, or other apparatus that may be required for specific clinical circumstances. These may be covered as treatment devices.
10. Medical Physics Services (77336, 77370 and 77331)
CPT code 77336 is a "weekly code;" however, for radiation therapy treatment that is not administered in five weekly fractions (such as brachytherapy) or for a course of radiation therapy consisting of one or two fractions, code 77336 may be reported.
CPT code 77370 may be justified for the complex interrelationships of electron and photon ports and complex dosimetric considerations in brachytherapy, including high dose rate remote afterloader applications, intravascular brachytherapy treatments, and interstitial radioactive seed implantation.
CPT code 77331 is Special dosimetry (e.g. TLD, microdosimetry) when prescribed by a physician. In some instances, measurement of the delivered radiation dose may be used to guide and determine the dose to selected positions within or around the implant treatment volume. (This can be very helpful, especially in difficult case such as retreatment using brachytherapy in previously irradiated areas.)
11. For coverage of intravascular brachytherapy see policy CV-035
12. For coverage of External Beam radiation see policy RAD-014.
Limitations
1. Although radiographs may be used in brachytherapy simulation, these images should not be reported as port-films.
2 Follow-up visits for 90 days after treatment are not separately payable. (This does not apply to a patient visit for complaints unrelated to the current treatment).
3. Only a physician authorized as an authorized user by the Nuclear Regulatory Commission or an Agreement State for brachytherapy should work with radioactive materials.
4. Products used for the patient's comfort may not be charged as treatment devices (e.g., pillows, pads, or cushions).
Radiation oncology consists of two primary treatment modalities: external beam radiation therapy (EBRT) and brachytherapy. Brachytherapy is a type of radiation therapy that utilizes natural or manufactured radioactive isotopes or radionuclides that are temporarily or permanently implanted to treat malignancies or certain benign conditions and derives a physical advantage based upon the inverse square law of physics. This is achieved by implanting a radioactive source in the form of wires or seeds, close to or into the tumor or treatment site. There are currently three basic clinical brachytherapy formats: interstitial, intracavitary or intraluminal therapy. Brachytherapy may use a solid radioactive source, such as a 'seed' or liquid colloid isotopes, and may be either temporary or permanent. Further, brachytherapy may be called high dose rate or low dose rate.
Brachytherapy may be used independently as the sole treatment or as an adjunctive treatment in combination with external beam therapy and other modalities such as surgery or chemotherapy.
Brachytherapy may be performed concomitantly with surgical resection or in conjunction with procedures such as endoscopy or angioplasty, which are required to achieve access to the site of the disease. There are two distinct phases required to complete the process known as brachytherapy:
1. the insertion or placement of non-radioactive applicators or conduits that receive or transmit the radioactive material into the body, and
2. the loading of the radioactive material (the active or therapeutic agent) into the conduits or directly into tissue.
Low-dose rate (LDR) Brachytherapy - Rate of dose delivery is low (10-100 cGy per HOUR).
LDR is usually delivered over several days in a hospital setting; however, LDR may consist of permanently implanted sources and be performed as either an ambulatory or in-patient procedure. Radiation therapy is delivered as the isotope decays.
Low-dose-rate brachytherapy is of two types:
1. Permanently inserted sources or temporarily inserted sources. Common permanent sources are Palladium 103, Iodine 125, Cesium 131 and Gold198 that are usually used for treatment of prostate cancer.
2. Common temporarily inserted seeds/sources are Iridium 192 and Cesium 137. Iridium is physically smaller and can be used for interstitial implants (breast, head and neck, complex gynecological, sarcomas and others). The Cesium is contained in a larger tube and is used mostly for intracavitary gynecological implants. Temporary (LDR) implants usually are in place 1 to 3 days and patients are admitted and must be kept under radiation safety conditions in isolation on the wards to protect medical personnel from low level exposure to radiation
Description of a Prostate Brachytherapy Low-Dose-Rate Procedure
Patients with prostate cancers that are eligible for seed implantation fall within a set of guidelines established by the treating radiation oncologist and urologist. These guidelines determine candidates for the procedure versus those patients who may be best suited for an alternative therapy. The physicians present the recommendations to the patient.
Prior to the permanent seed implant, a transrectal ultrasound, CT scan or MRI examination is done to determine the shape and size of the prostate and technical feasibility of prostate brachytherapy.
After the urology diagnostic work-up and low dose rate brachytherapy has been chosen by the patient, there are several aspects to the episode of care including preplan, implant, and post implant (post plan). The prostate is "mapped" to determine the number of seeds required. Some centers may perform a pre-plan calculation to determine which holes in the template the needles need to be inserted and how many seeds to deposit through each needle in order to adequately irradiate the prostate. Other centers are performing the planning in the operating room at the time of the implant. Preplan tumor mapping and simulations done prior to the implant should not be billed again at the time of the implant. Conversely, simulations done on the day of implant (real time) should not be billed a second time on a day prior to the implant. The implant is generally done on an outpatient basis without an overnight hospital stay at an outpatient hospital facility or an ASC. A radiation oncologist and urologist may be both present for the case, and work as a team along with other specialized staff or the radiation oncologist or surgeon may perform the procedure alone.
In the operating room, the patient is placed under anesthesia, general, spinal or local. The ultrasound probe, is attached to the "stepper" assembly that also holds the square grid template against the perineum. The physician pushes stainless steel needles through the holes in the template, into the perineum and then the prostate, guided by the images seen on the ultrasound.
The physician may be performing a real-time plan with computers assessing the prostate gland and needle placement, or they may be following the pre-plan blueprint. Throughout the procedure
there is an assessment of the implant and the prostate. This is done to assure an adequate placement is taking place to deliver sufficient radiation dose. This is done in 3D fashion with available technology.
The number of seeds used depends on the volume of the prostate.
Fifty to 150 seeds are inserted using 15-40 needles (Most prostate implants require 60 to 120 seeds). This varies with the size and shape of the prostate and other factors (e.g. seed activity). There are three types of radioactive material (radioisotopes) that can be implanted into the prostate: iodine (I-125); palladium (Pd-103); and cesium (Cs-131).
Post implant, a second dataset is done to produce an accurate and safe plan (post plan). The documentation should support the simulation done. This can be done on the day of the procedure or up to 4 weeks following the procedure. This allows for review of the plan and true delivery compared with the dose planned.
High-dose rate (HDR) brachytherapy - Treatment delivery is at higher dose rates (10-100 cGy per MINUTE).
HDR is performed by using a remote afterloading device to deliver the radioactive source(s). HDR allows the dose to be delivered customarily in minutes and usually on an outpatient basis and is often given in a series of multiple fractions.
High-dose-rate brachytherapy involves the use of a high activity radiation source with source radioactivity and energy far too great to allow manual handling. HDR may be used for virtually any site in the body that is suitable for brachytherapy.
Description of a High-Dose-Rate Procedure
The HDR brachytherapy system uses a single, tiny (1mm by 3 mm) source that contains a highly radioactive source of Iridium-192 that is laser welded to the end of a thin, flexible stainless steel cable. The HDR machine, called a remote afterloader, safely stores the radiation source between treatments and delivers the source directly into the patient during therapy. The first step in the HDR brachytherapy process is the placement of the brachytherapy catheters, needles or other treatment applicators into the patient.
Then, following localization radiographs or scans (simulation) and related computer based treatment planning calculations (treatment planning/dosimetry), HDR treatment is administered to the patient in a shielded vault. The computer-guided remote afterloader is used to direct the source with millimeter precision into the applicator system. The source moves in 5mm steps to specific locations within the hollow conduits implanted in the target volume. It stops at designated positions called "dwell" positions. The distribution of radiation dose is determined by the dwell position location and how long the source remains at each of the many potential sites. HDR brachytherapy treatment courses may vary from 1 to 12 or more treatments (also known as fractions), depending on the type of cancer being treated, the prescribed dose, whether external radiation is also being administered and many other factors.
Pulsed Dose Rate (PDR) Brachytherapy: Uses sources of intermediate strength and delivers a series of doses on a 1-2 hourly schedule over a 1-2 day treatment period. It is also a form of remote afterloading.
Indications
Brachytherapy may be indicated as a primary or adjunctive therapy in a variety of tumors. A dose rate is selected based on the individual needs of the patient. LDR (low dose rate) and HDR (high dose rate) brachytherapy are two delivery systems for brachytherapy that use radioactive material to deliver a dose of intensive radiation therapy to a specific well-defined local site (treatment volume). In both LDR and HDR the treatment site should be defined and accessible to the applicators that are the delivery medium for the radioactive sources. Brachytherapy is done to treat a primary or metastatic neoplasm, while sparing sensitive, normal tissues that may be nearby. LDR and HDR procedures may be given with intent to cure, intent to palliate, or to obtain local control (either cure or palliation). Both may be given in conjunction with a course of external beam radiation therapy, or as single modalities.
The typical requirements of brachytherapy may involve:
1. Treatment planning (77263)
Brachytherapy is routinely designated complex (CPT code 77263) because it requires complex treatment volume design, dose levels near normal tissue tolerance, analysis or special tests, complex fractionation, or delivery concurrent with other therapeutic modalities or treatment of previously irradiated tissues.
2. Dosimetry (77300)
Brachytherapy requires certain calculations to be made throughout the course of treatment. Each basic dosimetry calculation may be submitted when performed for brachytherapy treatment.
3. Radiation treatment management (77427 - three or more treatments a week) or (77431- one treatment a week) Special treatment procedure (77470)
Brachytherapy management requires an understanding of the process of treatment delivery. There is a completely different process for patient management. Treatment is done weekly, 2 or more times a week and occasionally twice per day.
The management of brachytherapy includes overall management of the patient during the course of radiation therapy. It includes review of the treatment record to assure that the therapy is proceeding according to the radiation plan and dose prescription, medical evaluation of the patient during the course of treatment, making the necessary adjustments to the applicator during the course of treatment, and any other modifications or clinical interventions needed to assure safe and effective treatment during the clinical course of therapy.
Special treatment procedure (77470):
The delivery of brachytherapy often requires special arrangements with the operating room and radiation safe ward, coordination of the applicator insertion process with other specialists, preparation and provision of the applicators and related equipment, scheduling and integration of required physics support, and acquisition and preparation of the radiation sources. Brachytherapy is often delivered in conjunction with external radiation, chemotherapy, or surgery. Integration of these processes makes brachytherapy a special treatment procedure.
The regulation reads:
Weekly Radiation Therapy Management (CPT 77427). Pay for a physician's weekly treatment management services under code 77427. Instruct billing entities to indicate on each claim the number of fractions for which payment is sought.
A weekly unit of treatment management is equal to five fractions or treatment sessions. A week for the purpose of making payments under these codes is comprised of five fractions regardless of the actual time period in which the services are furnished. It is not necessary that the radiation therapist personally examine the patient during each fraction for the weekly treatment management code to be payable.
Multiple fractions representing two or more treatment sessions furnished on the same day may be counted as long as there has been a distinct break in therapy sessions, and the fractions are of the character usually furnished on different days.
Code 77427 is also reported if there are three or four fractions beyond a multiple of five at the end of a course of treatment; one or two fractions beyond a multiple of five at the end of a course of treatment are not reported separately. The professional services furnished during treatment management typically consist of:
review of port films;
review of dosimetry, dose delivery, and treatment parameters;
review of patient treatment set-ups;
examination of patient for medical evaluation and management, (e.g., assessment of the patient's response to treatment, coordination of care and treatment, review of imaging and/or lab test results).
EXAMPLE:
18 fractions = 4 weekly services
62 fractions = 12 weekly services
8 fractions = 2 weekly services
6 fractions = 1 weekly service
If billings have occurred which indicate that the treatment course has ended (and, therefore, the number of residual fractions has been determined), but treatments resume, adjust your payments for the additional services consistent with the above policy.
EXAMPLE:
8 fractions = payment for 2 weeks
2 additional fractions are furnished by the same physician. No additional Medicare payment is made for the 2 additional fractions.
Please note that the management code should be used mainly if there will be more than one fraction of HDR or LDR
4. Simulation (77280-77295)
For brachytherapy, simulation may require the use of imaging examinations of the implanted sources or applicator(s) containing dummy sources. These films of the implanted sources are used to develop isodose curves and other dosimetry, and may be billed separately, when appropriate.
Brachytherapy simulation CPT code 77290 is the complex process of obtaining images of the implanted region for purposes of making position adjustments and for performing dose calculations. Non-radioactive "dummy" sources are used to geographically define the "eventual position" of the radioactive sources in temporary implant devices, whereas permanently implanted sources are imaged directly. Contrast may be utilized to delineate adjacent normal tissues and organs.
Subsequent "check" verification simulations during the course of temporary implants to confirm or correct applicator position are reported as simple CPT code 77280.
CPT code 77295 may be billed as part of the brachytherapy process when the needed parameters are included (i.e. 3D volume reconstruction with DVH for target and normal tissues, etc. This information can be obtained from CT, U/S or MRI.).
5. Isodose planning (77326-77328)
Brachytherapy requires an isodose plan. This plan determines the dose at each implanted source and throughout the treatment volume and doses to surrounding normal tissue.
6. Handling and Loading of Radioelement (77790)
Where brachytherapy techniques require the manual loading of an isotope (LDR), the supervision, loading and handling of the isotope may be separately reported.
7. Source Application/Placement (77750, 77761-77763, 77776-77778, 77781-77784, and 77789)
Selection and placement of after-loading applicators and the loading and unloading of radioactive sources may be performed by the radiation oncologist alone or in collaboration with another physician.
8. Applicator placement
The choice of applicators and the actual placement of the after-loading device may be performed by the radiation oncologist alone or in collaboration with another physician (e.g., gynecologist, urologist, pulmonologist, gastroenterologist, thoracic surgeon).
9. Treatment devices (77332-77334)
Treatment devices (e.g., blocks, shields and wedges) may include the use of certain templates, molds, or other apparatus that may be required for specific clinical circumstances. These may be covered as treatment devices.
10. Medical Physics Services (77336, 77370 and 77331)
CPT code 77336 is a "weekly code;" however, for radiation therapy treatment that is not administered in five weekly fractions (such as brachytherapy) or for a course of radiation therapy consisting of one or two fractions, code 77336 may be reported.
CPT code 77370 may be justified for the complex interrelationships of electron and photon ports and complex dosimetric considerations in brachytherapy, including high dose rate remote afterloader applications, intravascular brachytherapy treatments, and interstitial radioactive seed implantation.
CPT code 77331 is Special dosimetry (e.g. TLD, microdosimetry) when prescribed by a physician. In some instances, measurement of the delivered radiation dose may be used to guide and determine the dose to selected positions within or around the implant treatment volume. (This can be very helpful, especially in difficult case such as retreatment using brachytherapy in previously irradiated areas.)
11. For coverage of intravascular brachytherapy see policy CV-035
12. For coverage of External Beam radiation see policy RAD-014.
Limitations
1. Although radiographs may be used in brachytherapy simulation, these images should not be reported as port-films.
2 Follow-up visits for 90 days after treatment are not separately payable. (This does not apply to a patient visit for complaints unrelated to the current treatment).
3. Only a physician authorized as an authorized user by the Nuclear Regulatory Commission or an Agreement State for brachytherapy should work with radioactive materials.
4. Products used for the patient's comfort may not be charged as treatment devices (e.g., pillows, pads, or cushions).
Coding Information
Bill Type Codes:
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.
| 011x | Hospital Inpatient (Including Medicare Part A) |
| 012x | Hospital Inpatient (Medicare Part B only) |
| 013x | Hospital Outpatient |
| 085x | Critical Access Hospital |
Revenue Codes:
Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes.
All revenue codes billed on the inpatient claim for the dates of service in question may be subject to review.
CPT/HCPCS Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.
Revenue codes only apply to providers who bill these services to the fiscal intermediary. Revenue codes do not apply to physicians, other professionals and suppliers who bill these services to the carrier.Please note that not all revenue codes apply to every type of bill code. Providers are encouraged to refer to the FISS revenue code file for allowable bill types. Similarly, not all revenue codes apply to each CPT/HCPCS code. Providers are encouraged to refer to the FISS HCPCS file for allowable revenue codes.
All revenue codes billed on the inpatient claim for the dates of service in question may be subject to review.
| 0333 | Radiology - Therapeutic and/or Chemotherapy Administration - Radiation Therapy |
Many
of the CPT codes in the radiation oncology section can be used for both
external beam radiation therapy (EBRT) and brachytherapy, while others
are specific to one modality or the other. See policy RAD014 for more
information on these services.
The CPT codes below, with the
exception of 77261-77263, 77280-77295, 77336, 77370 and 79900 are those
specific only to brachytherapy. CPT codes 77300 (Basic Dosimetry),
77332-77334 (Treatment devices, designs and construction), 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), 77370 (Special medical radiation physics
consultation), and 77470 (Special treatment procedure) are also relevant to brachytherapy.
| 77261 | THERAPEUTIC RADIOLOGY TREATMENT PLANNING; SIMPLE |
| 77262 | THERAPEUTIC RADIOLOGY TREATMENT PLANNING; INTERMEDIATE |
| 77263 | THERAPEUTIC RADIOLOGY TREATMENT PLANNING; COMPLEX |
| 77280 | THERAPEUTIC RADIOLOGY SIMULATION-AIDED FIELD SETTING; SIMPLE |
| 77285 | THERAPEUTIC RADIOLOGY SIMULATION-AIDED FIELD SETTING; INTERMEDIATE |
| 77290 | THERAPEUTIC RADIOLOGY SIMULATION-AIDED FIELD SETTING; COMPLEX |
| 77295 | THERAPEUTIC RADIOLOGY SIMULATION-AIDED FIELD SETTING; 3-DIMENSIONAL |
| 77326 | BRACHYTHERAPY ISODOSE PLAN; SIMPLE (CALCULATION MADE FROM SINGLE PLANE, 1 TO 4 SOURCES/ RIBBON APPLICATION, REMOTE AFTERLOADING BRACHYTHERAPY, 1 TO 8 SOURCES) |
| 77327 | BRACHYTHERAPY ISODOSE PLAN; INTERMEDIATE (MULTIPLANE DOSAGE CALCULATIONS, APPLICATION INVOLVING 5 TO 10 SOURCES/RIBBONS, REMOTE AFTERLOADING BRACHYTHERAPY, 9 TO 12 SOURCES) |
| 77328 | BRACHYTHERAPY ISODOSE PLAN; COMPLEX (MULTIPLANE ISODOSE PLAN, VOLUME IMPLANT CALCULATIONS, OVER 10 SOURCES/RIBBONS USED, SPECIAL SPATIAL RECONSTRUCTION, REMOTE AFTERLOADING BRACHYTHERAPY, OVER 12 SOURCES) |
| 77331 | SPECIAL DOSIMETRY (EG, TLD, MICRODOSIMETRY) (SPECIFY), ONLY WHEN PRESCRIBED BY THE TREATING PHYSICIAN |
| 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 |
| 77370 | SPECIAL MEDICAL RADIATION PHYSICS CONSULTATION |
| 77470 | SPECIAL TREATMENT PROCEDURE (EG, TOTAL BODY IRRADIATION, HEMIBODY RADIATION, PER ORAL, ENDOCAVITARY OR INTRAOPERATIVE CONE IRRADIATION) |
| 77750 | INFUSION OR INSTILLATION OF RADIOELEMENT SOLUTION (INCLUDES 3-MONTH FOLLOW-UP CARE) |
| 77761 | INTRACAVITARY RADIATION SOURCE APPLICATION; SIMPLE |
| 77762 | INTRACAVITARY RADIATION SOURCE APPLICATION; INTERMEDIATE |
| 77763 | INTRACAVITARY RADIATION SOURCE APPLICATION; COMPLEX |
| 77776 | INTERSTITIAL RADIATION SOURCE APPLICATION; SIMPLE |
| 77777 | INTERSTITIAL RADIATION SOURCE APPLICATION; INTERMEDIATE |
| 77778 | INTERSTITIAL RADIATION SOURCE APPLICATION; COMPLEX |
| 77785 | REMOTE AFTERLOADING HIGH DOSE RATE RADIONUCLIDE BRACHYTHERAPY; 1 CHANNEL |
| 77786 | REMOTE AFTERLOADING HIGH DOSE RATE RADIONUCLIDE BRACHYTHERAPY; 2-12 CHANNELS |
| 77787 | REMOTE AFTERLOADING HIGH DOSE RATE RADIONUCLIDE BRACHYTHERAPY; OVER 12 CHANNELS |
| 77789 | SURFACE APPLICATION OF RADIATION SOURCE |
| 77790 | SUPERVISION, HANDLING, LOADING OF RADIATION SOURCE |
| Q3001 | RADIOELEMENTS FOR BRACHYTHERAPY, ANY TYPE, EACH |
Brachytherapy Sources Payable as of 01/01/2008 in the ASC setting
| A9527 | IODINE I-125, SODIUM IODIDE SOLUTION, THERAPEUTIC, PER MILLICURIE |
| C1716 | BRACHYTHERAPY SOURCE, NON-STRANDED, GOLD-198, PER SOURCE |
| C1717 | BRACHYTHERAPY SOURCE, NON-STRANDED, HIGH DOSE RATE IRIDIUM-192, PER SOURCE |
| C1719 | BRACHYTHERAPY SOURCE, NON-STRANDED, NON-HIGH DOSE RATE IRIDIUM-192, PER SOURCE |
| C2616 | BRACHYTHERAPY SOURCE, NON-STRANDED, YTTRIUM-90, PER SOURCE |
| C2634 | BRACHYTHERAPY SOURCE, NON-STRANDED, HIGH ACTIVITY, IODINE-125, GREATER THAN 1.01 MCI (NIST), PER SOURCE |
| C2635 | BRACHYTHERAPY SOURCE, NON-STRANDED, HIGH ACTIVITY, PALADIUM-103, GREATER THAN 2.2 MCI (NIST), PER SOURCE |
| C2636 | BRACHYTHERAPY LINEAR SOURCE, NON-STRANDED, PALADIUM-103, PER 1 MM |
| C2638 | BRACHYTHERAPY SOURCE, STRANDED, IODINE-125, PER SOURCE |
| C2639 | BRACHYTHERAPY SOURCE, NON-STRANDED, IODINE-125, PER SOURCE |
| C2640 | BRACHYTHERAPY SOURCE, STRANDED, PALLADIUM-103, PER SOURCE |
| C2641 | BRACHYTHERAPY SOURCE, NON-STRANDED, PALLADIUM-103, PER SOURCE |
| C2642 | BRACHYTHERAPY SOURCE, STRANDED, CESIUM-131, PER SOURCE |
| C2643 | BRACHYTHERAPY SOURCE, NON-STRANDED, CESIUM-131, PER SOURCE |
| C2698 | BRACHYTHERAPY SOURCE, STRANDED, NOT OTHERWISE SPECIFIED, PER SOURCE |
| C2699 | BRACHYTHERAPY SOURCE, NON-STRANDED, NOT OTHERWISE SPECIFIED, PER SOURCE |
| C9728 | PLACEMENT OF INTERSTITIAL DEVICE(S) FOR RADIATION THERAPY/SURGERY GUIDANCE (EG, FIDUCIAL MARKERS, DOSIMETER), FOR OTHER THAN THE FOLLOWING SITES (ANY APPROACH): ABDOMEN, PELVIS, PROSTATE, RETROPERITONEUM, THORAX, SINGLE OR MULTIPLE |
The following CPT procedure codes may be included for performing prostate brachytherapy:
| 55860 | EXPOSURE OF PROSTATE, ANY APPROACH, FOR INSERTION OF RADIOACTIVE SUBSTANCE; |
| 55875 | TRANSPERINEAL PLACEMENT OF NEEDLES OR CATHETERS INTO PROSTATE FOR INTERSTITIAL RADIOELEMENT APPLICATION, WITH OR WITHOUT CYSTOSCOPY |
| 55876 | PLACEMENT OF INTERSTITIAL DEVICE(S) FOR RADIATION THERAPY GUIDANCE (EG, FIDUCIAL MARKERS, DOSIMETER), PROSTATE (VIA NEEDLE, ANY APPROACH), SINGLE OR MULTIPLE |
| 76000 | FLUOROSCOPY (SEPARATE PROCEDURE), UP TO 1 HOUR PHYSICIAN TIME, OTHER THAN 71023 OR 71034 (EG, CARDIAC FLUOROSCOPY) |
| 76001 | FLUOROSCOPY, PHYSICIAN TIME MORE THAN 1 HOUR, ASSISTING A NONRADIOLOGIC PHYSICIAN (EG, NEPHROSTOLITHOTOMY, ERCP, BRONCHOSCOPY, TRANSBRONCHIAL BIOPSY) |
| 76872 | ULTRASOUND, TRANSRECTAL; |
| 76873 | ULTRASOUND, TRANSRECTAL; PROSTATE VOLUME STUDY FOR BRACHYTHERAPY TREATMENT PLANNING (SEPARATE PROCEDURE) |
| 76950 | ULTRASONIC GUIDANCE FOR PLACEMENT OF RADIATION THERAPY FIELDS |
| 76965 | ULTRASONIC GUIDANCE FOR INTERSTITIAL RADIOELEMENT APPLICATION |
| 77012 | COMPUTED TOMOGRAPHY GUIDANCE FOR NEEDLE PLACEMENT (EG, BIOPSY, ASPIRATION, INJECTION, LOCALIZATION DEVICE), RADIOLOGICAL SUPERVISION AND INTERPRETATION |
| C9725 | PLACEMENT OF ENDORECTAL INTRACAVITARY APPLICATOR FOR HIGH INTENSITY BRACHYTHERAPY |
The following CPT procedure codes may be included for performing prostate brachytherapy with a TC modifier:
| 77014 | COMPUTED TOMOGRAPHY GUIDANCE FOR PLACEMENT OF RADIATION THERAPY FIELDS |
The following CPT procedure code may be included for lung brachytherapy:
| 31626 | BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH PLACEMENT OF FIDUCIAL MARKERS, SINGLE OR MULTIPLE |
| 31643 | BRONCHOSCOPY, RIGID OR FLEXIBLE, INCLUDING FLUOROSCOPIC GUIDANCE, WHEN PERFORMED; WITH PLACEMENT OF CATHETER(S) FOR INTRACAVITARY RADIOELEMENT APPLICATION |
| 32553 | PLACEMENT OF INTERSTITIAL DEVICE(S) FOR RADIATION THERAPY GUIDANCE (EG, FIDUCIAL MARKERS, DOSIMETER), PERCUTANEOUS, INTRA- THORACIC, SINGLE OR MULTIPLE |
The following CPT procedure code may be included for esophageal brachytherapy:
| 43241 | UPPER GASTROINTESTINAL ENDOSCOPY INCLUDING ESOPHAGUS, STOMACH, AND EITHER THE DUODENUM AND/OR JEJUNUM AS APPROPRIATE; WITH TRANSENDOSCOPIC INTRALUMINAL TUBE OR CATHETER PLACEMENT |
The following CPT procedure codes may be included for gynecologic cases:
| 49327 | LAPAROSCOPY, SURGICAL; WITH PLACEMENT OF INTERSTITIAL DEVICE(S) FOR RADIATION THERAPY GUIDANCE (EG, FIDUCIAL MARKERS, DOSIMETER), INTRA-ABDOMINAL, INTRAPELVIC, AND/OR RETROPERITONEUM, INCLUDING IMAGING GUIDANCE, IF PERFORMED, SINGLE OR MULTIPLE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) |
| 49411 | PLACEMENT OF INTERSTITIAL DEVICE(S) FOR RADIATION THERAPY GUIDANCE (EG, FIDUCIAL MARKERS, DOSIMETER), PERCUTANEOUS, INTRA-ABDOMINAL, INTRA-PELVIC (EXCEPT PROSTATE), AND/OR RETROPERITONEUM, SINGLE OR MULTIPLE |
| 49412 | PLACEMENT OF INTERSTITIAL DEVICE(S) FOR RADIATION THERAPY GUIDANCE (EG, FIDUCIAL MARKERS, DOSIMETER), OPEN, INTRA-ABDOMINAL, INTRAPELVIC, AND/OR RETROPERITONEUM, INCLUDING IMAGE GUIDANCE, IF PERFORMED, SINGLE OR MULTIPLE (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) |
| 55920 | PLACEMENT OF NEEDLES OR CATHETERS INTO PELVIC ORGANS AND/OR GENITALIA (EXCEPT PROSTATE) FOR SUBSEQUENT INTERSTITIAL RADIOELEMENT APPLICATION |
| 57155 | INSERTION OF UTERINE TANDEM AND/OR VAGINAL OVOIDS FOR CLINICAL BRACHYTHERAPY |
| 57156 | INSERTION OF A VAGINAL RADIATION AFTERLOADING APPARATUS FOR CLINICAL BRACHYTHERAPY |
| 58346 | INSERTION OF HEYMAN CAPSULES FOR CLINICAL BRACHYTHERAPY |
The following CPT procedure codes may be included for breast cases:
| 19296 | PLACEMENT OF RADIOTHERAPY AFTERLOADING EXPANDABLE CATHETER (SINGLE OR MULTICHANNEL) INTO THE BREAST FOR INTERSTITIAL RADIOELEMENT APPLICATION FOLLOWING PARTIAL MASTECTOMY, INCLUDES IMAGING GUIDANCE; ON DATE SEPARATE FROM PARTIAL MASTECTOMY |
| 19297 | PLACEMENT OF RADIOTHERAPY AFTERLOADING EXPANDABLE CATHETER (SINGLE OR MULTICHANNEL) INTO THE BREAST FOR INTERSTITIAL RADIOELEMENT APPLICATION FOLLOWING PARTIAL MASTECTOMY, INCLUDES IMAGING GUIDANCE; CONCURRENT WITH PARTIAL MASTECTOMY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE) |
| 19298 | PLACEMENT OF RADIOTHERAPY AFTERLOADING BRACHYTHERAPY CATHETERS (MULTIPLE TUBE AND BUTTON TYPE) INTO THE BREAST FOR INTERSTITIAL RADIOELEMENT APPLICATION FOLLOWING (AT THE TIME OF OR SUBSEQUENT TO) PARTIAL MASTECTOMY, INCLUDES IMAGING GUIDANCE |
| C9726 | PLACEMENT AND REMOVAL (IF PERFORMED) OF APPLICATOR INTO BREAST FOR RADIATION THERAPY |
ICD-9 Codes that Support Medical Necessity
| 140.0 - 195.8 | MALIGNANT NEOPLASM OF UPPER LIP VERMILION BORDER - MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES |
| 196.0 - 198.89 | SECONDARY AND UNSPECIFIED MALIGNANT NEOPLASM OF LYMPH NODES OF HEAD FACE AND NECK - SECONDARY MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES |
| 199.0 - 199.1 | DISSEMINATED MALIGNANT NEOPLASM - OTHER MALIGNANT NEOPLASM OF UNSPECIFIED SITE |
| 200.00 - 208.91 | RETICULOSARCOMA UNSPECIFIED SITE - UNSPECIFIED LEUKEMIA IN REMISSION |
| 233.0 | CARCINOMA IN SITU OF BREAST |
| 235.0 - 238.9 | NEOPLASM OF UNCERTAIN BEHAVIOR OF MAJOR SALIVARY GLANDS - NEOPLASM OF UNCERTAIN BEHAVIOR SITE UNSPECIFIED |
| 372.40 - 372.45 | PTERYGIUM UNSPECIFIED - RECURRENT PTERYGIUM |
Diagnoses that Support Medical Necessity
ICD-9 Codes that DO NOT Support Medical Necessity
Any not listed above
ICD-9 Codes that DO NOT Support Medical Necessity Asterisk Explanation
Diagnoses that DO NOT Support Medical Necessity
General Information
1. Documentation
supporting the medical necessity of these services, such as ICD-9-CM
codes, must be submitted with each claim. Claims submitted without such
evidence will be denied as not medically necessary.
2. The treatment goal must be documented (curative, palliative or tumor control) in the medical record.
3. The record must contain documentation of the patient's informed consent to treatment.
4. A written, signed and dated prescription or treatment plan designed by the radiation oncologist must be on file. The prescription must include all of the following information: designation of the treatment site, designation of the isotope, designation of the number of source positions, the planned dose to each critical dose point.
5. Given the multiplicity of services that are inherent in brachytherapy, it is essential that the medical records reflect each service in a clear linear and temporally logical form. Flow charts, where helpful, are recommended. All procedures should be documented with a procedural note.
6. Medical records must be made available to Medicare upon request.
Appendices
2. The treatment goal must be documented (curative, palliative or tumor control) in the medical record.
3. The record must contain documentation of the patient's informed consent to treatment.
4. A written, signed and dated prescription or treatment plan designed by the radiation oncologist must be on file. The prescription must include all of the following information: designation of the treatment site, designation of the isotope, designation of the number of source positions, the planned dose to each critical dose point.
5. Given the multiplicity of services that are inherent in brachytherapy, it is essential that the medical records reflect each service in a clear linear and temporally logical form. Flow charts, where helpful, are recommended. All procedures should be documented with a procedural note.
6. Medical records must be made available to Medicare upon request.
American Society for
Therapeutic Radiology and Oncology/American College of Radiology (ASTRO
ACR) 2002 Radiation Oncology Coding User's Guide.
American College of Radiology (ACR) Standard for the Performance of High-Dose-Rate Brachytherapy, 2000.
ACR Standard for the Performance of Low-Dose-Rate Brachytherapy, 2000.
ACR Standard for the Performance of Brachytherapy Physics: Manually-Loaded Temporary Implants, 2000.
ACR Standard for the Performance of Brachytherapy Physics: Remotely-Loaded HDR Sources, 2000.
ACR Standard for Transperineal Permanent Brachytherapy of Prostate Cancer, 2000.
Cheng, BS; Nagalingam, S; Komanduri, MA; Tupchong, L. "Dosimetric Considerations of Stereotactic Brain Implants," Int J Radiation Oncology Biol Phys, 1989, v 17: 887-891.
Brenner, DJ; Huang, Y; Hall, EJ. "Fractionated High Dose-Rate Versus Low Dose-Rate Regimens for Intracavitary Brachytherapy of the Cervix: Equivalent Regimens for Combined Brachytherapy and External Irradiation," Int J Radiation Oncology Biol Phys, 1991, v 21: 1415-1423.
Nori, D; Allison, R; Kaplan, B; Samala, E; Osian, A; Karbowitz, S. "High Dose-Rate Intraluminal Irradiation in Bronchogenic Carcinoma," Chest, 1993, v 104: 1006-1011.
Waksman, Ron; Schwartz, Robert S. "Vascular Brachytherapy for Prevention of Restenosis: A Brief History and Overview." The Journal of Invasive Cardiology, January 1999, Vol. 11, No. 1: pp. 33-35.
Advantages of Cesium-131 for Permanent Seed Implant Brachytherapy, D.J. Swanberg and G.N. Brown, PhD.
Arthur, Douglas W. et al; Accelerated partial breast irradiation: an updated report from the American Brachytherapy Society; Brachytherapy 2002, 184-190
Benitez, Pamela R.; Partial Breast irradiation in breast-conserving therapy by way of interstial brachytherapy; AJS, Vol. 188; 2004, 355-364
Other carrier local coverage decisions and coding information.
Advisory Committee Meeting Notes
American College of Radiology (ACR) Standard for the Performance of High-Dose-Rate Brachytherapy, 2000.
ACR Standard for the Performance of Low-Dose-Rate Brachytherapy, 2000.
ACR Standard for the Performance of Brachytherapy Physics: Manually-Loaded Temporary Implants, 2000.
ACR Standard for the Performance of Brachytherapy Physics: Remotely-Loaded HDR Sources, 2000.
ACR Standard for Transperineal Permanent Brachytherapy of Prostate Cancer, 2000.
Cheng, BS; Nagalingam, S; Komanduri, MA; Tupchong, L. "Dosimetric Considerations of Stereotactic Brain Implants," Int J Radiation Oncology Biol Phys, 1989, v 17: 887-891.
Brenner, DJ; Huang, Y; Hall, EJ. "Fractionated High Dose-Rate Versus Low Dose-Rate Regimens for Intracavitary Brachytherapy of the Cervix: Equivalent Regimens for Combined Brachytherapy and External Irradiation," Int J Radiation Oncology Biol Phys, 1991, v 21: 1415-1423.
Nori, D; Allison, R; Kaplan, B; Samala, E; Osian, A; Karbowitz, S. "High Dose-Rate Intraluminal Irradiation in Bronchogenic Carcinoma," Chest, 1993, v 104: 1006-1011.
Waksman, Ron; Schwartz, Robert S. "Vascular Brachytherapy for Prevention of Restenosis: A Brief History and Overview." The Journal of Invasive Cardiology, January 1999, Vol. 11, No. 1: pp. 33-35.
Advantages of Cesium-131 for Permanent Seed Implant Brachytherapy, D.J. Swanberg and G.N. Brown, PhD.
Arthur, Douglas W. et al; Accelerated partial breast irradiation: an updated report from the American Brachytherapy Society; Brachytherapy 2002, 184-190
Benitez, Pamela R.; Partial Breast irradiation in breast-conserving therapy by way of interstial brachytherapy; AJS, Vol. 188; 2004, 355-364
Other carrier local coverage decisions and coding information.
Wisconsin: 01/16/2009
Illinois: 01/28/2009
Michigan: 01/07/2009
Minnesota: 01/22/2009
Iowa 02/12/2009
W. Missouri 02/12/2009
E. Missouri 02/12/2009
Kansas 02/12/2009
Nebraska 02/12/2009
This policy does not reflect the sole opinion of the contractor or the Contractor Medical Director(s). Although the final decision rests with the contractor, this policy was developed in cooperation with the Carrier Advisory Committee(s), which include representatives of various medical specialty societies.
This policy was presented at an open meeting on: 12/17/2008
Start Date of Comment Period
Illinois: 01/28/2009
Michigan: 01/07/2009
Minnesota: 01/22/2009
Iowa 02/12/2009
W. Missouri 02/12/2009
E. Missouri 02/12/2009
Kansas 02/12/2009
Nebraska 02/12/2009
This policy does not reflect the sole opinion of the contractor or the Contractor Medical Director(s). Although the final decision rests with the contractor, this policy was developed in cooperation with the Carrier Advisory Committee(s), which include representatives of various medical specialty societies.
This policy was presented at an open meeting on: 12/17/2008
02/12/2009
End Date of Comment Period
03/30/2009
Start Date of Notice Period
07/01/2009
Revision History Number
X
Revision History Explanation
Removed contractor 05392 based on the policy being effective 8/16/09.
Entered italicized print.
11/15/2009 - The description for CPT/HCPCS code 55876 was changed in group 3
11/15/2009 - The description for CPT/HCPCS code 31643 was changed in group 4
01/01/2010, HCPCS update impacting CPT codes 31626, 32553, 49411, C9728, 55876, C9725, C9726
04/19/2010-In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of American Somoa, California, Guam, Hawaii, Nevada and Northern Mariana Islands were removed from this LCD because claims processing for those states are transitioning from FI Contractor Wisconsin Physician Services (WPS - 52280) to MAC Part A Contractor Palmetto.
8/1/2010 - The description for Bill Type Code 11 was changed
8/1/2010 - The description for Bill Type Code 12 was changed
8/1/2010 - The description for Bill Type Code 13 was changed
8/1/2010 - The description for Bill Type Code 85 was changed
8/1/2010 - The description for Revenue code 0333 was changed
09/06/2010 - This policy was updated by the ICD-9 2010-2011 Annual Update.
10/01/2010 - Add 237.73, 237.79 (Included in range 140.0-239.9)
10/18/2010 - In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Colorado, New Mexico, Oklahoma and Texas were removed from this LCD because claims processing for those states are transitioning from FI Wisconsin Physicians Service (52280) to MAC Part A Trailblazer (04901).
11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:
77785 descriptor was changed in Group 1
77786 descriptor was changed in Group 1
55860 descriptor was changed in Group 3
55875 descriptor was changed in Group 3
55876 descriptor was changed in Group 3
76001 descriptor was changed in Group 3
76872 descriptor was changed in Group 3
76873 descriptor was changed in Group 3
57155 descriptor was changed in Group 7
01/01/2011, HCPCS update impacting codes 49327, 49412, 57156, 55876
02/21/2011 - In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Delaware, District of Columbia, Maryland, New Jersey and Pennsylvania were removed from this LCD because claims processing for these states are transitioning from FI Wisconsin Physician Service (WPS 52280) to MAC Part A contractor Highmark (12901).
08/27/2011 - This policy was updated by the ICD-9 2011-2012 Annual Update.
10/01/2011 ICD-9 code updates added codes 173.00-173.99 to range.
Reason for Change
Entered italicized print.
11/15/2009 - The description for CPT/HCPCS code 55876 was changed in group 3
11/15/2009 - The description for CPT/HCPCS code 31643 was changed in group 4
01/01/2010, HCPCS update impacting CPT codes 31626, 32553, 49411, C9728, 55876, C9725, C9726
04/19/2010-In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of American Somoa, California, Guam, Hawaii, Nevada and Northern Mariana Islands were removed from this LCD because claims processing for those states are transitioning from FI Contractor Wisconsin Physician Services (WPS - 52280) to MAC Part A Contractor Palmetto.
8/1/2010 - The description for Bill Type Code 11 was changed
8/1/2010 - The description for Bill Type Code 12 was changed
8/1/2010 - The description for Bill Type Code 13 was changed
8/1/2010 - The description for Bill Type Code 85 was changed
8/1/2010 - The description for Revenue code 0333 was changed
09/06/2010 - This policy was updated by the ICD-9 2010-2011 Annual Update.
10/01/2010 - Add 237.73, 237.79 (Included in range 140.0-239.9)
10/18/2010 - In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Colorado, New Mexico, Oklahoma and Texas were removed from this LCD because claims processing for those states are transitioning from FI Wisconsin Physicians Service (52280) to MAC Part A Trailblazer (04901).
11/21/2010 - For the following CPT/HCPCS codes either the short description and/or the long description was changed. Depending on which description is used in this LCD, there may not be any change in how the code displays in the document:
77785 descriptor was changed in Group 1
77786 descriptor was changed in Group 1
55860 descriptor was changed in Group 3
55875 descriptor was changed in Group 3
55876 descriptor was changed in Group 3
76001 descriptor was changed in Group 3
76872 descriptor was changed in Group 3
76873 descriptor was changed in Group 3
57155 descriptor was changed in Group 7
01/01/2011, HCPCS update impacting codes 49327, 49412, 57156, 55876
02/21/2011 - In accordance with Section 911 of the Medicare Modernization Act of 2003, the states of Delaware, District of Columbia, Maryland, New Jersey and Pennsylvania were removed from this LCD because claims processing for these states are transitioning from FI Wisconsin Physician Service (WPS 52280) to MAC Part A contractor Highmark (12901).
08/27/2011 - This policy was updated by the ICD-9 2011-2012 Annual Update.
10/01/2011 ICD-9 code updates added codes 173.00-173.99 to range.
This LCD has no Related Documents.
LCD Attachments
Coding and Billing Guidelinesn 01/01/2010 (PDF - 49 KB )
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