Radiation therapy is the application of radiation to treat malignant and non-malignant conditions for which its use is medically appropriate. It is also called teletherapy, radiotherapy, irradiation, or x-ray therapy.  There are several methods for delivering radiation therapy. The traditional methods are external beam radiation using energy generated from linear accelerators or Cobalt units and brachytherapy using radioactive sources placed in or near the tumor or in the area near cancer cells. 

The time needed to complete a course of radiation therapy can vary based the patient’s diagnosis and condition as well as the method chosen for the treatment. Planning for and delivering a course of radiation therapy treatment involves a variety of interrelated and distinct activities of varying complexity. A clinical team, under the direction of the radiation oncologist, includes the referring physician, a medical physicist, dosimetrist, radiation therapist, and simulation staff. This team coordinates and performs the medical services associated with a radiation treatment protocol. 

NOTE:  This policy includes frequency standards considered appropriate in the majority of cases involving radiation therapy treatment planning and delivery. However, each patient’s unique clinical circumstances may warrant individual consideration based on a review of applicable medical records.  Examples of when an allowance for more frequent services may be warranted include, but are not limited to:

1. a change in the treatment plan or method of treatment delivery,
2. a change in treatment field or volume of interest (for example, shrinking of the tumor volume),
3. when brachytherapy is given in addition to an external beam therapy.

The medical necessity for services exceeding the frequency standards described in this policy must be documented in the patient’s clinical records and be available for review upon request. 

A. Radiation Therapy Physics, Dosimetry, and Treatment Devices 

Clinical treatment planning (codes 77261, 77262, 77263) develops an appropriate plan or course of action necessary to treat the patient’s condition. During the planning process, the radiation oncologist works closely with the medical physicist and dosimetrist to identify the appropriate course of treatment.  This includes, but is not limited to:

• localizing the tumor, that is, determining the anatomic site of the tumor, its volume (size and shape), and any adjacent critical and/or healthy structures,
• determining the dosage and method or modality necessary to deliver the amount of radiation that is appropriate for the patient’s condition, as well as the size and number of treatment ports,
• planning for any treatment devices that may be necessary, and
• determining the duration of the therapy including the number of treatments required to treat the condition. 

A clinical course of radiation therapy consists of one treatment plan per course of therapy. It is usually performed prior to the initiation of treatment. Billing multiple treatment plans for a single course of treatment is not considered reasonable or necessary. However, when there is a substantive change in the patient’s tumor or general condition, the new or revised course of treatment may require a new treatment plan. Treatment planning is a professional service only code. The prescribed plan must be clearly documented in the patient’s medical records and available for review upon request. 

Simulation-aided field setting (codes 77280, 77285, 77290, 77295, 77299) directs or aims the treatment beams to the specific treatment volume (the size and shape of the tumor) identified in clinical treatment planning. This process includes determining the optimal patient and equipment positioning for treatment, beam entry sites, and treatment devices. The complexity of simulation is based on the number of ports of beam entry, treatment volumes, and the use and type of any treatment devices needed to shield or protect adjacent healthy organs or tissue. 

The typical course of radiation therapy consists of between one and three simulations. However, only one simulation is reimbursed per day. Portal changes based on unsatisfactory initial simulations should not be reported as additional simulations. 

Additional simulations may be necessary during a course of treatment to account for changes in port size, boost dose, or tumor volume, for example, when a new field is treated, or, when the geometry of a treatment field changes. Minor changes in port size do not warrant an additional allowance. 

The medical necessity for each simulation must be documented in the patient’s clinical records. 

Basic dosimetry (code 77300) is a mathematical calculation of the radiation dose to the tumor volume.  A qualified medical dosimetrist, medical physicist, physician, or other qualified individual performs the dosimetry calculation either manually or by computer. This service is medically necessary for each treatment field or port. Only one dosimetry calculation is eligible when there is no change in dosimetry parameters.  However, additional calculations may be necessary when a patient has off-axis calculations, calculations for different depth doses, different target areas, secondary film dosimetry, abutting fields, or any other situation requiring individual point calculations for radiation dosage. 

The typical course of radiation therapy consists of one to six dosimetry calculations depending on the location of the tumor and the complexity of the individual patient’s case. Radiation treatments to the head/neck, prostate and Hodgkin’s disease may require eight or more calculations.

Teletherapy isodose plans (codes 77305, 77310, 77315) ensure that the treatment volume (tumor) receives the prescribed dose of radiation. Teletherapy is the delivery of radiation treatments to a patient from equipment located remote from the body.

The typical course of radiation therapy consists of up to six isodose plans. One isodose plan is necessary for a course of therapy to a specific treatment area. However, additional isodose plans may be reimbursed when there is a need to change the method of treatment delivery, or there is a change in tumor volume. Other examples of when additional isodose plans may be necessary include but are not limited to:

• when the patient requires treatment with a combination of external beam radiation and brachytherapy.  In these instances, separate isodose calculations may be reported for the external beam therapy and the brachytherapy.
• near the end of treatment to accommodate any changes in the patient’s condition. 

Multiple points of calculation within an isodose plan should not be reported individually. This is considered a single service.

Special teletherapy port planning (code 77321) is performed when any special beam considerations are necessary. Some examples include the use of electrons in total skin irradiation, photons for hemibody irradiation, and proton or neutron beam therapy planning. The radiation oncologist must document his or her involvement in the planning, the selection of the special beam parameters, and the initiation of the treatment process. 

This service should only be reported once per day or per volume of interest. In addition, a special teletherapy port plan is an electron calculation. It should not be reported for the same treatment field with a basic radiation dosimetry calculation (code 77300) which is a photon calculation. The special teletherapy port plan, signed and dated by the radiation oncologist, must be documented in the patient’s clinical records and available for review upon request. 

Brachytherapy isodose plans (codes 77326, 77327, 77328)
Brachytherapy is a method of delivering ionizing radiation whose source is applied to the surface of the body or within the body a short distance from the area being treated. It is used to improve control of local disease, treat areas at high risk for recurrence of malignancy, preserve vital organ function, and minimize damage to surrounding normal tissue or organs. 

The isodose calculations determine the amount of radiation that will be absorbed by the tumor per implant or for the entire course of treatment for permanent implants. From this calculation, the treatment course can be modified as needed by increasing or decreasing the patient’s exposure to the isotope. 

One brachytherapy isodose plan is performed per course of treatment or per implantation when the position of the sources varies from one implant to another. 

For additional information on brachytherapy and related services, refer to “brachytherapy” under the “Miscellaneous Services.” 

Special dosimetry (code 77331) measures the radiation dose at a given point using special radiation monitoring and measuring devices such as thermoluminescent dosimeters, solid state diode probes, special dosimetry probes, other dosimetry probes, or film dosimetry. The results of these measurements aid in determining whether to accept or revise the current treatment plan. 

Special dosimetry is performed once per port when the physician determines that it is necessary to have a measurement of the amount of radiation a patient has actually received at a given point. It is not routinely performed each time the patient is treated. 

When special dosimetry is used, the typical frequency will be between one and six in total during a course of radiation therapy.

Treatment devices (design and construction) (codes 77332, 77333, 77334) are used when it is necessary to shield or protect normal, healthy critical structures (organs and/or tissue) from unnecessary irradiation. There are many different treatment devices, including, but not limited to: beam-shaping devices, custom-fabricated patient-immobilization devices, beam-modification devices, and special shielding devices. The type of device(s) used or constructed is determined by the radiation oncologist’s clinical evaluation of the patient’s anatomy and disease state. 

Documentation of the physician’s participation in determining the need for and level of complexity for any treatment devices designed and constructed must be documented in the patient’s clinical records. The radiation oncologist should write and sign an order for each custom device. The physician’s signature on the simulation work product and the isodose work product validates his or her participation in the design, fabrication and correct usage of the treatment devices. 

Charges for treatment devices should be reported at the onset of treatment. They may be replaced during treatment if additional or new devices are necessary. In special cases, medically necessary changes in beam geometry or port configuration may occur during a course of treatment. This may require the redesign and fabrication of new treatment devices. These unique clinical circumstances should be given individual consideration based on a review of the patient’s medical records. 

Pre-made, multiple-patient use, standard shaped blocks (for example, beam splitter blocks, two or four corner pelvis blocks, and midline cord blocks) are not considered custom blocks. Products used for patient comfort, such as pillows, pads, cushions, etc., are not considered treatment devices in this instance and are not eligible for payment. The use of passive restraints (for example, straps and sandbags, etc.) is not eligible for separate payment.

A course of radiation therapy may necessitate the design and construction of different devices, depending on the patient’s condition, treatment plan, and/or method of radiation treatment delivery. However, payment for an individual treatment device is limited to once for the entire course of treatment, regardless of the number of times that device is actually used. 

A continuing medical physics consultation (code 77336) represents the ongoing medical physics assessment provided to all patients receiving radiation therapy. The patient’s chart is reviewed to ensure that the radiation treatment administered conforms to the treatment parameters prescribed by the radiation oncologist. This assessment includes verification of accurate dose calculations, accurate data entry in the patient’s chart, proper patient positioning and beam orientation, patient radiation safety, and correct summation of dose at the conclusion of treatment. An examination of the patient setup may also be required to ensure the correct placement of any treatment devices or beam modifiers.  (Note: The use of a flow sheet for this type of documentation is not appropriate.) 

Code 77336 is considered a “weekly” code and should be reported once for each week (5 treatments) of therapy. The date of service reported for code 77336 should be the date of the last treatment for a particular “week” of therapy. At the end of a course of treatment, code 77336 is eligible regardless of the number of treatments a patient has received that week. 

A special medical radiation physics consultation (code 77370) may be necessary when a problem or unusual situation presents requiring a special evaluation, or if the patient is off treatment for any reason for a significant period of time. In these instances, the information acquired from this physics consultation would be used to design or modify the current treatment plan. Examples of situations that may require a special physics consultation include, but are not limited to: 

• 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;
• analysis of customized beam modification devices and special blocking procedures to protect critical organs and/or tissue during treatment;
• analysis of the effects of previous radiation therapy with assessment of cumulative radiation dose to critical organs or tissue. 

A special physics consultation is typically performed once per course of radiation therapy. The clinical indications warranting the special physics consultation must be documented in the patient’s medical records and available for review upon request. 

Therapeutic radiology port films (code 77417) are taken on the treatment machine using the treatment beam to ensure the therapy is delivered as prescribed by the simulation and dosimetry. Radiographs or port images produced by each treatment beam unit are compared with the simulator films or digitally reconstructed radiographs to verify that the treatment beams and fields planned at the time of simulation are synchronous. 

Any changes indicated by the port films must be incorporated into the treatment plan. Real-time or on-line portal imaging is considered the same as obtaining port films. This service is allowed as reported. 

B. Radiation therapy treatment delivery (codes 77401-77416)

The procedure codes for radiation treatment delivery (77401-77416) are technical component only services and recognize the various energy levels (in megavolts or MeV) administered to the patient as well as the area(s) treated. It is important to report the code for the actual procedure ordered and performed.  An area is an anatomically identifiable region, for example the neck, throat, bone, breast or prostate. An area may be treated using one or more ports. The right and left neck is considered one area, however brain and lung would be considered two areas. 

Radiation therapy treatment delivery codes 77402-77416 are eligible on a per treatment basis. Multiple treatments on the same day are eligible, provided there has been a distinct break in therapy services (for example, morning and afternoon treatment sessions). 

However, procedure code 77401 represents radiation treatment delivery using superficial and/or ortho voltage. This type of treatment is typically used for delivering radiation treatment to superficial skin lesions.  It is eligible once per day.

C. Clinical Treatment Management (codes 77427, 77431, 77432, 77499)

Clinical treatment management should only be used for external beam radiation therapy treatments.  Clinical treatment management should be reported in units of five treatments or fractions regardless of the actual time period in which the services are furnished. These treatments do not need to be furnished on consecutive days. There are four services typically included in treatment management: 

• review of port films,
• review of dosimetry, dose delivery and treatment parameters,
• review of patient setup, and
• medical evaluation and management of the patient (for example, assessing the patient’s response to treatment, coordination of care and treatment, and review of imaging and/or pathology studies). 

A weekly unit of treatment management is equal to five fractions, regardless of whether those fractions are on consecutive days. If, at the final billing of the treatment course there are three or four fractions beyond a multiple of five, those three or four fractions should be considered a week. However, three or four fractions are not eligible if there is no indication that the course of treatment has ended. Also, if there are one or two fractions beyond a multiple of five, the number will be rounded down.

Example:
18 fractions = 4 weekly services
 8 fractions = 2 weekly services
 6 fractions = 1 weekly service

Code 77431 is used when only one or two fractions are provided as an independent course of treatment.  This code should not be used to fill the last week of a longer course of treatment. 

NOTE:  When medical care and radiation therapy treatment management (codes 77427-77431) are reported by one doctor or his associate on the same day, only the highest paying service is reimbursed. 

Hyperfractionation is the delivery of radiation in smaller than usual doses, more than once per day. The technique usually requires delivery of two fractions daily, each fraction being a little more than half the dose given in a usual daily schedule. The standard weekly management codes should be used for these treatments, with the number of fractions divided by two to determine the number of daily treatments. The number of daily treatments should then be divided by five to determine the number of weekly treatments.

EXAMPLE:
10 fractions/2 = 5 days
 5 days/5 = 1 week

Hyperfractionation is typically utilized in treating the following conditions: 

• Lymphomas as well as head and neck tumors.
• Certain brain tumors in children particularly those in the brain stem.
• Rapidly growing tumors not responsive to single daily fractions.
• Malignant tumors of the genitourinary and respiratory systems as well as gynecologic malignant tumors and progressive tumors involving the breast. 

D. Miscellaneous Services

Brachytherapy (codes 77750, 77761, 77762, 77763, 77776, 77777, 77778, 77781, 77782, 77783, 77784, 77789, 77790, 77799) may be used to treat benign or malignant conditions. It can be performed as part of a treatment protocol involving external beam radiation therapy and other modalities such as surgery or chemotherapy, or it can be delivered independently as the sole method of treatment. 

The most common methods for delivering brachytherapy are:

• infusions or instillation (code 77750) where the radioactive source is either inserted into a body cavity or space, or ingested or infused into specific tissues;
• intracavitary source application (codes 77761, 77762, 77763)  where applicators or devices of various designs are placed within a body cavity (e.g., intravaginal, tandem and ovoids, nasal sinus or nasopharyngeal, intraesophageal, transanorectal, transbiliary, endobronchial) or any large interior organ in a body cavity, especially the abdomen;
• interstitial source application (codes 77776, 77777, 77778) where catheters, trocars, needles or other special applicators are inserted surgically or percutaneously into the interstitial tissue spaces (e.g., brain, eye, breast, chest wall, lung, pelvic structures, etc.);
• remote afterloading high intensity/high dose rate (HDR) brachytherapy (codes 77781, 77782, 77783, 77784) where a high-intensity radioactive source is inserted on the end of a cable into the applicator and moved through the applicator to a designated location for a specific length of time; or 
• surface application of a radioactive source (code 77789) where a mold or other applicator is placed directly on the skin or other external surface so that the radioactive source can be optimally located for effective treatment. 

In some cases, brachytherapy may be performed concomitantly with surgical resection, or in conjunction with surgical procedures such as endoscopy or angioplasty, when access to the site of the disease requires this intervention. As such, brachytherapy may require the professional expertise and services of other specialists in addition to the radiation oncologist. These specialists perform related-but-separate procedures before, during or after the brachytherapy procedure. In most cases, when different providers are involved in the brachytherapy treatment (e.g., a surgeon, radiation oncologist, and/or radiologist), each provider should only be reimbursed for the services he or she actually performs.    

Code 77790 (supervision, handling, and loading of radioelements) should only be reported with manual-loading low dose radiation brachytherapy. The service includes receipt, radioactivity assay and storage of the material. It also includes custom preparation of the radioactive sources for loading, such as any modifications of seeds in ribbons and pre-loading the permanent seeds into insertion devices. 

Code 77790 should not be reported with high-dose radiation brachytherapy (codes 77781, 77782, 77783, 77784). The codes for remote afterloading high intensity brachytherapy (77781-77784) include the supervision, handling and loading of the radioelement.

Intravascular Brachytherapy
For information on intravascular brachytherapy, refer to Medical Policy Bulletin R-10. 

Intensity Modulated Radiation Therapy
For information on coverage for IMRT, refer to Medical Policy Bulletin R-11. 

Intraoperative Radiation Therapy
For information on intraoperative radiation therapy, refer to Medical Policy Bulletin R-20.

Radiation therapy treatments for benign conditions
Radiation therapy used to treat the following nonmalignant conditions is considered to be of questionable current usefulness:  acne, bursitis, contact dermatitis, eczema, furunculosis, herpes zoster, keratosis, otitis media, pinguecula, plantar verrucae, psoriasis, pterygium (except strontium 90 application), sclerosis (post fracture), spurs, tendonitis, tineas, and verrucae vulgaris. In these instances, documentation must substantiate the medical necessity in each patient’s case. Services performed in conjunction with radiation therapy for these conditions are eligible only if the radiation therapy in question is eligible. 

Special treatment procedures (code 77470) represent the physician’s professional service required for special procedures such as hyperfractionation, total body irradiation, hemibody irradiation, oral, transvaginal or intracavitary cone use, brachytherapy, rectal endocavitary irradiation, hyperthermia, heavy particles (for example, protons/neutrons), and other time-consuming and/or complex treatment procedures. 

Code 77470 is eligible one or more times during a course of therapy in addition to weekly patient management.

NOTE:

This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records.

PRN References

04/1993, Radiation treatment delivery for superficial skin lesions
08/1993, Reporting radiation therapy services
08/2003, Changes in radiation therapy medical policy and reimbursement announced

Consortium Health Plans, Inc.

Radiation Oncology Coding Users’ Guide, 2001, published by the Joint Economics Committee of the American Society for Therapeutic Radiology and Oncology and the American College of Radiology

Mayo Clinic Health Letter, Vol. 21, No. 3, March 2003