Brachytherapy: CPT codes - 76000, 77336, 77334, 77290, 77300, 17999, 19296,31643, 55860 - Non-Intracoronary

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. Brachytherapy is accomplished by placing small encapsulated radioactive elements (aka, “seeds” or “sources”) directly in or near the tumor or treatment site. There are currently three basic clinical brachytherapy formats: interstitial applications, intracavitary applications (also called “intraluminal”) and surface applications (placed directly on the skin or other external target surface). 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 high- 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/or 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: the insertion of non-radioactive applicators or conduits that receive or transmit the radioactive material into the body and the loading of the radioactive material (the active or therapeutic agent) into the conduits or directly into tissue.

The typical requirements of brachytherapy may involve:

  • Treatment planning (CPT code 77263)

Brachytherapy (other than coronary, which is discussed in another policy) is routinely designated complex (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. If brachytherapy is used as an adjunct to external beam therapy, a single complex treatment planning code is used to encompass both modalities, unless provided by a different provider in a different place of service.

  • Dosimetry (CPT code 77300)

Brachytherapy requires certain calculations be made throughout the course of treatment. Each necessary basic dosimetry calculation may be submitted when performed for brachytherapy treatment.

  • Special treatment procedure (CPT code 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. Complex integration of these processes with brachytherapy may make a special treatment procedure code appropriate.

  • Simulation (CPT codes 77280–77295)

For brachytherapy, simulation may require the use of imaging examinations of the implanted sources or applicator(s) containing dummy (i.e., non-radioactive) sources. These films of the implanted sources are used to develop isodose curves and other dosimetry and may be billed separately, when appropriate. CPT code 77295 may be billed as part of the brachytherapy process when the needed parameters are included (i.e., three-dimensional (3D) volume reconstruction with dose volume histogram for target and normal tissues, etc.). Code 77295 precludes the use of codes 77326–77328 for the same treatment volume.

Brachytherapy requires an isodose plan. The plan determines the dose at each implanted source and throughout the treatment volume and doses to surrounding normal tissue.

  • Handling and loading of Radioelement (CPT code 77790)
Where brachytherapy techniques require the manual loading of an isotope (low-dose rate), the supervision, loading and handling of the isotope may be separately reported.
  • Source Application/Placement (CPT codes 77750, 77761–77763, 77776–77778, 77785, 77786, 77787 and 77789)
Selection and placement of afterloading applicators and the loading and unloading of radioactive sources may be performed by the radiation oncologist alone or in collaboration with another physician. Applicator placement:

    • The choice of applicators and the actual placement of the afterloading device may be performed by the radiation oncologist alone or in collaboration with another physician (e.g., gynecologist, urologist, pulmonologist).
    •  
  • Treatment devices (CPT codes 77332–77334)
Treatment devices may include the use of certain templates, molds or other apparatus that may be required for specific clinical circumstances. Premanufactured, commercially available devices are simple devices.

  • Medical Physics Services (CPT codes 77331, 77336 and 77370)

    • CPT code 77331 is special dosimetry (e.g., Thermoluminescent Dosimetry [TLD], microdosimetry) when prescribed by the treating 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.
    • CPT code 77336 is referred to as a “weekly code” (from the common five-dose fractions per week). However, for radiation therapy treatment that may not be administered in five weekly fractions (such as brachytherapy), code 77336 may be reported once for each completed five fractions and for a completed final group of three, four or five fractions. For a course of radiation therapy consisting of only one or two fractions, code 77336 may be reported once.
    • CPT code 77370 may be justified for the complex interrelationships of electron and photon ports and complex dosimetric consideration in brachytherapy, including high-dose rate remote after-loader applications, intravascular brachytherapy treatments and the interstitial radioactive seed implantation.
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. Low-Dose Rate (LDR) and High-Dose Rate (HDR) brachytherapy are two delivery systems for brachytherapy which 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. This is done to treat a primary or metastatic neoplasm while sparing sensitive, adjacent normal tissues. LDR and HDR procedures may be given with the intent to cure, palliate or obtain local control (either cure or palliation). Both may be given in conjunction with a course of External Beam Radiation Therapy (EBRT), or as a single modality.
  • 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 inpatient procedure that delivers radiation as the isotope decays.
  • 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.
  • Pulsed-Dose Rate (PDR) Brachytherapy uses sources of intermediate strength and delivers a series of doses on a one- to two-hour schedule over a one- to two-day treatment period. It is also a form of remote after-loading.
Limitations:
  • Although radiographs may be used in brachytherapy simulation, these images are not to be reported as port films.
  • 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.)
  • Products used for the patient’s comfort may not be charged as treatment devices (e.g., pillows, pad or cushions).
  • Only a physician authorized as a user by the Nuclear Regulatory Commission or an Agreement State for brachytherapy should work with radioactive materials.
CPT Evaluation and Management (E/M) codes are available for use by the physician when seeing new patients in the office, the freestanding clinic or the hospital setting.

The physician’s professional component for the brachytherapy procedure includes any necessary hospital admission and hospital care during the time the patient is undergoing the brachytherapy procedure. Admission, subsequent hospital care and discharge day summary are included in the global fee for brachytherapy procedures.

Breast Brachytherapy by Balloon Catheter(s)
Payment for the insertion of the device necessary for placement of breast brachytherapy radiation source beads will be allowed, although the literature remains equivocal on the efficacy of this mode of brachytherapy. Nevertheless, until definitive literature is available, payment for this service will continue as long as the following criteria, based on a White Paper prepared by breast surgeons in 2003, are followed and clearly documented in the patient’s medical record. If these criteria are not met, the service will be denied as not medically reasonable and necessary.

All three requirements must be met:
  • The tumor being treated is less than 3 cm or 2 cm if it is in stage T1.
  • There is no cancer at the surgical margins.
  • There are three or fewer lymph nodes containing cancer.
The afterloading balloon catheter may be placed at the same operative session as the performance of the breast surgery (CPT code 19297) or at a subsequent session (CPT code 19296) when the following criteria are met:
  • The prior site of the tumor is a fluid-filled seroma (cavity).
  • The seroma is not located directly under the skin.
  • The seroma is not large or irregular in shape.
An ultrasound may be performed to evaluate the presence, size and location of the fluid cavity, though this is a part of the procedure and not billed separately.

CPT code 19298 is used for placement of multiple tube or button-type catheters, whether done at the same session or subsequently, and these same above criteria must be met and documented in the record.

Compliance with the provisions in this policy is subject to monitoring by postpayment data analysis and subsequent medical review.
Notice: This LCD imposes diagnosis limitations that support diagnosis to procedure code automated denials. However, services performed for any given diagnosis must meet all of the indications and limitations stated in this policy, the general requirements for medical necessity as stated in CMS payment policy manuals, any and all existing CMS national coverage determinations, and all Medicare payment rules.
As published in CMS IOM 100-08, Section 13.5.1, to be covered under Medicare, a service shall be reasonable and necessary. When appropriate, contractors shall describe the circumstances under which the proposed LCD for the service is considered reasonable and necessary under Section 1862(a)(1)(A). Contractors shall consider a service to be reasonable and necessary if the contractor determines that the service is:
  • Safe and effective.
  • Not experimental or investigational (exception: routine costs of qualifying clinical trial services with dates of service on or after September 19, 2000, which meet the requirements of the clinical trials NCD are considered reasonable and necessary).
  • Appropriate, including the duration and frequency that is considered appropriate for the service, in terms of whether it is:
    • Furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition or to improve the function of a malformed body member.
    • Furnished in a setting appropriate to the patient’s medical needs and condition.
    • Ordered and furnished by qualified personnel.
    • One that meets, but does not exceed, the patient’s medical need.
    • At least as beneficial as an existing and available medically appropriate alternative.
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.
12X, 13X, 85X
Revenue 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.
Note: TrailBlazer has identified the Bill Type and Revenue Codes applicable for use with the CPT/HCPCS codes included in this LCD. Providers are reminded that not all CPT/HCPCS codes listed can be billed with all Bill Type and/or Revenue Codes listed. CPT/HCPCS codes are required to be billed with specific Bill Type and Revenue Codes. Providers are encouraged to refer to the CMS Internet-Only Manual (IOM) Pub. 100-04, Claims Processing Manual, for further guidance.
0333
CPT/HCPCS Codes
Note:
Providers are reminded to refer to the long descriptors of the CPT codes in their CPT book. The American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) require the use of short CPT descriptors in policies published on the Web.
17999©
Skin tissue procedure
19296©
Place po breast cath for rad
19297©
Place breast cath for rad
19298©
Place breast rad tube/caths
31643©
Diag bronchoscope/catheter
43241©
Upper gi endoscopy with tube
55860©
Surgical exposure prostate
57155©
Insert uteri tandems/ovoids
57156©
Ins vag brachytx device
58346©
Insert heyman uteri capsule
58999©
Genital surgery procedure
76000©
Fluoroscope examination
76001©
Fluoroscope exam extensive
76873©
Echograp trans r pros study
76965©
Echo guidance radiotherapy
77261©
Radiation therapy planning (Non-OPPS only)
77262©
Radiation therapy planning (Non-OPPS only)
77263©
Radiation therapy planning (Non-OPPS only)
77280©
Set radiation therapy field
77285©
Set radiation therapy field
77290©
Set radiation therapy field
77295©
Set radiation therapy field
77300©
Radiation therapy dose plan
77326©
Brachytx isodose calc simp
77327©
Brachytx isodose calc interm
77328©
Brachytx isodose plan compl
77332©
Radiation treatment aid(s)
77333©
Radiation treatment aid(s)
77334©
Radiation treatment aid(s)
77336©
Radiation physics consult
77370©
Radiation physics consult
77470©
Special radiation treatment
77750©
Infuse radioactive materials
77761©
Apply intrcav radiat simple
77762©
Apply intrcav radiat interm
77763©
Apply intrcav radiat compl
77776©
Apply interstit radiat simpl
77777©
Apply interstit radiat inter
77778©
Apply interstit radiat compl
77785©
hdr brachytx 1 channel
77786©
hdr brachytx 2-12 channel
77787©
hdr brachytx over 12 chan
77789©
Apply surface radiation
77790©
Radiation handling
77799©
Radium/radioisotope therapy
Q3001©
Radioelements for brachytherapy, any type, each (Non-OPPS only)






Billing for Brachytherapy Sources - General

Brachytherapy sources (e.g., brachytherapy devices or seeds, solutions) are paid separately from the services to administer and deliver brachytherapy in the OPPS, per section 1833(t)(2)(H) of the Act, reflecting the number, isotope, and radioactive intensity of devices furnished, as well as stranded versus non-stranded configurations of sources. Therefore, providers must bill for brachytherapy sources in addition to the brachytherapy services with which the sources are applied, in order to receive payment for the sources. The separately payable sources are found in Addendum B of the most recent OPPS annual update published on the CMS web site. New sources meeting the OPPS definition of a brachytherapy source may be added for payment beginning any quarter, and the new source codes and descriptors are announced in recurring update notifications.

Each unit of a billable source is identified by the unit measurement in the respective source’s long descriptor. Seed-like sources are generally billed and paid “per source” based on the number of units of the source HCPCS code reported, including the billing of the number of sources within a stranded configuration of sources. Providers therefore must bill the number of units of a source used with the brachytherapy service rendered.

Definition of Brachytherapy Source for Separate Payment


Brachytherapy sources eligible for separate billing and payment must be radioactive sources, meaning that the source contains a radioactive isotope. Separate brachytherapy source payments reflect the number, isotope, and radioactive intensity of sources furnished to patients, as well as stranded and non-stranded configurations.



 Billing of Brachytherapy Sources Ordered for a Specific Patient


A hospital may report and charge Medicare and the Medicare beneficiary for all brachytherapy sources that are ordered by the physician for a specific patient, acquired by the hospital, and used in the care of the patient. Specifically, brachytherapy sources prescribed by the physician in accordance with high quality clinical care, acquired by the hospital, and actually implanted in the patient may be reported and charged. In the case where most, but not all, prescribed sources are implanted in the patient, CMS will consider the relatively few brachytherapy sources that were ordered but not implanted due to specific clinical considerations to be used in the care of the patient and billable to Medicare under the following circumstances. The hospital may charge for all sources if they were specifically acquired by the hospital for the particular patient according to a physician’s prescription for the sources that was consistent with standard clinical practice and high quality brachytherapy treatment, in order to ensure that the clinically appropriate number of sources was available for the implantation procedure, and they were not implanted in any other patient. Those sources that were not implanted must have been disposed of in accordance with all appropriate requirements for their handling. In general, the number of sources used in the care of the patient but not implanted would not be expected to constitute more than a small fraction of the sources actually implanted in the patient. Under these circumstances, the beneficiary is liable for the copayment for all the sources billed to Medicare.


 Billing for Brachytherapy Source Supervision, Handling and Loading Costs


Providers should report charges related to supervision, handling, and loading of radiation sources, including brachytherapy sources, in one of two ways:

1. Report the charge separately using CPT code 77790 (Supervision, handling, loading of radiation source), in addition to reporting the associated HCPCS procedure code(s) for application of the radiation source;

2. Include the supervision, handling, and/or loading charges as part of the charge reported with the HCPCS procedure code(s) for application of the radiation source.

Do not bill a separate charge for brachytherapy source storage costs. These costs are treated as part of the department's overhead costs.


Payment for New Brachytherapy Sources


Not otherwise specified (NOS) brachytherapy source codes are available for payment of new brachytherapy sources for which source codes have not yet been established: C2698 (Brachytherapy source, stranded, not otherwise specified, per source), and C2699 (Brachytherapy source, non-stranded, not otherwise specified, per source). The payment rates for these NOS codes are based on a rate equal to the lowest stranded or non-stranded payment rate for such sources, respectively, on a per source basis (as opposed, for example, to per mCi). Once CMS establishes a new HCPCS code for a new source, the new code will be assigned to its own APC, with the payment rate set based on consideration of external data and other relevant information, until claims data are available for the standard OPPS rate making methodology.

ICD-9-CM Codes That Support Medical Necessity
The CPT/HCPCS codes included in this LCD will be subjected to “procedure to diagnosis” editing. The following lists include only those diagnoses for which the identified CPT/HCPCS procedures are covered. If a covered diagnosis is not on the claim, the edit will automatically deny the service as not medically necessary.
Medicare is establishing the following limited coverage for CPT/HCPCS codes 77326, 77327, 77328, 77750, 77761, 77762, 77763, 77776, 77777, 77778, 77785, 77786, 77787, 77789, 77790 and Q3001:
Covered for:
140.0–140.1
Malignant neoplasm of lip
140.3–140.6
Malignant neoplasm of lip
140.8–140.9
Malignant neoplasm of lip
141.0–141.6
Malignant neoplasm of tongue
141.8–141.9
Malignant neoplasm of tongue
142.0–142.2
Malignant neoplasm of major salivary glands
142.8–142.9
Malignant neoplasm of major salivary glands
143.0–143.1
Malignant neoplasm of gum
143.8–143.9
Malignant neoplasm of gum
144.0–144.1
Malignant neoplasm of floor of mouth
144.8–144.9
Malignant neoplasm of floor of mouth
145.0–145.6
Malignant neoplasm of other and unspecified parts of mouth
145.8–145.9
Malignant neoplasm of other and unspecified parts of mouth
146.0–146.9
Malignant neoplasm of oropharynx
147.0–147.3
Malignant neoplasm of nasopharynx
147.8–147.9
Malignant neoplasm of nasopharynx
148.0–148.3
Malignant neoplasm of hypopharynx
148.8–148.9
Malignant neoplasm of hypopharynx
149.0–149.1
Malignant neoplasm of other and ill-defined sites within lip, oral cavity and pharynx
149.8–149.9
Malignant neoplasm of other and ill-defined sites within lip, oral cavity and pharynx
150.0–150.5
Malignant neoplasm of esophagus
150.8–150.9
Malignant neoplasm of esophagus
151.0–151.6
Malignant neoplasm of stomach
151.8–151.9
Malignant neoplasm of stomach
152.0–152.3
Malignant neoplasm of small intestine, including duodenum
152.8–152.9
Malignant neoplasm of small intestine, including duodenum
153.0–153.9
Malignant neoplasm of hepatic flexure
154.0–154.3
Malignant neoplasm of rectum, rectosigmoid junction and anus
154.8
Malignant neoplasm of other sites of rectum rectosigmoid junction and anus
155.0–155.2
Malignant neoplasm of liver and intrahepatic bile ducts
156.0–156.2
Malignant neoplasm of gallbladder and extrahepatic bile ducts
156.8–156.9
Malignant neoplasm of gallbladder and extrahepatic bile ducts
157.0–157.4
Malignant neoplasm of pancreas
157.8–157.9
Malignant neoplasm of pancreas
158.0
Malignant neoplasm of retroperitoneum
158.8–158.9
Malignant neoplasm of retroperitoneum and peritoneum
159.0–159.1
Malignant neoplasm of other and ill-defined sites within digestive organs and peritoneum
159.8–159.9
Malignant neoplasm of other and ill-defined sites within digestive organs and peritoneum
160.0–160.5
Malignant neoplasm of nasal cavities, middle ear and accessory sinuses
160.8–160.9
Malignant neoplasm of nasal cavities, middle ear and accessory sinuses
161.0–161.3
Malignant neoplasm of larynx
161.8–161.9
Malignant neoplasm of larynx
162.0
Malignant neoplasm of trachea
162.2–162.5
Malignant neoplasm of trachea, bronchus and lung
162.8–162.9
Malignant neoplasm of trachea, bronchus and lung
163.0–163.1
Malignant neoplasm of pleura
163.8–163.9
Malignant neoplasm of pleura
164.0–164.3
Malignant neoplasm of thymus, heart and mediastinum
164.8–164.9
Malignant neoplasm of thymus, heart and mediastinum
165.0
Malignant neoplasm of upper respiratory tract part unspecified
165.8–165.9
Malignant neoplasm of other and ill-defined sites within the respiratory system and intrathoracic organs
170.0–170.9
Malignant neoplasm of bone and articular cartilage
171.0
Malignant neoplasm of connective and other soft tissue of head face and neck
171.2–171.9
Malignant neoplasm of connective and other soft tissue
172.0–172.9
Malignant melanoma of skin
173.0–173.9
Other malignant neoplasm of skin
174.0–174.6
Malignant neoplasm of female breast
174.8–174.9
Malignant neoplasm of female breast
175.0
Malignant neoplasm of nipple and areola of male breast
175.9
Malignant neoplasm of other and unspecified sites of male breast
176.0–176.5
Kaposi’s sarcoma
176.8–176.9
Kaposi’s sarcoma
179
Malignant neoplasm of uterus-part uns
180.0–180.1
Malignant neoplasm of cervix uteri
180.8–180.9
Malignant neoplasm of cervix uteri
181
Malignant neoplasm of placenta
182.0–182.1
Malignant neoplasm of body of uterus
182.8
Malignant neoplasm of other specified sites of body of uterus
183.0–183.5
Malignant neoplasm of ovary and other uterine adnexa
183.8–183.9
Malignant neoplasm of ovary and other uterine adnexa
184.0–184.4
Malignant neoplasm of other and unspecified female genital organs
184.8–184.9
Malignant neoplasm of other and unspecified female genital organs
185
Malignant neoplasm of prostate
186.0
Malignant neoplasm of undescended testis
186.9
Malignant neoplasm of other and unspecified testis
187.1–187.9
Malignant neoplasm of penis and other male genital organs
188.0–188.9
Malignant neoplasm of bladder
189.0–189.4
Malignant neoplasm of kidney and other and unspecified urinary organs
189.8–189.9
Malignant neoplasm of kidney and other and unspecified urinary organs
190.0–190.9
Malignant neoplasm of eye
191.0–191.9
Malignant neoplasm of brain
192.0–192.3
Malignant neoplasm of other and unspecified parts of nervous system
192.8–192.9
Malignant neoplasm of other and unspecified parts of nervous system
193
Malignant neoplasm of thyroid gland
194.0–194.1
Malignant neoplasm of other endocrine glands and related structures
194.3–194.6
Malignant neoplasm of other endocrine glands and related structures
194.8–194.9
Malignant neoplasm of other endocrine glands and related structures
195.0–195.5
Malignant neoplasm of other and ill-defined sites
195.8
Malignant neoplasm of other specified sites
196.0–196.3
Secondary and unspecified malignant neoplasm of lymph nodes
196.5–196.6
Secondary and unspecified malignant neoplasm of lymph nodes
196.8–196.9
Secondary and unspecified malignant neoplasm of lymph nodes
197.0–197.8
Secondary malignant neoplasm of respiratory and digestive systems
198.0–198.7
Secondary malignant neoplasm of other specified sites
198.81–198.82
Other specified sites
198.89
Other specified sites
199.0–199.2
Malignant neoplasm within specification of site
200.00–200.08
Reticulosarcoma
200.10–200.18
Lymphosarcoma
200.20–200.28
Burkitt’s tumor or lymphoma
200.30–200.38
Marginal zone lymphoma
200.40–200.48
Mantle cell lymphoma
200.50–200.58
Primary central nervous system lymphoma
200.60–200.68
Anaplastic large cell lymphoma
200.70–200.78
Large cell lymphoma
200.80–200.88
Other named variants
201.00–201.08
Hodgkin’s paragranuloma
201.10–201.18
Hodgkin’s granuloma
201.20–201.28
Hodgkin’s sarcoma
201.40–201.48
Lymphocytic-histiocytic predominance
201.50–201.58
Nodular sclerosis
201.60–201.68
Mixed cellularity
201.70–201.78
Lymphocytic depletion
201.90–201.98
Hodgkin’s disease unspecified
202.00–202.08
Nodular lymphoma
202.10–202.18
Mycosis fungoides
202.20–202.28
Sezary’s disease
202.30–202.38
Malignant histiocytosis
202.40–202.48
Leukemic reticuloendotheliosis
202.50–202.58
Letterer-siwe disease
202.60–202.68
Malignant mast cell tumors
202.80–202.88
Other lymphomas
202.90–202.98
Other and unspecified malignant neoplasms of lymphoid and histiocytic tissue
203.00–203.02
Multiple myeloma
203.10–203.12
Plasma cell leukemia
203.80–203.82
Other immunoproliferative neoplasms
204.00–204.02
Acute (Lymphoid leukemia)
204.10–204.12
Chronic (Lymphoid leukemia)
204.20–204.22
Subacute (Lymphoid leukemia)
204.80–204.82
Other lymphoid leukemia
204.90–204.92
Unspecified lymphoid leukemia
205.00–205.02
Acute (Myeloid leukemia)
205.10–205.12
Chronic (Myeloid leukemia)
205.20–205.22
Subacute
205.30–205.32
Myeloid sarcoma
205.80–205.82
Other myeloid leukemia
205.90–205.92
Unspecified myeloid leukemia
206.00–206.02
Acute (Monocytic leukemia)
206.10–206.12
Chronic (Monocytic leukemia)
206.20–206.22
Subacute (Monocytic leukemia)
206.80–206.82
Other monocytic leukemia
206.90–206.92
Unspecified monocytic leukemia
207.00–207.02
Acute erythremia and erythroleukemia
207.10–207.12
Chronic erythremia
207.20–207.22
Megakaryocytic leukemia
207.80–207.82
Other specified leukemia
208.00–208.02
Acute (Leukemia of unspecified cell type)
208.10–208.12
Chronic (Leukemia of unspecified cell type)
208.20208.22
Subacute (Leukemia of unspecified cell type)
208.80–208.82
Other leukemia of unspecified cell type
208.90–208.92
Unspecified leukemia
233.0
Carcinoma in situ of breast
235.0–235.9
Neoplasm of uncertain behavior of digestive and respiratory systems
236.0–236.7
Neoplasm of uncertain behavior of genitourinary organs
236.90–236.99
Other and unspecified urinary organs
237.0–237.6
Neoplasm of uncertain behavior of endocrine glands and nervous system
237.70–237.73
Neurofibromatosis
237.79
Other neurofibromatosis
237.9
Other and unspecified parts of nervous system
238.0–238.6
Neoplasm of uncertain behavior of other and unspecified sites and tissues
238.71–238.77
Neoplasm of other lymphatic and hematopoietic tissues
238.79
Neoplasm of other lymphatic and hematopoietic tissues
238.8–238.9
Neoplasm of uncertain behavior of other and unspecified sites and tissues
372.40–372.45
Pterygium
Note: Limited coverage is not being established for the other services referenced in the LCD at this time.
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.


Documentation Requirements
  • Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.
  • 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.
  • The treatment goal must be documented (curative, palliative or tumor control) in the medical record.
  • The record must contain documentation of the patient’s informed consent to treatment.
  • A written, signed and dated prescription or treatment plan designed by the radiation oncologist must be on file. The prescription must include all the following information: designation of the treatment site, the isotope and the number of source positions, and the planned dose to each point.
  • 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 must be documented with a procedural note.

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