CPT - 77261, 77301, 77280 - 77295, 77300- Intensity Modulated Radiation Therapy (IMRT)


Intensity-Modulated Radiation Therapy (IMRT) is a computer-based method of planning for, and delivery of, generally narrow, patient-specific, spatially and often temporally modulated beams of radiation to solid tumors within a patient. IMRT planning and delivery uses an approach for obtaining the highly conformal dose distributions needed to irradiate complex targets positioned near, or invaginated by, sensitive normal tissues, thus improving the therapeutic ratios. IMRT delivers a more precise radiation dose to the tumor while sparing the surrounding normal tissues by using non-uniform radiation beam intensities that are determined by various computer-based optimization techniques.
The computer-based optimization process is referred to as “inverse planning.” Inverse planning develops a dose distribution based on the input of specific dose constraints for the Planned Treatment Volume (PTV) and nearby clinical structures and is the beginning of the IMRT treatment planning process. The Gross Tumor Volume (GTV), the PTV and surrounding normal tissues must be identified by a contouring procedure and the optimization must sample the dose with a grid spacing of 1 cm or less.
IMRT uses non-uniform and customized fluence distributions in treatment delivery. Delivery of IMRT requires either the use of a Multi-Leaf Collimator (MLC) with leaves that project to a nominal 1 cm or less at the treatment unit isocenter or the use of compensator-based beam modulation treatment using three or more high-resolution compensator convergent beam modulated fields. An MLC may use a dynamic (DMLC) or segmented mode (SMLC) to create the three-dimensional, intensity-modulated dose distribution. The average segments (or “steps”) per gantry position required to meet IMRT delivery is five. The exact delivery method is not restricted as long as the particular technique chosen has the ability to model the highly modulated intensity patterns that result from the planning process described above (e.g., solid modulators or compensators may be an alternative to MLC).
The use of an MLC just to produce simple one-dimensional ramp intensity distributions is excluded because the inverse planning process is not necessary to produce this simple intensity variation.
The use of an MLC does not, in itself, constitute or define IMRT (for example, it is possible to use an MLC for simple, three-dimensional (3-D) conformal therapy).
Note also, traditional “field-in-field technique,” which is neither MLC nor compensator-based, is not considered IMRT but rather external beam therapy.
IMRT delivery imposes a more stringent requirement than conventional radiation therapy in terms of accounting for patient position and organ motion. Methods that account for organ motion include but are not limited to:
  • Use of published studies on organ movement when developing the PTV.
  • Image-guided adaptive radiotherapy (e.g., ultrasound-guided or portal-image-guided setup with implanted fiducial markers).
  • Respiratory gating of diaphragm movement for thoracic and upper abdominal sites.
Indications of Coverage
The decision process for using IMRT requires an understanding of accepted practices that take into account the risks and benefits of such therapy compared to conventional treatment techniques. While IMRT technology may empirically offer advances over conventional or 3-D conformal radiation, a comprehensive understanding of all consequences is required before applying this technology.
IMRT is not a replacement therapy for conventional and 3-D conformal radiation therapy methods. IMRT is considered reasonable and necessary in instances where sparing the surrounding normal tissue is essential and the patient has at least one of the following conditions met:
  • Important dose limiting structures adjacent to, but outside the PTV, are sufficiently close and require IMRT to assure safety and morbidity reduction.
  • An immediately adjacent volume has been irradiated and abutting portals must be established with high precision.
  • GTV margins are concave or convex and in close proximity to critical structures that must be protected to avoid unacceptable morbidity.
  • Only IMRT techniques would decrease the probability of grade 2 or grade 3 radiation toxicity as compared to conventional radiation in greater than 15 percent of radiated similar cases.
IMRT is an evolving technology and, as such, this IMRT LCD will be reviewed and updated as often as necessary. Currently, IMRT is indicated for primary brain tumors, brain metastasis, prostate cancer, lung cancer (with special provision for organ motion), pancreas cancer and other upper abdominal sites (with special provision for organ motion), spinal cord tumors, head and neck cancer, adrenal tumors, pituitary tumors, and situations in which extremely high precision is required. Indications will include some left breast tumors due to risk to immediately adjacent cardiac and pericardial structures, though it would only rarely if ever be medically necessary for tumors of the right breast.
IMRT may be necessary in some gynecologic tumors where its high precision is especially necessary to avoid immediately adjacent structures (such as bowel) or where there is a special need to avoid marrow. It may also be necessary in some lymphomas, malignant lymph nodes or sarcomas where anatomic location gives rise to a need for special care to avoid adjacent structures. The clinical record must clearly demonstrate medical necessity for these services.
Patient-Specific IMRT Treatment Verification
The accepted methodology to perform the computer plan distribution verification aspect of the treatment planning process is to deliver the plan to an extended phantom that contains 2-D film in planes that correspond to planes in the IMRT plan that can be compared. Since there are literally thousands of beamlets used in delivering IMRT dose patterns, delivering these plans to such a phantom will indicate any deviations from the physician’s (radiation oncologist) prescription and corrective action can be taken before the patient is treated.
Generally, film phantoms can be calibrated such that film density corresponds to dose on the 2-D film patterns when processed, so that a one-to-one comparison with the appropriate slice on the IMRT dose plan can be obtained. If not, ion chamber apertures can be built into the phantoms to make absolute dose measurements that can be compared to the appropriate points on the dose plan. These point dose measurements, however, are not a substitute for the 2-D planar comparisons mentioned above.
Since this complex measurement system tests many of the parameters associated with the delivery of IMRT (multi-leaf collimator operation, gantry angle position, couch collision potential, etc.), it represents the “gold standard” in IMRT plan/delivery verification. Surrogates for the complete set of measurements with film phantom/ion chamber methods have been proposed. For those methods utilizing “step and shoot” or dynamic MLC, intensity map measurement in 2-D have been proposed using film, electronic portal imaging devices or electronic 2-D measuring tools. The plan intensity maps may be obtained in similar planes and compared to these measurements. If they align properly, the physician’s prescription is assumed to be verified by this process. These measurements are made for each radiation field and appear to be an appropriate surrogate for the previously mentioned film phantom measurements. The time and intensity for this type of procedure closely approximates that of the film phantom technique and is acceptable.
Other methods are currently not acceptable surrogates for these measurements. Computer-calculated machine settings (MU Calc, for example) for the radiation fields planned and used for IMRT do not test many of the parameters used in IMRT treatment delivery. This method consumes much less time and effort to be construed as IMRT treatment verification and, hence, does not qualify, by itself, as an acceptable surrogate to IMRT film phantom measurements or the fluence mapping devices described earlier. It does not, for example, test the MLC performance during a treatment delivery. Updated information from ASTRO/ACR and others on alternative IMRT verification methods will be reviewed as they become available. Until such time, other methods remain not acceptable.
Use of Clinical Treatment Planning in IMRT (CPT Codes 77261–77263) Prior to the Specific IMRT Treatment Plan (77301)
Clinical treatment planning includes interpretation of special testing, tumor localization, treatment volume determinations, treatment time/dosage determinations, choice of treatment modality(ies), selection of appropriate treatment devices and other procedures such as concurrent or sequential chemotherapy or surgery. A separate charge for clinical treatment planning may be appropriately claimed at the appropriate level of service (77261, 77262 or 77263) when based on separately documented work itemizing the specific services provided. Review of records, pathology reports and/or imaging studies are typically part of the basis for claiming either a higher-level E/M service preceding treatment planning, or as a component of this code, but this same work should not be counted as a basis for both services.
Use of Simulation-Aided Field Setting in IMRT (CPT Codes 77280–77295)
Simulation-aided field setting complex (77290) during a course of IMRT is appropriate for the initial setup of the patient where an immobilization device may be constructed, isocenter(s) and volume of interest are determined, and CT or other imaging is obtained for subsequent reconstruction of target(s) and critical structure(s). CT and other imaging are separately coded (e.g., 76370) when necessary and performed. Also, a simple simulation (77280) may be appropriately provided and claimed once during a course of IMRT, either as a separate service or at the time of the first fraction. The record must document the simulation is for the purpose of field verification and occurs on a separate day from and after the code 77290 service.
Use of Intensity Modulated Radiotherapy Plan (CPT Code 77301), Including Dose Volume Histograms for Target and Critical Structure Partial Tolerance Specification
Intensity-modulated radiotherapy plan (77301) is a separate and distinct step in the process of care whose product is the computerized plan developed by the physician, medical physicist and dosimetrist, and is required for the delivery of IMRT. Note that all exclusions that apply to 77295 apply to 77301.
Use of Basic Radiation Dosimetry Calculation, Central Axis Depth Dose Calculation, TDF, NSD, Gap Calculation, Off-Axis Factor, Tissue Inhomogeneity Factors, Calculation of Non-Ionizing Radiation Surface and Depth Dose, As Required During Course of Treatment, Only When Prescribed by the Treating Physician (CPT Code 77300) in IMRT
The IMRT plan (CPT 77301) produces Monitor Units (MUs) for each gantry angle. A separate claim for basic dosimetry (77300) is appropriate only when there is a separate and distinct service, prescribed by the treating physician, over and above that which is a part of the IMRT plan. Code 77300 is appropriate to describe a necessary, independent calculation(s) performed outside the parameters of, and generally on a different date of service than, the IMRT plan (77301). It is not appropriate to automatically report this service for the computerized IMRT plan or for the films, phantoms or equivalent performed as a part of the code 77301 service or as may be a part of a separately performed and billed code 77370 service (see below).
Use of Teletherapy Isodose Plan in IMRT (CPT Codes 77305–77321)
A claim for a separate teletherapy isodose plan during a course of IMRT is appropriate only when the claim applies to another modality (e.g., an accompanying “boost” with external beam).
Use of Brachytherapy Isodose Plan in IMRT (CPT Codes 77326–77328)
A claim for a separate brachytherapy isodose plan during a course of IMRT is appropriate only when the claim applies to a separate, accompanying brachytherapy modality.
Use of Special Dosimetry in IMRT (CPT Code 77331)
Dosimetry of the hybrid plan is part of the work and practice expense of code 77301. Therefore, a claim for special dosimetry during a course of IMRT is appropriate only when the need for and use of the special dosimetry are carefully documented and occur at a time other than that necessary as a part of IMRT planning (77301) (e.g., a special check on a pacemaker site when into a course of therapy). Special dosimetry could also be appropriate when it applies to another modality (e.g., an accompanying “boost” with external beam).
Use of Treatment Devices (e.g., “Blocks”) in IMRT (CPT Codes 77332–77334)
Medicare would not expect to see providers billing frequently for the design and construction of devices that are separate and distinct from the “device” derived from the computerized IMRT plan. The Correct Coding Initiative (CCI) bundles the device codes 77332–77334 into 77301. In cases where these separate devices are billed, the medical record must clearly demonstrate the medical necessity and rationale for the service.
Use of Continuing Medical Physics Consultation in IMRT (Weekly Physics QA: Code 77336)
Continuing medical physics is appropriate for the weekly continuing medical physics process and reports the work and oversight of the medical physicist in the care of the IMRT patient. It is not appropriately reported for work associated with the creation of the IMRT plan.
Use of Special Medical Radiation Physics Consultation in IMRT (CPT Code 77370)
A claim for special medical radiation physics consultation during a course of IMRT is appropriate only where the need for and use of the consultation are carefully documented and occur at a time other than that necessary as a part of IMRT planning (e.g., a special physics assessment requested when already into a course of therapy). A medical physics consultation could also be appropriate where it applies to another modality (e.g., an accompanying “boost“with external beam).
Use of Other Radiation Treatment Delivery on the Same Day as IMRT Treatment Delivery (CPT Codes 77418, 0073T)
Radiation treatment delivery codes 77401–77416, 77422–77423 and 0082T may not be used on the same date of service as IMRT treatment delivery (CPT code 0073T or 77418). These other delivery codes may be used prior to or subsequent to an IMRT treatment course for treatment with a different modality.
Radiation Treatment Management (CPT Code 77427)
Radiation treatment management (77427) is reported by the physician for the weekly (defined as five-fraction) management of patients receiving radiation therapy, including IMRT.
Use of “Special Treatment Procedure” in IMRT (CPT Code 77470)
A claim for “special treatment procedure” (e.g., total body irradiation, hemibody radiation, per oral, endocavitary or intraoperative cone irradiation) would not be appropriate for services that are a necessary part of IMRT planning, but might rarely be appropriate during a course of IMRT when the respective treatment is being delivered as a separate therapy. Providers are cautioned that the use of this code implies a special treatment procedure with moderate physician work and very considerable practice expense (such as in Total Body Irradiation (TBI)). This service is not to be claimed for much less significant “special procedures” that would more appropriately use code 77499 or are a regular variant of IMRT or regular combination with IMRT.
Limitations of Coverage
IMRT is not considered reasonable and necessary when at least one of the criteria listed in the “Indications and Limitations of Coverage and/or Medical Necessity” section or one of the diagnoses listed in the “ICD-9-CM Codes That Support Medical Necessity” section of this LCD are not present.
Compliance with the provisions in this LCD is subject to monitoring by post payment 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 the 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.
0073T©
Delivery, comp imrt
77301©
Radiotherapy dose plan, imrt
77338©
Design mlc device for imrt
77418©
Radiation tx delivery, imrt
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 0073T, 77301, 77338 and 77418:
Covered for:
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
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
143.1
Lower gum
143.8
Other sites of gum
143.9
Gum, unspecified
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 the lip, oral cavity and pharynx
149.8–149.9
Malignant neoplasm of other and ill-defined sites within the lip, oral cavity and pharynx
150.0–150.5
Malignant neoplasm esophagus
150.8–150.9
Malignant neoplasm esophagus
153.0–153.9
Malignant neoplasm of colon
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
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, bronchus and lung
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
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
174.0–174.6*
Malignant neoplasm of female breast
174.8–174.9*
Malignant neoplasm of female breast
175.0*
Malignant neoplasm of male breast
175.9*
Malignant neoplasm of other and unspecified sites of male breast
185
Malignant neoplasm of prostate
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
195.0–195.5
Malignant neoplasm of other and ill-defined sites
195.8
Malignant neoplasm of other specified sites
196.0
Secondary and unspecified malignant neoplasm of lymph nodes of head face and neck
198.3
Secondary malignant neoplasm of brain and spinal cord
225.1–225.2
Benign neoplasm of brain and other parts of nervous system
227.3–227.4
Benign neoplasm of other endocrine glands and related structures
227.6
Benign neoplasm of aortic body and other paraganglia
747.81
Congenital anomalies of cerebrovascular system
Note: * ICD-9-CM codes 174.0, 174.1, 174.2, 174.3, 174.4, 174.5, 174.6, 174.8, 174.9, 175.0 and 175.9 – Indications will include some left breast tumors due to risk to immediately adjacent cardiac and pericardial structures, though IMRT would only rarely if ever be medically necessary for tumors of the right breast.
IMRT used to avoid critical adjacent structures for the following conditions requires a dual diagnosis.
Medicare is establishing the following limited coverage dual-diagnosis requirement for CPT/HCPCS codes 0073T,77301, 77338 and 77418:
Covered for:
Primary Diagnosis Codes:
179
Malignant neoplasm of uterus-part unspecified
180.0–180.1
Malignant neoplasm of cervix uteri
180.8–180.9
Malignant neoplasm of cervix uteri
182.0–182.1
Malignant neoplasm of body of uterus
182.8
Malignant neoplasm of other specified sites of body of uterus
183.0
Malignant neoplasm of ovary
183.2–183.5
Malignant neoplasm of ovary and other uterine adnexa
183.8–183.9
Malignant neoplasm of ovary and other uterine adnexa
184.0
Malignant neoplasm of vagina
184.8–184.9
Malignant neoplasm of other and unspecified female genital organs
198.4
Sec malig neo nerve nec
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 of lymphosarcoma and reticulosarcoma
Secondary Diagnosis Code:
V49.89
Other specified conditions influencing health status
Note: Providers should continue to submit ICD-9-CM diagnosis codes without decimals on their claim forms and electronic claims.
Diagnoses That Support Medical Necessity
N/A
ICD-9-CM Codes That DO NOT Support Medical Necessity
N/A
Diagnoses That DO NOT Support Medical Necessity
All diagnoses not listed in the “ICD-9-CM Codes That Support Medical Necessity” section of this LCD.
Documentation Requirements
Documentation supporting medical necessity should be legible, maintained in the patient’s medical record and made available to Medicare upon request.
Documentation in the patient’s medical records must include:
  • The reasonable and necessary requirements as outlined under the “Indications and Limitations of Coverage and/or Medical Necessity” section of this LCD and must be available to Medicare for review upon request.
  • The prescription must define the goals and requirements of the treatment plan, including the specific dose constraints for the target(s) and nearby critical structures.
  • A statement by the treating physician documenting the special need for performing IMRT on the patient in question, rather than performing conventional or 3-D treatment planning and delivery.
  • A signed and dated IMRT inverse plan that meets prescribed dose constraints for the PTV and surrounding normal tissue using either Dynamic Multi-Leaf Collimator (DMLC) or Segmented Multi-Leaf Collimator (SMLC) (average number of “steps” required to meet IMRT delivery is five), or inverse planned IMRT solid compensators to achieve intensity modulation radiation delivery.
  • The target verification methodology that includes the following:
    • Documentation of the Clinical Treatment Volume (CTV) and the PTV.
    • Documentation of immobilization and patient positioning.
    • Means of dose verification and secondary means of verification.
  • The MUs generated by the IMRT treatment plan must be independently checked before the patient’s first treatment.
  • Documentation of fluence distributions recomputed in a phantom is required, or an equivalent methodology consistent with patient-specific IMRT treatment verification described above.
  • Documentation that accounts for structures moving in and out of high and low dose regions created by respiration. Voluntary breath-holding is not considered appropriate and the solution for movement can best be accomplished with gating technology.
  • Documentation for clinical treatment planning (77261–77263) should evidence the criteria are met, which are outlined in The ASTRO/ACR Guide to Radiation Oncology Coding 2005, page 38.
When requesting a written redetermination (formerly appeal), providers must include all relevant documentation with the request.

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