Billing and Coding: Proton Beam Therapy

This article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Proton Beam Therapy. Coding Information: Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare. For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim. A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act. The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported. Documentation Requirements: The patient's medical record must contain documentation that fully supports the medical necessity for services included within the related LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures. Documentation in the patient medical record must: Support one or more medical necessity requirement(s) as provided under the "Indications and Limitations of Coverage and/or Medical Necessity" section of this policy. Include a treatment prescription that defines the goals of the treatment plan- including specific dose-volume parameters for the target and nearby critical structures- as well as pertinent details of beam delivery, such as method of beam modulation, field arrangement, and expected positional and range uncertainties. Include a treatment plan, signed by a physician, which meets the prescribed dose-volume parameters for the clinical target volume (CTV) and surrounding organs at risk (OARs) in the presence of expected uncertainties. Describe the target setup verification methodology, including patient positioning, immobilization and use of image guidance. Include verification of planned dose distribution via independent dose calculation or physical measurement.