Billing and Coding: Proton Beam Radiotherapy

This Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L33937, Proton Beam Radiotherapy. Please refer to the LCD for reasonable and necessary requirements. Coding Guidance Notice: It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier. Documentation Requirements All documentation must be maintained in the patient's medical record and made available to the contractor upon request. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient. The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed. Utilization Guidelines In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice. Compliance with the provisions in LCD L33937, Proton Beam Radiotherapy may be monitored and addressed through post payment data analysis and subsequent medical review audits.