Billing and Coding: Radiation Therapies

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Radiation Therapies L39553. Scope : The guidance provided by this billing and coding article applies to IMRT, SRS, and SBRT. Guidance does not apply to radiation services not specifically enumerated within policy L39553 Radiation Therapies (e.g. conventional radiation, 3D CRT). Documentation Requirements All documentation must be maintained in the patient's medical record. The documentation must support the medical necessity of the services as specified in this article and it must be 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 and credentials of the physician, non-physician practitioner, dosimetrist, physicist or radiation therapist responsible for and providing the described care for the patient. The submitted medical record must support the use of the selected ICD-10-CM diagnosis code(s). The submitted CPT ® /HCPCS code(s) must describe the service performed. It is the provider’s responsibility to select codes carried out to the highest level of specificity and selected from the ICD-10-CM and CPT ® code books appropriate to the year in which the service is rendered for the claim(s) submitted. For all radiation therapy, the medical record must include the patient’s primary diagnosis for which the prescribed radiation therapy is needed, the patient’s history for this illness as well as active co-morbid medical conditions, the patient’s performance status when applicable and as required by the LCD, any relevant imaging reports, the proposed treatment plan, the number and location and size of tumors that are present, the stage of disease, and the anatomic site of the radiation delivery. For any type of radiation therapy for non-cancer diagnosis coverage (such as, but not limited to epilepsy, trigeminal/facial nerve applications, movement disorders, Parkinson’s disease, tremor conditions), it is important to clearly and very specifically document to the prior therapies tried and failed. Names of therapies and durations given and whether improvement or worsening occurred is crucial to support a decision to proceed with aggressive radiation therapy. Failure to document with specificity and precision related to the past diagnostic and attempted treatment for a condition as it relates to a unique beneficiary may well result in a non-coverage decision due to lack of reasonable and necessary standards having been met. For Stereotactic Body Radiation Therapy (SBRT) and Stereotactic Radiosurgery (SRS), the patient’s record must support the medical necessity of treatment. Supporting clinical records must include not only the patient’s medical history and physical examination findings, but also the patient’s current functional status, as described by an overall performance status score (e.g., Karnofsky Performance Status (KPS) or Eastern Cooperative Oncology Group (ECOG) Performance Status score). A radiation oncologist must evaluate the clinical and technical aspects of the treatment and document this evaluation as well as the resulting management decision. Justification for aggressive local therapy to 1 or more deposits of metastatic cancer for either total disease clearance in the setting of oligometastatic disease or to reduce overall burden of systemic disease for a specifically defined clinical benefit must be documented. In the case of recurrent disease requiring palliation or when tumor cannot be treated as effectively or safely by other radiotherapy methods due to proximity of previously irradiated volumes, documentation to those beneficiary unique facts must be documented in the medical record. Medical record documentation maintained by the provider must indicate the medical necessity for radiation oncology procedure as outlined in the LCD L39553 and must include ALL of the following for a radiation oncology procedure which employs inverse planning: The type of radiation therapy that will be delivered must be precisely documented and cannot be inferred from the equipment or technology or computerized optimization being utilized. The type of radiation therapy planning that was ultimately used must be precisely documented and cannot be inferred from the equipment or technology or computerized optimization being utilized. A treatment plan/prescription must be present and must define the goals and requirements of the treatment, including the specific dose constraints for the target(s) and nearby critical structures. A statement by the treating physician documenting the special advantages and genuine need for performing the specified radiation therapy delivery type and planning type on the patient in question, especially in comparison to conventional forward treatment planning and/or delivery. With IMRT planning and delivery documentation, the physician must address the other organs at risk (OAR) or adjacent critical structures. Review by the radiation oncologist of the radiologic images of the target and all critical structures with representative isodose distributions that characterize the three-dimensional (3D) dose. The document containing this review must be signed with credentials and dated. Radiation oncologist review of dose-volume histograms for all targets and critical structures specifically documented as reviewed or authenticated via signature with credentials and date. Description of the number and location of each treatment step/rotation or portal to accomplish the treatment plan. Documentation of dosimetric verification of treatment setup and delivery, signed by both the radiation oncologist and the medical physicist with a legible signature and credentials and date. For compensator-based radiation therapy delivery, the unique compensator design should be documented for each step or portal. Documentation of fluence distributions recomputed in a phantom, or an equivalent methodology consistent with patient specific treatment verification. Target verification methodology documentation to include documentation of the clinical treatment volume (CTV) and the planning target volume (PTV); documentation of immobilization/patient positioning, and means of dose verification and secondary means of verification. Other procedures performed during the episode of care must have documentation that supports the professional and technical components by identifying the place of service, the date of service, the supervising physician, and proof of work provided. If applicable, when billing for respiratory management simulation, documentation must be present that identifies structures that move between high- and low-dose regions due to respiration. The documentation must include the medical necessity of this service. This is more extensive documentation than what would occur with just a simulation note since it is part of the isodose planning process. Since the work occurs over several days and involves the therapists, the dosimetrist, the physicist and the physician, the narrative supporting this service would and should appear in several documents. The simulation note should document the physician review of respiratory motion management set-up and use at the time of simulation. The treatment plan document must indicate that the physician created and intended to cover the target volume in all phases of respiratory motion. 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. For SRS and SBRT, the ICD-10-CM code for treatment includes the metastatic process being addressed through the usage of these modalities. CPT ® /HCPCS code(s) may be subject to National Correct Coding Initiative (NCCI) edits. Please refer to NCCI Policy Manual for correct coding guidelines and specific applicable code combinations prior to billing Medicare.