Biology-Guided Radiation Therapy (BgRT) — Coding and Billing Guidance
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This coding manual provides billing, coding, and administrative guidance for radiation oncology services used by eviCore when administering Cigna health benefit plans; it is intended to guide coding and prior authorization processes but does not itself guarantee coverage.
No material clinical or coverage changes in this revision.
Coverage and Billing Criteria
Coverage policy context
General coverage stance and limitations
Billing and coverage criteria
Billing allowed, restricted, or bundled rules for listed CPT codes with common exclusions and documentation requirements.
ANY of the following
- Special physics consultation and special treatment procedure: One unit of CPT 77370 or 77399 (physics) or one unit of CPT 77470 (special treatment procedure) is allowed per episode when supported by specific clinical documentation; both 77370 and 77399 cannot be reported for the same episode; these require a physician request and custom report and check-off sheets/templates are insufficient.
Coverage and billing criteria
Coverage and billing rules — codes covered when billed according to the listed limitations, documentation, and exclusivity rules.
COVERAGE CRITERIA — Summary
Coverage and billing criteria summarized as allowable reporting, unit limits, fraction/episode constraints, and prohibited combinations.
Allowed codes and units when authorized
When authorization is granted for each specified procedure, the following coding and unit allowances apply:
Coding Tables, Limits, and Edits
| CPT | Common Procedural Terminology codes — five-digit codes developed by the AMA used to report procedures. |
| HCPCS | Healthcare Common Procedure Coding System level I (CPT) and level II (drugs, supplies, services not in CPT) codes. |
| NCCI/CCI/MUE | National Correct Coding Initiative / Correct Coding Initiative and Medically Unlikely Edits applied per CMS; eviCore adheres to these edits. |
| 77402 | Radiation treatment delivery, simple; includes imaging guidance when performed |
| 77407 | Radiation treatment delivery, intermediate; single isocenter, includes imaging guidance when performed |
| 77412 | Radiation treatment delivery, complex; multiple isocenters or active motion management, includes imaging guidance when performed |
| 77336 | Continuing medical physics consultation — report per week of therapy; allowed one unit every 5 fractions |
| 77370 | Special medical radiation physics consultation — limited to unusual complex situations; requires physician request and custom report |
| 77399 | Unlisted medical radiation physics procedure — requires physician request and custom report |
| 77470 | Special treatment procedure — additional physician work for complex/unconventional plans; one unit per episode when supported |
| 77402 | Radiation treatment delivery, >=1 MeV; simple (Level 1), includes imaging guidance when performed |
| 77407 | Radiation treatment delivery, >=1 MeV; intermediate (Level 2), single isocenter, includes imaging guidance when performed |
| 77412 | Radiation treatment delivery, >=1 MeV; complex (Level 3), multiple isocenters or single isocenter with active motion management, includes imaging guidance when performed |
| 77371 | Radiation treatment delivery, stereotactic radiosurgery (SRS), cranial, single session (Cobalt) |
| 77372 | Radiation treatment delivery, stereotactic radiosurgery (SRS), cranial, single session (LINAC) |
| 77373 | Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, entire course not to exceed 5 fractions |
| G0339 | Image-guided robotic LINAC-based SRS, complete course in one session or first session of fractionated treatment |
| G0340 | Image-guided robotic LINAC-based SRS, fractionated treatment, per session, fractions 2-5 |
| 77423 | High energy neutron radiation treatment delivery |
| 77600 | Hyperthermia, externally generated; superficial |
| 77605 | Hyperthermia, externally generated; deep |
| 77610 | Hyperthermia generated by interstitial probe(s); 5 or fewer applicators |
| 77615 | Hyperthermia generated by interstitial probe(s); more than 5 applicators |
| 77620 | Hyperthermia generated by intracavitary probe(s) |
| 77316 | Brachytherapy isodose plan; simple |
| 77317 | Brachytherapy isodose plan; intermediate |
| 77318 | Brachytherapy isodose plan; complex |
| 19296 | Placement of afterloading expandable catheter into breast for interstitial radioelement application (separate date) |
| 19297 | Placement of afterloading expandable catheter into breast concurrent with partial mastectomy |
| 79101 | Radiopharmaceutical therapy, intravenous administration |
| A9513 | Lutetium Lu 177, dotatate, therapeutic, per millicurie |
| A9606 | Radium Ra-223 dichloride, therapeutic, per microcurie |
| A9607 | Lutetium Lu 177 vipivotide tetraxetan, therapeutic, per millicurie |
| A9699 | Radiopharmaceutical, therapeutic, not otherwise classified |
Authorization, Documentation, and Billing Actions
Inclusion of codes is not authorization
The inclusion of any procedure code in this manual does not imply the code is under eviCore management or requires prior authorization. Providers must refer to the specific health plan's procedure code list for management and prior authorization requirements; obtaining an authorization does not guarantee payment for all billed procedures.
Benefit plan takes precedence
A member's specific benefit plan document, coverage policies, and eligibility rules may supersede eviCore guidance. In the event of conflict, the customer's benefit plan document takes precedence and providers should obtain written payer-specific instructions.
Out-of-scope procedures must be directed to payer
Certain treatments and requests are outside eviCore review and must be directed to the health plan for consideration rather than submitted to eviCore.
- Examples: SpaceOAR™, Optune®, MRgFUS (MR-guided focused ultrasound), GliaSite®, HIPEC (Hyperthermic Intraperitoneal Chemotherapy).
- Radiation treatments delivered during an inpatient stay (e.g., non-breast IORT) are also out of scope.
Planning code allowances tied to authorization
When an IMRT authorization is granted, one unit of CPT 77301 is allowed per episode of care; when 3-D conformal therapy is authorized, one unit of CPT 77295 is allowed per episode; one unit of CPT 77306 or 77307 is allowed for each authorized treatment site when a teletherapy isodose plan is authorized.
Respiratory management and adaptive planning restrictions
The respiratory motion management add-on code +77293 is only allowed once per episode of care and must be billed on the same date of service as the primary procedure; adaptive planning has no associated CPT codes and additional planning/device/dosimetry codes cannot be reported when adaptive planning is performed.
- +77293: allowed once per episode and only as an add-on on the same date as the primary procedure.
- Adaptive planning: no CPT codes; additional planning/device/dosimetry codes are not reportable when adaptive planning is performed.
Fiducial placement allowed with definitive RT authorization
When definitive radiation therapy is authorized, one unit of a fiducial placement CPT is allowed; the provider must select the appropriate code based on anatomical site (e.g., CPT 32553, 49411, 49412, 55876).
- One unit allowed when definitive RT authorized.
- Choose the CPT code appropriate to the anatomic site per CPT descriptions.
Documentation required for physics consults and special procedures
Special physics consultation (77370 or 77399) and special treatment procedure (77470) require supporting clinical documentation and a physician request; when supported, each is limited to one unit per episode of care and check-off sheets or templates are insufficient.
Modality exclusivity — do not mix delivery modalities same date
Treatment delivery codes for a given modality cannot be reported with a different treatment modality on the same date of service; superficial/orthovoltage delivery codes and many device/planning codes are excluded from concurrent reporting with other modalities.
Proton delivery units and BID rules
One unit of CPT 77520–77525 (proton delivery) is allowed per date of service regardless of number of treatment sites; if BID treatment is utilized, two units are allowed with the second unit reported with the appropriate modifier on a separate claim line.
- One unit per date of service for 77520–77525 regardless of number of sites.
- BID: second unit allowed with correct modifier on separate line.
- Proton delivery codes cannot be reported with a different modality on the same date.
SRS/SBRT episode and fraction rules
CPT 77371 and 77372 are allowed as a single-session SRS to treat all cranial lesions as a complete episode; sequential single-fraction use for multiple synchronous metastases is not allowed. CPT 77373 covers multi-fraction SRS/SBRT up to a maximum of 5 fractions as a complete episode, and SRS/SBRT codes cannot be reported as a boost or combined with a different technique during an episode.
- 77371/77372: single-session cranial SRS — one unit for complete episode; not allowed for sequential single-fraction treatments of multiple synchronous metastases.
- 77373: multi-fraction SRS/SBRT allowed up to 5 fractions per complete episode; >5 fractions must be reported as 3D conformal or IMRT.
- SRS/SBRT codes (77371–77373 and G0339/G0340) cannot be used as a boost or combined with a different technique during an episode.
Neutron beam delivery unit and exclusivity
One unit of CPT 77423 (neutron beam delivery) is allowed per date of service regardless of number of treatment sites and cannot be reported with a different treatment modality on the same date.
- One unit per date of service for 77423.
- Cannot be reported with a different treatment modality on same date.
Hyperthermia billing limits and HIPEC exclusion
One unit of CPT 77600–77620 (hyperthermia) is allowed per date of service; these codes are not reportable for HIPEC and cannot be reported when used alone or in conjunction with chemotherapy.
- One unit per date of service for 77600–77620.
- Not reportable for HIPEC.
- Cannot be reported when used alone or with chemotherapy.
Brachytherapy isodose planning limits
One unit of CPT 77316, 77317, or 77318 (brachytherapy isodose planning) is allowed per brachytherapy treatment; these codes cannot be reported with CPT 77295 for the same brachytherapy treatment.
- One unit of 77316–77318 per brachytherapy treatment.
- Do not report 77316–77318 with 77295 for the same brachytherapy treatment.
Radiopharmaceutical dosing and unit limits when authorized
When a radiopharmaceutical authorization is granted, the policy specifies allowed CPT/HCPCS units and dose maxima by agent (for example: I-131 CPT 79005 — one dose; Lutathera CPT 79101 — 4 doses with HCPCS A9513 limited to 200 mCi per dose, max 800 mCi; Pluvicto CPT 79101 — 6 doses with HCPCS A9607 limited to 200 mCi per dose, max 1,200 mCi; Xofigo CPT 79101 — 6 doses with HCPCS A9606 dosed by patient weight).
BgRT reporting rules and fraction limits
When BgRT is authorized, HCPCS G0562 is allowed but is included in IMRT dose planning (CPT 77301) and therefore cannot be reported separately; G0563 is allowed up to a maximum of 5 fractions as a complete episode of care; HCPCS A9609 is allowed for one unit for BgRT modeling and one unit per authorized BgRT treatment.
Definitions and Abbreviations
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