CurrentHumanaPolicy CP2014019

Radiation Therapy Management (CPT 77427)

This Humana payment policy describes billing and reimbursement requirements for CPT code 77427 (radiation treatment management, 5 treatments) for Medicare Advantage and Commercial products and affects providers submitting claims to Humana.

Policy Summary

PayerHumana

PolicyRadiation Therapy Management (CPT 77427)

Policy CodePolicy CP2014019

Change TypeNo material change

Effective DateSep 1, 2014

Next Review Date

Key ActionSubmit each 77427 charge as a single unit representing five sessions and include from/to service dates plus a Loop 2400 note indicating the number of fractions.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5sessions per CPT 77427 unit

3-4end-of-course exception

1max units per charge

NTE*ADD*X FRACTION(S)~Loop 2400 note syntax

from/toservice date submission

Billing and Submission Criteria

Policy Summary

PayerHumana

PolicyRadiation Therapy Management (CPT 77427)

Policy CodePolicy CP2014019

Change TypeNo material change

Effective DateSep 1, 2014

Next Review Date

Key ActionSubmit each 77427 charge as a single unit representing five sessions and include from/to service dates plus a Loop 2400 note indicating the number of fractions.

SourceLink

On This Page

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Billing and submission criteria for CPT 77427

Humana allows reimbursement for CPT code 77427 when billed according to the following billing rules and submission requirements.

ALL of the following

ALL of the following
- One unit represents five sessions; CPT 77427 may only be submitted for five sessions regardless of the time period in which services were furnished.
- End-of-course exception
  - At the end of a course of treatment, a provider may submit a single-unit charge for three or four sessions (single-unit charge must be distinct from all other units).
  - Charges at the end of a course of treatment for fewer than three sessions are denied as inappropriately billed.
Multiple fractions representing two or more treatment sessions on the same day may be counted separately only if there was a distinct break between same-day therapy sessions and the fractions are of a character usually furnished on different days.
Humana allows no more than one unit per charge and denies any additional unit(s) on the same claim as inappropriately billed.
Each 77427 charge must include a 'from' date (date of the first session of the charge) and a 'to' date (date of the last session of the charge).
Provider must submit a note indicating the number of fractions performed using Loop 2400 syntax in the 837 transaction: 'NTE*ADD*X FRACTION(S)~' (example: 'NTE*ADD*5 FRACTIONS~').

Codes and Unit Definitions

Radiation Therapy ManagementCPTCovered

77427

Radiation treatment management, 5 treatments

Sessions per unit

Standard unit definitionOne unit = five sessions (CPT 77427 may only be submitted for five sessions).

End-of-course exceptionA single unit of three or four sessions is allowed only at the end of a course of treatment; fewer than three sessions at end of course are denied.

Multiple same-day fractionsMultiple fractions on the same day may be counted separately only if there was a distinct break between same-day sessions and the fractions are usually furnished on different days.

Unit submission ruleEach unit of five sessions must be submitted as a distinct single-unit charge; three- or four-session end-of-course units must also be submitted as a distinct single-unit charge.

Denial for undercountingHumana denies charges billed for fewer than five sessions (except the 3–4 session end-of-course exception) as inappropriately billed.

Authorization and Documentation Requirements

Prior Authorization

General plan authorization requirements

In addition to this policy, claims payments are subject to other plan requirements for processing and payment, including, but not limited to: medical necessity and reasonableness determinations; and any applicable referral or prior authorization requirements. Providers must ensure services are ordered and documented in accordance with the member's plan benefits and network rules. Failure to obtain required referrals or authorizations, or to document medical necessity, may result in claim denial or recoupment.

Applies to Medicare Advantage and Commercial members.
Claims remain subject to plan terms: medical necessity, reasonableness, referral/authorization rules.
Obtain prior authorization when required by the member's plan before performing services.
Document clinical rationale and supporting records to demonstrate medical necessity at time of service and on claim submission.

Key Terms

CPT code 77427

CPT code77427

Short descriptionRadiation treatment management, 5 treatments.

Coverage statusCovered with criteria (billing rules apply per policy).

Fraction

DefinitionAn amount of radiation treatment.

Relation to sessionOne or more fractions comprise sessions delivered during radiation therapy.

Use in documentationProviders must report the number of fractions performed when submitting CPT 77427 charges.

Session

DefinitionThe encounter in which a fraction of radiation is delivered.

Session countingSessions are used to measure units for CPT 77427 (one unit = five sessions).

Same-day sessionsMultiple sessions on the same day may be counted separately only if there was a distinct break between therapy sessions.