CurrentPremera BluecrossPolicy N/A

Intensity Modulated Radiation Therapy (IMRT) planning and related simulation/dosimetry coding for outpatient facility claims

Defines how Premera recognizes and adjudicates CPT codes related to IMRT planning and related simulation/dosimetry services on outpatient facility (CMS 1450/837I) claims; applies to Premera and affiliated lines of business and products.

Policy Summary

PayerPremera Bluecross

PolicyIMRT planning and related simulation/dosimetry coding for outpatient facility claims

Policy CodePolicy N/A

Change TypeAdded temporal bundling and inclusivity rules

Effective DateOct 3, 2025

Next Review DateN/A

Key ActionDo not report listed codes separately from 77301 when billed by the same facility on the same date or within 30 days unless modifier 59/XS is documented to indicate a different tumor or unrelated service.

SourceLink

POLICY UPDATE CHANGES

Effective with claim dates of service on and after October 3, 2025, a set of CPT codes (77014, 77280, 77285, 77290, 77295, 77306, 77307, 77316, 77317, 77318, 77321, 77331, and 77370) are considered inclusive to CPT code 77301 when submitted by the same facility on the same date or within 30 days before or after.

13codes considered inclusive to 77301 when billed ±30 days or same date by same facility

±30dtime window for inclusivity to 77301

CMS 1450 / 837Iclaims/formats governed

Premera & affiliateslines of business covered

Coverage criteria and bundling rules

IMRT planning bundling and reporting criteria

Covered when the following facility-level bundling rules are met:

CPT code 77301 (Intensity modulated radiotherapy plan) is the primary IMRT planning code to which specified related planning, simulation, and dosimetry codes may be considered inclusive.

ALL of the following

The following CPT codes are considered inclusive to 77301 when submitted by the same facility on the same date of service or within 30 days before or after the 77301 date: 77014, 77280, 77285, 77290, 77295, 77306, 77307, 77316, 77317, 77318, 77321, 77331, 77370.

ALL of the following

Exceptions — separate reporting may be appropriate
- If the procedures represent services for a different tumor or an unrelated service on a different date of service, appending modifier 59 (Distinct Procedural Service) or XS (Separate Structure) to the related codes may be appropriate when documentation and diagnosis(es) support the separate service.

Policy Summary

PayerPremera Bluecross

PolicyIMRT planning and related simulation/dosimetry coding for outpatient facility claims

Policy CodePolicy N/A

Change TypeAdded temporal bundling and inclusivity rules

Effective DateOct 3, 2025

Next Review DateN/A

SourceLink

On This Page

Relevant CPT codes and coding details

IMRT planning and related simulation/dosimetry codesCPT

77301	Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specifications
77014	Computed tomography guidance for placement of radiation therapy fields
77280	Therapeutic radiology simulation-aided field setting; simple
77285	Therapeutic radiology simulation-aided field setting; intermediate
77290	Therapeutic radiology simulation-aided field setting; complex
77295	3-dimensional radiotherapy plan, including dose-volume histograms
77306	Teletherapy isodose plan; simple
77307	Teletherapy isodose plan; complex
77316	Brachytherapy isodose plan; simple
77317	Brachytherapy isodose plan; intermediate

1–10 of 14

1/2

Temporal bundling window

Temporal bundling windowCodes listed (77014, 77280, 77285, 77290, 77295, 77306, 77307, 77316, 77317, 77318, 77321, 77331, 77370) are considered inclusive to CPT 77301 when submitted by the same facility on the same date of service or within 30 days before or after the 77301 date.

Facility requirementInclusivity applies only when the codes are submitted by the same facility on the CMS 1450/837I outpatient facility claim.

Effective dateRule effective for claim dates of service on and after October 3, 2025.

Claim formats governedApplies to CMS 1450 (UB-04) and 837I outpatient facility claim submissions.

Provider billing and modifier guidance

Billing Rule

Modifier guidance for separate services

Append applicable modifiers or bill separately when services are distinct and unrelated to the IMRT planning episode. Use modifiers to indicate separate, distinct services when performed for a different tumor site or on a different date of service. Do not append modifiers when the service is considered inclusive to CPT 77301 per this policy (services listed as inclusive when billed on the same date or within 30 days before/after the IMRT planning procedure).

When a service is for a different tumor or an unrelated condition, append the appropriate modifier (e.g., -59, -XS, -XU, or other PAI modifiers per payer guidance) or bill the service on a separate claim as required.
Do NOT append modifiers to procedures that are specifically listed as inclusive to CPT 77301 when billed on the same date or within ±30 days of the IMRT planning date (77014, 77280, 77285, 77290, 77295, 77306, 77307, 77316, 77317, 77318, 77321, 77331, 77370).
If services are rendered on a different date of service for a separate tumor/site, document medical necessity and site-specific rationale in the medical record to support separate billing and modifier use.

OpenPayer

Intensity Modulated Radiation Therapy (IMRT) planning and related simulation/dosimetry coding for outpatient facility claims

Coverage criteria and bundling rules

Relevant CPT codes and coding details

Provider billing and modifier guidance

Key definitions