CurrentPremera BluecrossPolicy CP.PP.427.v1.1

Intensity Modulated Radiation Therapy (IMRT)/Proton Beam Therapy Planning and Treatment Coding - Outpatient Facility claims

Defines how the Plan recognizes and reimburses services included in IMRT treatment plans billed on outpatient facility claims for Premera Blue Cross and affiliated lines of business; describes inclusive and separately reportable CPT codes and billing modifiers guidance.

Policy Summary

PayerPremera Bluecross

PolicyIMRT/Proton Beam Therapy Planning and Treatment Coding - Outpatient Facility claims

Policy CodePolicy CP.PP.427.v1.1

Change TypeMaterial change — addition of inclusive code list and billing window

Effective DateOct 3, 2025

Next Review Date

Key ActionWhen listed CPT codes are for a different tumor on a different date, append modifier 59 or XS with supporting documentation to report separately.

SourceLink

POLICY UPDATE CHANGES

Effective with claim dates of service on and after October 3, 2025, a list of CPT codes is considered inclusive to CPT 77301 when submitted on the same date or within 30 days before/after.

Code 77014 updated with termination date (code terminated effective January 1, 2026).

77301Primary CPT code governing IMRT planning inclusivity

13Number of CPT codes listed as inclusive to 77301 when billed within 30 days

30 daysTemporal window before/after 77301 within which listed codes are considered inclusive

NCCI editsOverride modifiers not allowed per NCCI when treating the same tumor

Premera linesApplies to

When Services Are Considered Inclusive or Separately Billable

IMRT planning inclusivity and separate reporting criteria

Covered when ALL of the following conditions are met:

ALL of the following

The following CPT codes are considered inclusive to CPT 77301 when submitted/billed on the same date or within 30 days before or after the IMRT planning procedure (77301): 77014 (terminated effective 1/1/2026), 77280, 77285, 77290, 77295, 77306, 77307, 77316, 77317, 77318, 77321, 77331, and 77370.

These procedure codes should not be reported separately by the same facility if performed as part of developing an IMRT treatment plan, whether billed on the same date of service as 77301 or within 30 days before or after 77301.

Exceptions (ONE of)

The procedures represent services for a different tumor on a different date of service unrelated to the IMRT plan (77301).

Policy Summary

PayerPremera Bluecross

PolicyIMRT/Proton Beam Therapy Planning and Treatment Coding - Outpatient Facility claims

Policy CodePolicy CP.PP.427.v1.1

Change TypeMaterial change — addition of inclusive code list and billing window

Effective DateOct 3, 2025

Next Review Date

Key ActionWhen listed CPT codes are for a different tumor on a different date, append modifier 59 or XS with supporting documentation to report separately.

SourceLink

On This Page

CPT Codes and Temporal Billing Window

CPT codes referenced; many are considered inclusive with 77301 when billed within 30 daysCPT

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 (code terminated effective January 1, 2026)
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

Inclusion window

Inclusion windowCPT codes listed are considered inclusive to 77301 when submitted on the same date or within 30 days before or after the 77301 procedure.

Effective dateEffective with claim dates of service on and after October 3, 2025.

Applies toApplies when submitted by the same facility for outpatient facility claims (Premera BC and affiliated lines of business).

Separate reporting exceptionIf the procedure represents a service for a different tumor on a different date of service unrelated to 77301, appending modifier 59 or XS may be appropriate when documentation/diagnosis support a different tumor.

Billing Modifiers and Provider Guidance

Billing Rule

Modifier guidance for separate tumor services

When billing services that could be related to an IMRT treatment plan (e.g., simulation, 3‑D planning, CT guidance, teletherapy or brachytherapy isodose planning), ensure documentation clearly supports the clinical scenario. If the service is for a separate tumor on a different date of service and is unrelated to the IMRT plan/service (CPT 77301), append an appropriate modifier to indicate a distinct procedural service only when supported by documentation and diagnosis. Per NCCI edits, override modifiers are not allowed when treating the same tumor — these procedure codes should not be reported separately by the same facility if they are part of developing an IMRT treatment plan (whether billed on the same date as 77301 or within 30 days before or after).

Affected codes: 77014 (terminated effective 2026-01-01), 77280, 77285, 77290, 77295, 77306, 77307, 77316, 77317, 77318, 77321, 77331, 77370
When for a different tumor on a different date and unrelated to 77301, append modifier 59 (Distinct Procedural Service) or modifier XS (Separate Structure) as appropriate and supported by documentation and diagnosis
Do not append override modifiers to sidestep NCCI edits when services are for the same tumor — risk of denial if documentation does not support a separate tumor/service

OpenPayer

Intensity Modulated Radiation Therapy (IMRT)/Proton Beam Therapy Planning and Treatment Coding - Outpatient Facility claims

When Services Are Considered Inclusive or Separately Billable

CPT Codes and Temporal Billing Window

Billing Modifiers and Provider Guidance

Key Terms