Currentpriority healthPolicy 027

Radiation Oncology - Billing, Coding and Documentation

This document defines billing, coding, documentation, and bundling rules for radiation oncology services (simulation, planning, dosimetry, devices, physics consults, treatment delivery including IMRT, brachytherapy, PBT, superficial and conventional therapy) and applies to all Priority Health plans.

Policy Summary

Payerpriority health

PolicyRadiation Oncology - Billing, Coding and Documentation

Policy CodePolicy 027

Change TypeNo material change

Effective DateJul 1, 2024

Next Review DateFeb 2, 2025

Key ActionSubmit required documentation (treatment goals, signed plan, dose specs, simulation/physics/dosimetry reports) to support radiation oncology claims.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

All plansApplies to

5SBRT fraction max

1 per course77370 frequency

177338 per plan

MultipleExample codes listed

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria and Medical Necessity

COVERAGE CRITERIA

Stance and coverage rules for modalities and special services

IMRT is considered reasonable and medically necessary when sparing the surrounding normal tissue is of added clinical benefit to the patient.

Brachytherapy (including electronic): Electronic high-dose-rate brachytherapy (0394T, 0395T) requires documentation of procedure details, prescribed dose and dose calculation, date and duration, and provider signature to support claims.

Superficial radiation therapy (77401): Superficial radiation therapy includes treatment planning, devices, isodose plans, and continuing physics consultation; these services are considered inclusive to the superficial treatment and are not separately payable.

Special treatment procedures (77470/77399): Special treatment procedure (77470) is reserved for circumstances requiring extra and inordinate time and effort and is limited to one per course; CPT 77399 (unlisted) should be used only when no other code adequately describes the service and requires supporting rationale and documentation.

Simulation frequency and billing: A typical course requires one to three simulations; no more than one simulation should be reported on any given day; verification simulations for IMRT are not separately billable with IMRT courses.

Dosimetry and isodose planning: Only one 77300 dosimetry calculation is billable per port/beam angle or arc for 3D and IMRT; isodose and port plans are inclusive of dosimetry calculations and not separately reportable.

Treatment device billing rules: Only one beam‑modifying device is billable per port/field; treatment device services have professional and technical components and mirrored paired devices are billed according to professional/technical distinctions; passive restraints are not billable.

Medical physics consults: Continuing medical physics consultation (77336) may be reported periodically (for example, after every five treatments) and special medical physics consultation (77370) is reportable one time per course when indicated (e.g., pregnancy, SRS/SBRT, implanted device) with physician request and customized written report.

Coverage and limits for radiation modalities

Coverage stance and general medical necessity rationale for advanced radiation modalities.

IMRT medical necessity: IMRT is reasonable and medically necessary when delivery of highly conformal external beam radiation with variable beam intensity provides added clinical benefit by sparing adjacent normal tissues compared with conventional techniques.

Proton Beam Therapy (PBT) medical necessity: Proton Beam Therapy is considered reasonable when sparing surrounding normal tissue is of added clinical benefit and the clinical benefit cannot be adequately achieved with photon-based radiation therapy; claims for proton delivery (e.g., 77520/77522/77523 and related codes) must be supported by documentation of treatment details, ports, compensators/blocks, dates and provider signature.

SBRT / SRS limits: SRS is typically single‑session and SBRT applies to multi‑session stereotactic therapy; SBRT/SRS delivery is limited to a maximum of five fractions per course for billing purposes, and stereotactic management (CPT 77435) is payable once per course.

Coding, bundling and documentation requirements

Coding, bundling, and documentation requirements affecting coverage.

Diagnosis coding specificity: Diagnosis code(s) must be coded to the highest level of specificity to describe the patient's condition for the service performed; unspecified diagnosis codes will be denied.

Bundling and NCCI: Priority Health follows CMS NCCI guidance for bundling of radiation oncology services; some services performed as part of treatment plan development bundle and may be billed on different days per CMS guidance.

Documentation required to support claims: Extensive documentation must be maintained and may be requested to support claims, including treatment goals, signed treatment plan/prescription, simulation and physics/dosimetry reports, dose specifications, procedure notes, and provider signatures; unlisted or special procedure claims must include detailed rationale and documentation.

Unlisted and special procedure documentation:

Coding, Billing and Code Lists

Clinical treatment planningCPTCovered

77261	Therapeutic radiology treatment planning; simple
77262	Therapeutic radiology treatment planning; intermediate
77263	Therapeutic radiology treatment planning; complex

Treatment simulationmixedCovered

77280	Simulation; simple
77285	Simulation; intermediate
77290	Simulation; complex
77293	Respiratory motion management simulation (add-on)
G0562	Simulation including acquisition of PET/CT for radiopharmaceutical-directed planning

Dosimetry and isodose plansCPTCovered

77300	Basic radiation dosimetry calculation
77331	Special dosimetry (e.g., TLD, microdosimetry)
77306	Teletherapy isodose plan; simple
77307	Teletherapy isodose plan; complex

Treatment devicesCPTCovered

77333	Treatment devices design and construction; intermediate
77334	Treatment devices design and construction; complex
77338	MLC device(s) for IMRT design and construction per IMRT plan

Medical physics consultsCPTCovered

77336	Continuing medical physics consultation, reported per week
77370	Special medical radiation physics consultation (one time per course when indicated)

Unlisted / special proceduresCPTCovered

77399	Unlisted procedure, medical radiation physics, dosimetry, treatment devices, special services
77470	Special treatment procedure (total body irradiation, hemibody, etc.)

Conventional radiation therapy deliverymixedCovered

77402	Radiation treatment delivery; simple
77407	Radiation treatment delivery; intermediate
77412	Radiation treatment delivery; complex
G6003	Radiation treatment delivery up to 5 MeV (example group G6003-G6006)

Brachytherapy (including electronic)CPTCovered

0394T	High dose rate electronic brachytherapy, skin surface, per fraction
0395T	High dose rate electronic brachytherapy, interstitial/intracavitary, per fraction

IMRT delivery codesmixedCovered

77385	IMRT delivery; simple
77386	IMRT delivery; complex
G6015	IMRT delivery via narrow spatially/temporally modulated beams
G6016	Compensator-based beam modulation delivery

Proton beam therapyCPTCovered

77520

Proton beam therapy code listed

Proton beam therapy (additional delivery codes referenced)CPTCovered

77522	Proton treatment delivery; simple with/without compensation (referenced in documentation requirements)
77523	Proton treatment delivery; intermediate (referenced in documentation requirements)

Radiation therapy delivery and imaging codesCPTCovered

77385	IMRT delivery, simple (includes guidance and tracking when performed)
77386	IMRT delivery, complex (includes guidance and tracking when performed)
77373	SBRT treatment delivery, per fraction, entire course not to exceed 5 fractions
77417	Therapeutic radiology port images; may be billed 1 time per 5 fractions

Dosimetry calculations per port/angle

Dosimetry calculation limitOnly one 77300 calculation is billable per port/beam angle or arc for 3D and IMRT external beam treatments.

Multiple calculations not allowedMultiple calculations per beam angle are not allowed (e.g., split carriage fields) due to linear accelerator limitations.

Monitor unit calculationsMonitor unit calculations (CPT 77300) are considered bundled into brachytherapy isodose planning codes (CPT 77316–77318).

Special dosimetry frequencySpecial dosimetry (CPT 77331) measurements may occur only once per port/field when supported by medical necessity.

Documentation for special dosimetryTo support CPT 77331, document the treating physician’s prescription, type of dosimetry, date/time, and results of measurements.

77338 units per IMRT plan

77338 per IMRT planOnly 1 unit of CPT 77338 (MLC device(s) for IMRT design and construction) is billable per IMRT plan regardless of the number of ports constructed.

Treatment device componentsTreatment device services contain professional and technical components; professional component is based on physician’s participation in design and technical on fabrication time/materials.

Beam-modifying device ruleOnly one beam‑modifying device is billable per port/field; mirrored paired devices billed as one professional and one technical device.

SBRT fraction limit

SBRT/SRS fraction maximumMaximum of 5 fractions per course for SBRT (CPT 77373/G0563/G0340 etc.); stereotactic deliveries exceeding five treatments will not be authorized as stereotactic management.

CPT 77373 course limitCPT 77373 is defined as SBRT delivery per fraction with entire course not to exceed 5 fractions.

CPT 77435 payment frequencyOne (1) stereotactic body radiation therapy management (CPT 77435) pays only once per course and aligns with authorized fraction counts (1 or 2–5 fractions).

Port image billing frequency

Port image billing frequencyCPT 77417 (therapeutic radiology port images) may be billed 1 time for each 5 fractions of therapy and is billed as 1 unit regardless of number of images taken.

Imaging bundlingOnly one type of imaging may be allowed for the same treatment site; Priority Health follows standard bundling rules for imaging services.

IGRT limitationsIGRT precise target localization requirements are not met for superficial or orthovoltage treatment; image guidance cannot be reported for those treatments.

Provider Billing Actions, Documentation & Authorization

Documentation Required

Proton beam therapy documentation

Proton beam therapy (PBT) documentation — Providers must include clear, specific documentation in the medical record to support claims for proton treatment delivery codes (CPT 77520–77525). Documentation must demonstrate the medical necessity of PBT (for example, sparing of surrounding normal tissue that cannot be achieved with photon therapy) and include treatment-specific details as described below.

Document the details of the proton therapy delivered (beam type, energies, fractionation, and clinical rationale).
Record the number of treatment areas irradiated and number of ports used (single non-tangential port vs multiple ports or tangential ports).
Specify use of compensators and/or custom blocks when applicable; if no compensators were used, explicitly document their absence.
When multiple isocenters, patch fields, or complex delivery techniques are used, document those design elements and why they were required.
Include date and duration of each treatment session and progress/response notes as appropriate.
Document proximity to sensitive structures or other anatomic considerations that justify PBT over photon therapy.
Ensure the treatment plan, signatures of treating providers, and inclusion of relevant planning data (dosimetry, port usage, compensators, bolus/compensation devices) are in the chart.

Definitions

Radiation therapy

Radiation therapy definitionRadiation therapy uses high‑energy radiation (X‑rays, gamma rays, charged particles) delivered externally (external‑beam) or internally (brachytherapy) to treat cancer.

Delivery methodsDelivery methods include external‑beam radiation therapy (e.g., conventional, IMRT, SBRT, PBT) and internal radiation therapy (brachytherapy).

Multidisciplinary componentsA course may involve treatment planning, simulation, dosimetry, devices, medical physics, and radiation treatment management.

Course of radiation

Course of radiationA course of radiation includes clinical treatment planning (CPT 77261–77263), simulation (CPT 77280–77290), treatment planning, medical radiation physics/dosimetry, treatment devices/special services, and radiation treatment management.

Typical simulation frequencyTypical simulations per course are 1–3; no more than one simulation reported on the same day.

Included servicesDosimetry, devices, and continuing physics consultation may be part of the course and subject to bundling rules.

IMRT

IMRT definitionIntensity Modulated Radiation Therapy (IMRT) is a technology delivering highly conformal external‑beam radiation with beam intensity varying across the field to spare adjacent normal tissues.

Clinical indicationIMRT is considered reasonable and medically necessary when sparing surrounding normal tissue provides added clinical benefit.

Representative codesIMRT delivery codes include CPT 77385 (simple) and 77386 (complex); other modality‑specific HCPCS/G‑codes may apply.

PBT (Proton Beam Therapy)

Proton Beam Therapy (PBT)Proton Beam Therapy (PBT) delivers conformal external‑beam radiation using positively charged subatomic particles with unique dose deposition characteristics.

Regulatory notePBT is approved by the U.S. Food and Drug Administration.

Clinical advantagePBT can deliver dose to targets while giving less collateral dose to surrounding normal tissues compared to photon‑based therapy.

IMRT (alternate)

IMRT (alternate)IMRT: delivery of highly conformal external beam radiation with variable beam intensity to spare adjacent normal tissues; used near sensitive normal tissues.

Technology featuresIMRT uses modulated beam intensities across multiple fields/arcs to shape dose distributions precisely.

Codes includedIncludes CPT 77385, 77386 and applicable G‑codes for specialized delivery techniques.

PBT (alternate)

PBT (alternate)Proton Beam Therapy uses positively charged particles to deliver conformal external‑beam radiation with unique dose deposition characteristics.

Clinical roleUsed when reduced collateral dose to normal tissues is clinically beneficial compared to photon therapy.

Example codeRepresentative CPT code listed: 77520.

SBRT / SRS

SBRT definitionStereotactic Body Radiation Therapy (SBRT) is a high‑precision, high‑dose external‑beam modality for extracranial sites aimed at maximizing tumor cell kill while minimizing injury to adjacent normal tissues.

SRS distinctionStereotactic Radiosurgery (SRS) generally refers to single‑session, stereotactic treatment for intracranial targets; SRS involves a multidisciplinary team and may ablate targets without incision.

Course limitsSRS is typically single‑session; SBRT uses fractionated stereotactic delivery with a maximum of five fractions per course.

IGRT

IGRT definitionImage Guided Radiation Therapy (IGRT) uses imaging technology to modify treatment delivery to account for changes in the target's position.

Common guidance codesExamples include 77014 (CT guidance), 77387 (guidance for localization, includes intrafraction tracking) and 77417 (therapeutic port images).

Port image billingCPT 77417 may be billed once per each 5 fractions and is billed as one unit regardless of number of images taken.