CurrentUnitedHealthcarePolicy N/A

Therapeutic radiology clinical treatment planning reimbursement

Defines reimbursable units and episode-of-care rules for therapeutic radiology clinical treatment planning (CPT 77261, 77262, 77263) for UnitedHealthcare Community Plan Medicaid providers submitting on CMS-1500 or UB-04 forms.

Policy Summary

PayerUnitedHealthcare Community Plan Medicaid

PolicyTherapeutic radiology clinical treatment planning reimbursement

Policy CodePolicy N/A

Change TypeImplemented / state exception updates

Effective DateN/A

Next Review DateN/A

Key ActionDo not bill more reimbursable units per 90-day episode than allowed; units in excess will be denied.

SourceLink

POLICY UPDATE CHANGES

Policy implemented by UnitedHealthcare Community Plan on 02/01/2025.

State exceptions updated multiple times (e.g., New Jersey and Texas removed on various dates in 2025).

Question-and-answer entry added (Question 4 referencing brachytherapy within 90-day episode).

90 dayslength of treatment planning episode of care

77261-77263primary planning CPT codes

Units over limitdenied if over limits

Exception appliesbrachytherapy exception

Medicaid

Policy Summary

PayerUnitedHealthcare Community Plan Medicaid

PolicyTherapeutic radiology clinical treatment planning reimbursement

Policy CodePolicy N/A

Change TypeImplemented / state exception updates

Effective DateN/A

Next Review DateN/A

Key ActionDo not bill more reimbursable units per 90-day episode than allowed; units in excess will be denied.

SourceLink

On This Page

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

Coverage criteria for planning and management codes

Reimbursement is allowed for specified treatment planning and treatment management codes up to the reimbursable units per 90-day episode; exceptions and additional policies apply.

Within the 90‑day episode, UnitedHealthcare will consider reimbursement for services, procedures, and units outlined under the Treatment Management Codes; the reimbursable units per episode are designed to capture all reimbursable work associated with these codes.

Units billed in excess of the reimbursable units per treatment planning episode will not be considered for reimbursement and will be denied.

Professional (modifier 26) and Technical (modifier TC) components billed with the same code are counted together when calculating allowed units; other modifiers may be appended but do not affect accumulation of units.

Exceptions

When brachytherapy services are present within the 90‑day episode of care, the unit limitations described in this policy are not applicable.
State-specific exceptions and unit exceptions may apply (see state exceptions; e.g., Missouri Medicaid has a unit exception allowing 18 units for CPT 77300).

Additional reimbursement rules may apply (for example: IMRT, CCI procedure-to-procedure edits, and Maximum Frequency Per Day) and may affect reimbursement determination.

Coding and Reimbursable Codes

Treatment planning codesCPTCovered

77261	Therapeutic radiology clinical treatment planning – moderate complexity
77262	Therapeutic radiology clinical treatment planning – complex
77263	Therapeutic radiology clinical treatment planning – comprehensive

Examples of treatment management / related codes with reimbursable unit guidanceCPTCovered

77300	Basic dosimetry calculation
77280	Simulation

Reimbursable units per 90-day episode

Reimbursable units policyReimbursable units are limited per treatment planning episode; units billed in excess of the reimbursable units per 90‑day episode will not be considered for reimbursement.

Scope of unitsUnits capture all reimbursable work associated with the initial treatment planning codes (CPT 77261, 77262, 77263) during the episode.

Application to treatment management codesWithin the episode of care, UnitedHealthcare will consider reimbursement for services, procedures, and units outlined under the Treatment Management Codes section of the Applicable Codes.

Interaction with other reimbursement policiesAdditional reimbursement policies (e.g., IMRT, CCI, Maximum Frequency Per Day) may apply to these codes and affect unit reimbursement.

State exceptions notedSome states have exceptions to unit rules (document lists state exemptions and unit exceptions such as Missouri allowing 18 units for CPT 77300).

Provider Actions and Billing Rules

Billing Rule

Episode-based unit limits and billing rules

Do not bill more reimbursable units per 90‑day episode than allowed. An episode of care begins when one of the therapeutic radiology treatment planning CPT codes (77261, 77262, 77263) is billed; units billed in excess of the reimbursable units per treatment planning episode will not be considered for reimbursement and will be denied. A new 90‑day episode begins when a new planning code is billed or when the patient’s condition changes such that an additional planning code is appropriate.

Episode starts when CPT 77261, 77262, or 77263 is billed; only one planning code is allowed per episode unless patient condition change justifies a new episode. [[do not include in user content]]

Billing Rule

Modifier handling for unit accumulation

When calculating allowed reimbursable units, professional (26) and technical (TC) components billed with the same code are counted together; other modifiers may be appended but do not affect accumulation of units.

Definitions

Episode of Care

Episode startAn episode of care begins when the first therapeutic radiology clinical treatment planning code (77261, 77262, or 77263) is billed.

Episode durationThe episode extends up to 90 days or until a new treatment planning code is billed (which starts a new episode).

Coverage within episodeWithin the episode of care, reimbursement is considered for services, procedures, and units listed in the Treatment Management Codes section of the policy.

Effect of excess unitsUnits billed in excess of the reimbursable units for the episode will not be considered for reimbursement.

State-specific notesState exceptions may modify episode or unit rules (see policy state exceptions for details).