The Intensity Modulated Radiation Therapy (IMRT) Policy addresses when an IMRT simulation is performed on the same tumor within 90 days prior to an IMRT plan, reimbursement of the simulation will be included in the reimbursement for the IMRT plan whether the simulation is reported on the same or different date of service. In addition, the IMRT policy addresses certain radiation therapy services that may be performed 30 days prior to, on, or as part of the development of the IMRT plan.
For purposes of this policy, the Same Group Physician and/or Other Health Care Professional is defined as all physicians and/or other health care professionals of the same group reporting the same Federal Tax Identification number.
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Q: There are NCCI edits that address IMRT simulation and planning codes; how does this policy differ from NCCI?
A: Current NCCI procedure-to-procedure edits between CPT code 77301 and pre-IMRT plan simulation codes (77280-77290) address codes reported on the same date of service and do not address simulation codes billed on different dates of service.
Q: Will UnitedHealthcare reimburse an IMRT simulation after an IMRT plan has been executed to accommodate changes to the tumor(s) or when tumor(s) have appeared in a new location?
A: Yes. UnitedHealthcare understands the need to perform subsequent IMRT simulation(s) after treatment has begun to adjust for changes to the patient’s condition and will reimburse IMRT simulations reported after treatment has begun.
Q: Will UnitedHealthcare reimburse more than one subsequent IMRT simulation?
A: A simulation service after an IMRT has been performed may be reimbursed when reported with modifier 59 or XU to indicate it was performed in support of a separate and distinct non-IMRT radiation therapy for a different tumor.
Q: Will UnitedHealthcare reimburse for an additional IMRT treatment plan if the patient’s care requires a Boost Treatment?
A: Yes. If the patient’s condition requires a Boost Treatment, an additional IMRT treatment may be reimbursed when reported with modifier 59 or XU to indicate it was performed separate and distinct from the original IMRT plan.
Q: When will UnitedHealthcare consider image guidance (CPT 77014) for separate reimbursement after an IMRT plan (77301) has been executed?
A: Image guidance may be considered for separate reimbursement when not performed on the same date of services as the IMRT plan (77301).