LCD Reference Article Billing and Coding Article

Billing and Coding: Intraoperative Radiation Therapy

A56684

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Draft Article
Draft Articles are works in progress and not necessarily a reflection of the current billing and coding practices. Revisions to codes are carefully and thoroughly reviewed and are not intended to change the original intent of the LCD.

Document Note

Note History

Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A56684
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Intraoperative Radiation Therapy
Article Type
Billing and Coding
Original Effective Date
07/11/2019
Revision Effective Date
01/01/2023
Revision Ending Date
N/A
Retirement Date
N/A
AMA CPT / ADA CDT / AHA NUBC Copyright Statement

CPT codes, descriptions and other data only are copyright 2023 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

Current Dental Terminology © 2023 American Dental Association. All rights reserved.

Copyright © 2023, the American Hospital Association, Chicago, Illinois. Reproduced with permission. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be copied without the express written consent of the AHA. AHA copyrighted materials including the UB‐04 codes and descriptions may not be removed, copied, or utilized within any software, product, service, solution or derivative work without the written consent of the AHA. If an entity wishes to utilize any AHA materials, please contact the AHA at 312‐893‐6816.

Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB‐04 Manual and/or codes and descriptions; and/or making any commercial use of UB‐04 Manual or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. The American Hospital Association (the "AHA") has not reviewed, and is not responsible for, the completeness or accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the preparation of this material, or the analysis of information provided in the material. The views and/or positions presented in the material do not necessarily represent the views of the AHA. CMS and its products and services are not endorsed by the AHA or any of its affiliates.

CMS National Coverage Policy

Title XVIII of the Social Security Act, §1833(e) prohibits Medicare payment for any claim lacking the necessary information to process that claim.

Article Guidance

Article Text

The information in this article contains billing, coding or other guidelines that complement the Local Coverage Determination (LCD) for Intraoperative Radiation Therapy L37779.

ICD-10-CM diagnosis codes supporting medical necessity must be submitted with each claim. Claims submitted without such evidence will be denied as not medically necessary.

Response To Comments

Number Comment Response
1
N/A

Coding Information

Bill Type Codes

Code Description
N/A

Revenue Codes

Code Description
N/A

CPT/HCPCS Codes

Group 1

(6 Codes)
Group 1 Paragraph

These CPT/HCPCS codes are considered medically necessary when Coverage Indications, Limitations and/or Medical Necessity are met as outlined in the Intraoperative Radiation Therapy L37779 LCD.

"C" HCPCS codes are applicable to Part A outpatient services only.

Group 1 Codes
Code Description
19294 PREPARATION OF TUMOR CAVITY, WITH PLACEMENT OF A RADIATION THERAPY APPLICATOR FOR INTRAOPERATIVE RADIATION THERAPY (IORT) CONCURRENT WITH PARTIAL MASTECTOMY (LIST SEPARATELY IN ADDITION TO CODE FOR PRIMARY PROCEDURE)
76145 MEDICAL PHYSICS DOSE EVALUATION FOR RADIATION EXPOSURE THAT EXCEEDS INSTITUTIONAL REVIEW THRESHOLD, INCLUDING REPORT
77424 INTRAOPERATIVE RADIATION TREATMENT DELIVERY, X-RAY, SINGLE TREATMENT SESSION
77425 INTRAOPERATIVE RADIATION TREATMENT DELIVERY, ELECTRONS, SINGLE TREATMENT SESSION
77469 INTRAOPERATIVE RADIATION TREATMENT MANAGEMENT
C9726 PLACEMENT AND REMOVAL (IF PERFORMED) OF APPLICATOR INTO BREAST FOR INTRAOPERATIVE RADIATION THERAPY, ADD-ON TO PRIMARY BREAST PROCEDURE
N/A

CPT/HCPCS Modifiers

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

ICD-10-CM Codes that Support Medical Necessity

Group 1

(35 Codes)
Group 1 Paragraph

For CPT® codes 76145, 77424, 77425 and 77469-intraoperative radiation management and delivery

The following ICD-10 codes can be billed as stand-alone primary diagnoses:

Group 1 Codes
Code Description
C18.0 Malignant neoplasm of cecum
C18.1 Malignant neoplasm of appendix
C18.2 Malignant neoplasm of ascending colon
C18.3 Malignant neoplasm of hepatic flexure
C18.4 Malignant neoplasm of transverse colon
C18.5 Malignant neoplasm of splenic flexure
C18.6 Malignant neoplasm of descending colon
C18.7 Malignant neoplasm of sigmoid colon
C18.8 Malignant neoplasm of overlapping sites of colon
C18.9 Malignant neoplasm of colon, unspecified
C19 Malignant neoplasm of rectosigmoid junction
C20 Malignant neoplasm of rectum
C48.0 Malignant neoplasm of retroperitoneum
C49.0 Malignant neoplasm of connective and soft tissue of head, face and neck
C49.11 Malignant neoplasm of connective and soft tissue of right upper limb, including shoulder
C49.12 Malignant neoplasm of connective and soft tissue of left upper limb, including shoulder
C49.21 Malignant neoplasm of connective and soft tissue of right lower limb, including hip
C49.22 Malignant neoplasm of connective and soft tissue of left lower limb, including hip
C49.3 Malignant neoplasm of connective and soft tissue of thorax
C49.4 Malignant neoplasm of connective and soft tissue of abdomen
C49.5 Malignant neoplasm of connective and soft tissue of pelvis
C49.6 Malignant neoplasm of connective and soft tissue of trunk, unspecified
C49.8 Malignant neoplasm of overlapping sites of connective and soft tissue
C49.9 Malignant neoplasm of connective and soft tissue, unspecified
C53.0 Malignant neoplasm of endocervix
C53.1 Malignant neoplasm of exocervix
C53.8 Malignant neoplasm of overlapping sites of cervix uteri
C53.9 Malignant neoplasm of cervix uteri, unspecified
C54.0 Malignant neoplasm of isthmus uteri
C54.1 Malignant neoplasm of endometrium
C54.2 Malignant neoplasm of myometrium
C54.3 Malignant neoplasm of fundus uteri
C54.8 Malignant neoplasm of overlapping sites of corpus uteri
C54.9 Malignant neoplasm of corpus uteri, unspecified
C55 Malignant neoplasm of uterus, part unspecified

Group 2

(19 Codes)
Group 2 Paragraph

For CPT® codes 19294, 76145, 77424, 77425, 77469 and C9726 -procedures concerning intraoperative radiation in the treatment of invasive malignancies of the breast

**NOTE- The following ICD-10 codes describe invasive malignancies of the breast. As per the Coverage Indications in the Intraoperative Radiation Therapy L37779 LCD, the beneficiary must be a woman who is 50 years of age or greater. When any ICD-10 code in the range C50.011-C50.912 is billed, it must be billed in conjunction with the specific secondary ICD-10 code to indicate ER positive status- Z17.0. The billing of Z17.0 alone is not sufficient for claim payment.

Group 2 Codes
Code Description
C50.011 Malignant neoplasm of nipple and areola, right female breast
C50.012 Malignant neoplasm of nipple and areola, left female breast
C50.111 Malignant neoplasm of central portion of right female breast
C50.112 Malignant neoplasm of central portion of left female breast
C50.211 Malignant neoplasm of upper-inner quadrant of right female breast
C50.212 Malignant neoplasm of upper-inner quadrant of left female breast
C50.311 Malignant neoplasm of lower-inner quadrant of right female breast
C50.312 Malignant neoplasm of lower-inner quadrant of left female breast
C50.411 Malignant neoplasm of upper-outer quadrant of right female breast
C50.412 Malignant neoplasm of upper-outer quadrant of left female breast
C50.511 Malignant neoplasm of lower-outer quadrant of right female breast
C50.512 Malignant neoplasm of lower-outer quadrant of left female breast
C50.611 Malignant neoplasm of axillary tail of right female breast
C50.612 Malignant neoplasm of axillary tail of left female breast
C50.811 Malignant neoplasm of overlapping sites of right female breast
C50.812 Malignant neoplasm of overlapping sites of left female breast
C50.911 Malignant neoplasm of unspecified site of right female breast
C50.912 Malignant neoplasm of unspecified site of left female breast
Z17.0 Estrogen receptor positive status [ER+]

Group 3

(2 Codes)
Group 3 Paragraph

For CPT® codes 19294, 76145, 77424, 77425, 77469 and C9726- procedures concerning intraoperative radiation in the treatment of intraductal carcinoma in situ.

The following ICD-10 codes describe intraductal carcinoma in situ of the breast:

Group 3 Codes
Code Description
D05.11 Intraductal carcinoma in situ of right breast
D05.12 Intraductal carcinoma in situ of left breast
N/A

ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

Group 1 Paragraph

All other codes not listed under Covered ICD-10 Codes

Group 1 Codes

N/A

N/A

ICD-10-PCS Codes

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Additional ICD-10 Information

N/A

Bill Type Codes

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the article should be assumed to apply equally to all claims.

Code Description
N/A

Revenue Codes

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the article should be assumed to apply equally to all Revenue Codes.

Code Description
N/A

Other Coding Information

Group 1

Group 1 Paragraph

N/A

Group 1 Codes

N/A

N/A

Coding Table Information

Excluded CPT/HCPCS Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A N/A
N/A
Non-Excluded CPT/HCPCS Ended Codes - Table Format
Code Descriptor Generic Name Descriptor Brand Name Exclusion Effective Date Exclusion End Date Reason for Exclusion
N/A

Revision History Information

Revision History Date Revision History Number Revision History Explanation
01/01/2023 R6

Under CPT/HCPCS Codes Group 1: Codes the description was revised for 19294. This revision is due to the 2023 Annual/Q1 CPT/HCPCS Code Update and is retroactive effective for dates of service on or after 1/1/23.

07/01/2021 R5

Formatting was corrected throughout the article.

01/01/2021 R4

Under ICD-10 Codes that Support Medical Necessity Group 2: Paragraph and ICD-10 Codes that Support Medical Necessity Group 3: Paragraph: added 76145. This revision is due to the Q1 2021 CPT/HCPCS Code Update and is retroactive effective for dates of service on or after 1/1/2021.

01/01/2021 R3

Under CPT/HCPCS Codes Group 1 Codes: added 76145. Under ICD-10 Codes that Support Medical Necessity Group 1 Paragraph: added 76145. This revision is due to the Q1 2021 CPT/HCPCS Code Update and is retroactive effective for dates of service on or after 1/1/2021.

10/10/2019 R2

This article is being revised in order to adhere to CMS requirements per Chapter 13, Section 13.5.1 of the Program Integrity Manual, to remove all coding from LCDs and incorporate into related Billing and Coding Articles. Title XVIII of the Social Security Act, §1833(e) was removed from the CMS National Coverage Policy section of the related Intraoperative Radiation Therapy L37779 LCD and placed in this article.

07/11/2019 R1

All coding located in the Coding Information section has been removed from the related Intraoperative Radiation Therapy L37779 LCD and added to this article.

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Associated Documents

Medicare BPM Ch 15.50.2 SAD Determinations
Medicare BPM Ch 15.50.2
Related Local Coverage Documents
LCDs
L37779 - Intraoperative Radiation Therapy
Related National Coverage Documents
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SAD Process URL 1
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SAD Process URL 2
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Statutory Requirements URLs
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Rules and Regulations URLs
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CMS Manual Explanations URLs
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Other URLs
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Public Versions
Updated On Effective Dates Status
01/11/2023 01/01/2023 - N/A Currently in Effect You are here
Some older versions have been archived. Please visit the MCD Archive Site to retrieve them.

Keywords

  • IORT
  • Radiation Therapy