LCD Reference Article Billing and Coding Article

Billing and Coding: Proton Beam Therapy

A56827

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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.

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Contractor Information

Article Information

General Information

Source Article ID
N/A
Article ID
A56827
Original ICD-9 Article ID
Not Applicable
Article Title
Billing and Coding: Proton Beam Therapy
Article Type
Billing and Coding
Original Effective Date
11/07/2019
Revision Effective Date
10/01/2021
Revision Ending Date
N/A
Retirement Date
N/A

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.

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CMS National Coverage Policy

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Article Guidance

Article Text

This article contains coding and other guidelines that complement the Local Coverage Determination (LCD) for Proton Beam Therapy.

 

Coding Information:

Procedure codes may be subject to National Correct Coding Initiative (NCCI) edits or OPPS packaging edits. Refer to NCCI and OPPS requirements prior to billing Medicare.

For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim.

A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.

The diagnosis code(s) must best describe the patient's condition for which the service was performed. For diagnostic tests, report the result of the test if known; otherwise the symptoms prompting the performance of the test should be reported.

Documentation Requirements:

The patient's medical record must contain documentation that fully supports the medical necessity for services included within the related LCD. (See "Indications and Limitations of Coverage.") This documentation includes, but is not limited to, relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures.


Documentation in the patient medical record must:

  1. Support one or more medical necessity requirement(s) as provided under the "Indications and Limitations of Coverage and/or Medical Necessity" section of this policy.
  2. Include a treatment prescription that defines the goals of the treatment plan- including specific dose-volume parameters for the target and nearby critical structures- as well as pertinent details of beam delivery, such as method of beam modulation, field arrangement, and expected positional and range uncertainties.
  3. Include a treatment plan, signed by a physician, which meets the prescribed dose-volume parameters for the clinical target volume (CTV) and surrounding organs at risk (OARs) in the presence of expected uncertainties.
  4. Describe the target setup verification methodology, including patient positioning, immobilization and use of image guidance.
  5. Include verification of planned dose distribution via independent dose calculation or physical measurement.

Response To Comments

Number Comment Response
1
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Coding Information

Bill Type Codes

Code Description

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Revenue Codes

Code Description

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CPT/HCPCS Codes

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CPT/HCPCS Modifiers

Group 1

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Group 1 Codes

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ICD-10-CM Codes that Support Medical Necessity

Group 1

(218 Codes)
Group 1 Paragraph

Note: ICD-10 codes must be coded to the highest level of specificity

Group 1 Codes
Code Description
C00.0 - C14.8 Malignant neoplasm of external upper lip - Malignant neoplasm of overlapping sites of lip, oral cavity and pharynx
C30.0 - C32.9 Malignant neoplasm of nasal cavity - Malignant neoplasm of larynx, unspecified
C40.00 - C40.82 Malignant neoplasm of scapula and long bones of unspecified upper limb - Malignant neoplasm of overlapping sites of bone and articular cartilage of left limb
C41.0 - C41.2 Malignant neoplasm of bones of skull and face - Malignant neoplasm of vertebral column
C41.3 Malignant neoplasm of ribs, sternum and clavicle
C41.4 Malignant neoplasm of pelvic bones, sacrum and coccyx
C41.9 Malignant neoplasm of bone and articular cartilage, unspecified
C45.1 Mesothelioma of peritoneum
C45.7 Mesothelioma of other sites
C47.0 Malignant neoplasm of peripheral nerves of head, face and neck
C48.0 Malignant neoplasm of retroperitoneum
C48.8 Malignant neoplasm of overlapping sites of retroperitoneum and peritoneum
C49.0 Malignant neoplasm of connective and soft tissue of head, face and neck
C64.1 - C64.9 Malignant neoplasm of right kidney, except renal pelvis - Malignant neoplasm of unspecified kidney, except renal pelvis
C69.00 - C72.9 Malignant neoplasm of unspecified conjunctiva - Malignant neoplasm of central nervous system, unspecified
C75.0 Malignant neoplasm of parathyroid gland
C75.1 - C75.3 Malignant neoplasm of pituitary gland - Malignant neoplasm of pineal gland
C75.5 Malignant neoplasm of aortic body and other paraganglia
C7A.8 Other malignant neuroendocrine tumors
C76.0 - C76.8 Malignant neoplasm of head, face and neck - Malignant neoplasm of other specified ill-defined sites
C78.7 Secondary malignant neoplasm of liver and intrahepatic bile duct
C79.31 Secondary malignant neoplasm of brain
D32.0 - D33.9 Benign neoplasm of cerebral meninges - Benign neoplasm of central nervous system, unspecified
D35.2 - D35.4 Benign neoplasm of pituitary gland - Benign neoplasm of pineal gland
D35.6 Benign neoplasm of aortic body and other paraganglia
D42.0 - D43.2 Neoplasm of uncertain behavior of cerebral meninges - Neoplasm of uncertain behavior of brain, unspecified
D43.4 Neoplasm of uncertain behavior of spinal cord
D44.10 - D44.12 Neoplasm of uncertain behavior of unspecified adrenal gland - Neoplasm of uncertain behavior of left adrenal gland
D44.3 - D44.5 Neoplasm of uncertain behavior of pituitary gland - Neoplasm of uncertain behavior of pineal gland
D44.6 - D44.7 Neoplasm of uncertain behavior of carotid body - Neoplasm of uncertain behavior of aortic body and other paraganglia
D49.6 - D49.7 Neoplasm of unspecified behavior of brain - Neoplasm of unspecified behavior of endocrine glands and other parts of nervous system
G95.20 - G95.29 Unspecified cord compression - Other cord compression
G95.9 Disease of spinal cord, unspecified
Q28.2 - Q28.3 Arteriovenous malformation of cerebral vessels - Other malformations of cerebral vessels

Group 2

(344 Codes)
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Asterisk

* ICD-10 codes T66.XXXA, T66.XXXD, T66.XXXS (Effects of Radiation, Unspecified) and Z92.3 (Personal History of Irradiation) may only be used where prior radiation therapy to the site is the governing factor necessitating PBT in lieu of other radiotherapy. An ICD-10 diagnosis code for the anatomic diagnosis must also be used with appropriate documentation.

Group 2 Codes
Code Description
C15.3 Malignant neoplasm of upper third of esophagus
C15.4 Malignant neoplasm of middle third of esophagus
C15.5 Malignant neoplasm of lower third of esophagus
C15.8 Malignant neoplasm of overlapping sites of esophagus
C16.0 Malignant neoplasm of cardia
C19 - C25.9 Malignant neoplasm of rectosigmoid junction - Malignant neoplasm of pancreas, unspecified
C33 - C34.92 Malignant neoplasm of trachea - Malignant neoplasm of unspecified part of left bronchus or lung
C38.4 Malignant neoplasm of pleura
C39.0 - C39.9 Malignant neoplasm of upper respiratory tract, part unspecified - Malignant neoplasm of lower respiratory tract, part unspecified
C43.0 Malignant melanoma of lip
C43.111 Malignant melanoma of right upper eyelid, including canthus
C43.112 Malignant melanoma of right lower eyelid, including canthus
C43.121 Malignant melanoma of left upper eyelid, including canthus
C43.122 Malignant melanoma of left lower eyelid, including canthus
C43.21 - C43.22 Malignant melanoma of right ear and external auricular canal - Malignant melanoma of left ear and external auricular canal
C43.31 Malignant melanoma of nose
C43.39 Malignant melanoma of other parts of face
C43.4 Malignant melanoma of scalp and neck
C43.59 Malignant melanoma of other part of trunk
C44.00 - C44.1292 Unspecified malignant neoplasm of skin of lip - Squamous cell carcinoma of skin of left lower eyelid, including canthus
C44.1321 - C44.99 Sebaceous cell carcinoma of skin of right upper eyelid, including canthus - Other specified malignant neoplasm of skin, unspecified
C45.0 Mesothelioma of pleura
C50.011 - C58 Malignant neoplasm of nipple and areola, right female breast - Malignant neoplasm of placenta
C61 Malignant neoplasm of prostate
C69.01 - C69.02 Malignant neoplasm of right conjunctiva - Malignant neoplasm of left conjunctiva
C74.00 - C74.92 Malignant neoplasm of cortex of unspecified adrenal gland - Malignant neoplasm of unspecified part of left adrenal gland
C76.3 Malignant neoplasm of pelvis
C79.32 - C79.49 Secondary malignant neoplasm of cerebral meninges - Secondary malignant neoplasm of other parts of nervous system
C81.01 - C81.03 Nodular lymphocyte predominant Hodgkin lymphoma, lymph nodes of head, face, and neck - Nodular lymphocyte predominant Hodgkin lymphoma, intra-abdominal lymph nodes
C81.06 Nodular lymphocyte predominant Hodgkin lymphoma, intrapelvic lymph nodes
C81.11 - C81.13 Nodular sclerosis Hodgkin lymphoma, lymph nodes of head, face, and neck - Nodular sclerosis Hodgkin lymphoma, intra-abdominal lymph nodes
C81.16 Nodular sclerosis Hodgkin lymphoma, intrapelvic lymph nodes
C81.21 - C81.23 Mixed cellularity Hodgkin lymphoma, lymph nodes of head, face, and neck - Mixed cellularity Hodgkin lymphoma, intra-abdominal lymph nodes
C81.26 Mixed cellularity Hodgkin lymphoma, intrapelvic lymph nodes
C81.31 - C81.33 Lymphocyte depleted Hodgkin lymphoma, lymph nodes of head, face, and neck - Lymphocyte depleted Hodgkin lymphoma, intra-abdominal lymph nodes
C81.36 Lymphocyte depleted Hodgkin lymphoma, intrapelvic lymph nodes
C81.41 - C81.43 Lymphocyte-rich Hodgkin lymphoma, lymph nodes of head, face, and neck - Lymphocyte-rich Hodgkin lymphoma, intra-abdominal lymph nodes
C81.46 Lymphocyte-rich Hodgkin lymphoma, intrapelvic lymph nodes
C81.71 - C81.73 Other Hodgkin lymphoma, lymph nodes of head, face, and neck - Other Hodgkin lymphoma, intra-abdominal lymph nodes
C81.76 Other Hodgkin lymphoma, intrapelvic lymph nodes
C81.91 - C81.93 Hodgkin lymphoma, unspecified, lymph nodes of head, face, and neck - Hodgkin lymphoma, unspecified, intra-abdominal lymph nodes
C81.96 Hodgkin lymphoma, unspecified, intrapelvic lymph nodes
C82.01 - C82.03 Follicular lymphoma grade I, lymph nodes of head, face, and neck - Follicular lymphoma grade I, intra-abdominal lymph nodes
C82.06 Follicular lymphoma grade I, intrapelvic lymph nodes
C82.11 - C82.13 Follicular lymphoma grade II, lymph nodes of head, face, and neck - Follicular lymphoma grade II, intra-abdominal lymph nodes
C82.16 Follicular lymphoma grade II, intrapelvic lymph nodes
C82.21 - C82.23 Follicular lymphoma grade III, unspecified, lymph nodes of head, face, and neck - Follicular lymphoma grade III, unspecified, intra-abdominal lymph nodes
C82.26 Follicular lymphoma grade III, unspecified, intrapelvic lymph nodes
C82.31 - C82.33 Follicular lymphoma grade IIIa, lymph nodes of head, face, and neck - Follicular lymphoma grade IIIa, intra-abdominal lymph nodes
C82.36 Follicular lymphoma grade IIIa, intrapelvic lymph nodes
C82.41 - C82.43 Follicular lymphoma grade IIIb, lymph nodes of head, face, and neck - Follicular lymphoma grade IIIb, intra-abdominal lymph nodes
C82.46 Follicular lymphoma grade IIIb, intrapelvic lymph nodes
C82.61 - C82.63 Cutaneous follicle center lymphoma, lymph nodes of head, face, and neck - Cutaneous follicle center lymphoma, intra-abdominal lymph nodes
C82.66 Cutaneous follicle center lymphoma, intrapelvic lymph nodes
C82.81 - C82.83 Other types of follicular lymphoma, lymph nodes of head, face, and neck - Other types of follicular lymphoma, intra-abdominal lymph nodes
C82.86 Other types of follicular lymphoma, intrapelvic lymph nodes
C82.91 - C82.93 Follicular lymphoma, unspecified, lymph nodes of head, face, and neck - Follicular lymphoma, unspecified, intra-abdominal lymph nodes
C82.96 Follicular lymphoma, unspecified, intrapelvic lymph nodes
C83.31 - C83.33 Diffuse large B-cell lymphoma, lymph nodes of head, face, and neck - Diffuse large B-cell lymphoma, intra-abdominal lymph nodes
C83.36 Diffuse large B-cell lymphoma, intrapelvic lymph nodes
C85.21 - C85.23 Mediastinal (thymic) large B-cell lymphoma, lymph nodes of head, face, and neck - Mediastinal (thymic) large B-cell lymphoma, intra-abdominal lymph nodes
C85.26 Mediastinal (thymic) large B-cell lymphoma, intrapelvic lymph nodes
D03.21 - D03.22 Melanoma in situ of right ear and external auricular canal - Melanoma in situ of left ear and external auricular canal
T66.XXXA Radiation sickness, unspecified, initial encounter
T66.XXXD Radiation sickness, unspecified, subsequent encounter
T66.XXXS Radiation sickness, unspecified, sequela
Z92.3 Personal history of irradiation
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ICD-10-CM Codes that DO NOT Support Medical Necessity

Group 1

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Any diagnosis not listed above.

 

Group 1 Codes

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ICD-10-PCS Codes

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Group 1 Codes

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Additional ICD-10 Information

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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

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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.

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Code Description

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Other Coding Information

Group 1

Group 1 Paragraph

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Group 1 Codes

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

Revision History Date Revision History Number Revision History Explanation
10/01/2021 R1

Based on the annual ICD-10 updates for 2022, C56.3 was added to ICD-10 Codes that Support Medical Necessity Group 2 code range C50.011 - C58.

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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
L35075 - Proton Beam Therapy
Related National Coverage Documents
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SAD Process URL 2
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Public Versions
Updated On Effective Dates Status
09/24/2021 10/01/2021 - N/A Currently in Effect You are here
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