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Jurisdiction 11 Part B
Medical Review Probe: Outpatient Oncology Radiation Therapy Procedure Codes

The J11 A/B MAC Medical Review department will perform a service-specific prepay probe review on outpatient claims in North Carolina, South Carolina, Virginia and West Virginia. Data analysis identified 13 oncology radiation therapy outpatient services with significant frequency in these states. Further analysis indicated the procedure codes listed below as most frequently billed codes for oncology radiation therapy in North Carolina, South Carolina, Virginia and West Virginia. Claims review will be performed on approximately 100 claims per state for each of the procedure codes selected. The procedure codes identified are:

  • CPT code 77418 (Intensity modulated treatment delivery, single or multiple fields/arcs, via narrow spatially and temporally modulated beams, binary, dynamic mlc, per treatment session)
  • CPT code 77413 (Radiation treatment delivery, three or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam: 6-10 mev)
  • CPT code 77427 (Radiation treatment management, five treatments)
  • CPT code 77295 (Therapeutic radiology simulation-aided field setting: 3-dimensional)
  • CPT code 77334 (Treatment devices, design and construction: complex(irregular blocks, special shields, compensators, wedges, molds or casts)
  • CPT code 77300 (Basic radiation dosimetry calculation, central axis depth dose calculation, TDF, NSD, gap calculation, off axis factor, tissue inhomogeneity factors, calculation of non-ionizing radiation surface and depth dose, as required during course of treatment)
  • CPT code 77290 (Therapeutic radiology simulation-aided field setting: complex)
  • CPT code 77336 (Continuing medical physics consultation, including assessment of treatment parameters, quality assurance of dose delivery, and review of patient treatment documentation in support of the radiation oncologist, reported per week of therapy)
  • CPT code 77280 (Therapeutic radiology simulation-aided field setting simple)
  • CPT code 77263 (Therapeutic radiology treatment planning: complex)
  • CPT code 77470 (Special treatment procedure - e.g., total body irradiation, hemibody radiation, per oral, endocavitary or intraoperative cone irradiation)
  • CPT code 77331 (Special dosimetry -e.g., tld, microdosimetry - (specify), only when prescribed by the treating physician)
  • CPT code 77417 (Therapeutic radiology port film(s)

Providers who receive an Additional Documentation Request (ADR) must submit the requested medical record information within 30 days to:

J11 Part B Medical Review
Mail Code: AG-230
P.O. Box 100238
Columbia, SC  29202-3238

Or fax it to (803) 699-2434

Providers should ensure the accuracy of their billing and send the following documentation when responding to the ADRs:

  • Patient’ medical record
  • Chart notes
  • Diagnostic test results/reports, including imaging reports
  • Clinical/therapy notes
  • Physician progress notes
  • Please submit all documentation to support the medical necessity of services/ procedure code billed
  • If you question the legibility of your signature, you may submit a signature log or an attestation statement in your ADR response. Medicare requires that medical record entries for services provided/ordered be authenticated by the author. The method used shall be a handwritten or an electronic signature. Stamp signatures are not acceptable. Patient identification, date of service and provider of the service should be clearly identified on the submitted documentation.

Completed review results will be posted to the Palmetto GBA website. Individual providers with significant denials will be contacted for one-on-one education.

 

last updated on 04/11/2012
ver 1.0.37