Medicare Coverage of Intensity Modulated Radiation Therapy (IMRT)

Medicare makes bundled payments to hospitals to cover a range of Intensity Modulated Radiation Therapy (IMRT) planning services that may be performed to develop an IMRT treatment plan. IMRT is an advanced, high-precision type of radiation therapy used to treat cancer and noncancerous tumors by using computer-controlled linear accelerators to safely and painlessly deliver precise radiation doses to a malignant tumor or specific areas within the tumor while minimizing the dose to surrounding normal tissue.

IMRT is considered reasonable and necessary in instances where:

• Sparing the surrounding normal tissue is essential; and
• The patient has met all the conditions for IMRT as defined by CMS
  • An immediately adjacent area has been previously irradiated and abutting portals must be established with high precision
  • Dose escalation is planned to deliver radiation doses in excess of those commonly utilized for similar tumors with conventional treatment
  • The target volume is concave or convex, and the critical normal tissues are within or around that convexity or concavity
  • The target volume is in close proximity to critical structures that must be protected
  • The volume of interest must be covered with narrow margins to adequately protect immediately adjacent structures. According to the coding guide (ASTRO, 2015), the most common sites that currently support the use of IMRT include:
    • Carcinoma of the prostate
    • Primary, metastatic or benign tumors of the central nervous system, including the brain, brain stem and spinal cord
    • Primary, metastatic tumors of the spine where spinal cord tolerance may be exceeded by conventional treatment
    • Primary, metastatic or benign lesions to the head and neck area, including:
      • Aerodigestive tract
      • Orbits
      • Salivary glands
      • Sinuses
      • Skull base
  • Reirradiation that meets the requirements for medical necessity (as noted above)
  • Selected cases of thoracic and abdominal malignancies
  • Selected cases (e.g., nonroutine breast cancers with close proximity to critical structures)
  • Other pelvic and retro peritoneal tumors that meet requirements for medical necessity (as noted above)

IMRT allows for the radiation dose to be focused to regions within the tumor and conform more precisely to the three-dimensional (3-D) shape of the tumor by modulating — or controlling — the intensity of the radiation beam in multiple small volumes. Treatment is carefully planned by using 3-D computed tomography (CT) or magnetic resonance (MRI) images of the patient in conjunction with computerized dose calculations to determine the dose intensity pattern that will best conform to the tumor shape. Typically, combinations of multiple intensity-modulated fields coming from different beam directions produce a custom tailored radiation dose that maximizes tumor dose while also minimizing the dose to adjacent normal tissues.

Currently, IMRT is being used most extensively to treat cancers of the prostate, head and neck, and central nervous system. IMRT may be necessary in lung cancer cases involving bilateral mediastinal involvement, extension to the midline of the mediastinum, cardiac involvement, or tumor abutting or involving vertebrae or brachial plexus, or great vessels. Although not routinely indicated in breast cancer, IMRT may be necessary when more than 2 gantry angles are required to meet dose constraints or when internal mammary nodes must be treated. IMRT is also indicated in pancreatic cancer, anal cancer and for postoperative use in endometrial, cervical and advanced rectal cancer.

IMRT is provided in two treatment phases:

• Planning — Multistep process in which imaging, calculations, and simulations are performed to develop an IMRT treatment plan
• Delivery — Radiation is delivered to a beneficiary’s treatment site (i.e., a tumor) at the various intensity levels prescribed in the IMRT treatment plan.

In a recent Office of Inspector General (OIG) report (OIG A-09-16-02033), it was determined that Medicare payments for outpatient IMRT did not comply with Medicare billing requirements. To assess whether payments for outpatient IMRT planning services complied with Medicare billing requirements, the OIG selected a random sample of 100 line items for complex simulations billed by hospitals between June 2016 and February 2017. The sample represented payments of $21,390 to 91 hospitals. According to the findings, all 100 sampled line items resulted in improper payments for services performed as part of IMRT planning because the hospitals separately billed for complex simulations when they were performed as part of IMRT planning.

The OIG reviewed only planning services billed using CPT code 77290 to evaluate compliance with billing requirements and found that none of the line items in the sample met those requirements. Also, $4.2 million in potential overpayments for other IMRT planning services that were not included in the sample were identified as well. According to the report, the hospitals appeared to be unfamiliar with or misinterpreted CMS guidance for billing IMRT planning services. In addition, existing NCCI code-pair edits didn’t prevent overpayments for code 77290 because these edits applied only to services billed on the same day as code 77301, and the services in this sample were billed on different dates of service.

When IMRT is furnished to beneficiaries in a hospital outpatient department that is paid under the hospital Outpatient Prospective Payment System (OPPS), CPT codes 77014, 77280, 77285, 77290, 77295, 77306 through 77321, 77331, and 77370 are included in the Ambulatory Payment Classification (APC) payment for CPT code 77301 (IMRT planning). Therefore, these codes should not be reported in addition to CPT code 77301, when provided prior to, or as part of, the development of the IMRT plan. The charges for these services should instead be included in the charge associated with CPT code 77301, even if the individual services associated with IMRT planning are performed on dates of service other than the date on which CPT code 77301 is reported.

For more information on the actions CMS has taken or plans to take to address these recommendations see Appendix E of the OIG report (OIG A-09-16-02033).

Educational Resources:

MLN Matters Number: SE18013 (PDF, 70 KB)

Medicare Claims Processing Manual, Chapter 4, Section 200.3.1 (Instruction for IMRT services coding) (PDF, 1.2 MB)

MLN Matters Article MM9658 (PDF, 95 KB)

Office of Inspector General Report (OIG A-09-16-02033): Medicare Improperly Paid Hospitals Millions of Dollars for Intensity-Modulated Radiation Therapy Planning Services (PDF, 2.3 MB)