Article - Billing and Coding: Intensity Modulated Radiation Therapy (IMRT) (A56746)

CMS National Coverage PolicySocial Security Act (Title XVIII) Standard References:Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider of services or other person under this part unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person under this part for the period with respect to which the amounts are being paid or for any prior period.Article TextThis Billing and Coding Article provides billing and coding guidance for Local Coverage Determination (LCD) L36773 Intensity Modulated Radiation Therapy (IMRT). Please refer to the LCD for reasonable and necessary requirements.Coding GuidanceNotice:It is not appropriate to bill Medicare for services that are not covered (as described by the entire LCD) as if they are covered. When billing for non-covered services, use the appropriate modifier.Documentation RequirementsAll documentation must be maintained in the patient's medical record and made available to the contractor upon request.Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service[s]). The documentation must include the legible signature of the physician or non-physician practitioner responsible for and providing the care to the patient.The submitted medical record must support the use of the selected ICD-10-CM code(s). The submitted CPT/HCPCS code must describe the service performed.Medical record documentation maintained by the provider must indicate the medical necessity for IMRT as outlined in the LCD L36773 and must include all of the following for IMRT planning and delivery:The treatment plan/prescription must define the goals and requirements of the treatment, including the specific dose constraints for the target(s) and nearby critical structures.A statement by the treating physician documenting the special need for performing IMRT on the patient in question, rather than performing conventional or three-dimensional treatment planning and delivery. The physician must address the other organs at risk or adjacent critical structures.Review (signed and dated) by the radiation oncologist of the CT or MRI based images of the target and all critical structures with representative isodose distributions that characterize the three-dimensional dose.Radiation oncologist review of dose-volume histograms for all targets and critical structures.Description of the number and location of each treatment step/rotation or portal to accomplish the treatment plan.Documentation of dosimetric verification of treatment setup and delivery, signed by both the radiation oncologist and the medical physicist.For compensator-based IMRT, the unique compensator design should be documented for each step or portal.Documentation of fluence distributions recomputed in a phantom, or an equivalent methodology consistent with patient specific IMRT treatment verification.Target verification methodology documentation to include documentation of the clinical treatment volume (CTV) and the planning target volume (PTV); documentation of immobilization and patient positioning, and means of dose verification and secondary means of verification.Other procedures performed during the episode of care must have documentation that supports the professional and technical components as applicable by identifying the place of service, the date of service, the supervising physician, and proof of work provided.