Horizon Blue Cross Blue Shield of New Jersey 2012 Radiation Therapy Payment Rules
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- Oswald Robertson
- 8 years ago
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1 Description Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or wout cytosocopy Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter) prostate, single or multiple Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter) prostate, single or multiple Description Source Placement of needles, catheters, or other device(s) into the head and/or neck region (percutaneous, transoral, or transnasal) for subsequent interstitial radioelement application Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), percutaneous, intra-abdominal, intra-pelvic (except prostate), and/or retroperitoneum, single or multiple ( ) py Guidance (Eg, Fiducial Markers, Dosimeter), Open, Intra- Abdominal, Intrapelvic, And/Or Retroperitoneum, Including Image Guidance, If Performed, Single Or Multiple (List Separately In Addition To For Primary Procedure) Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or out cytosocopy Insertion of a vaginal radiation afterloading apparatus for clinical brachytherapy Ultrasound Localization of Radiation Therapy Fields 0197T Intra-fraction localization and tracking of target or patient motion during delivery of radiation therapy (eg, 3D positional tracking, gating, 3D surface tracking), each fraction of treatment CT guidance for placement of radiation therapy fields Ultrasound Localization of Radiation Therapy Fields CT guidance for placement of radiation therapy fields stereoscopic x-ray guidance for localization of target volume CT guidance for placement of radiation therapy fields 0197T Intra-fraction localization and tracking of target or patient motion during delivery of radiation therapy (eg, 3D positional tracking, gating, 3D surface tracking), each fraction of treatment Therapeutic Radiology treatment planning;simple Continuing medical physics consultation Therapeutic Radiology treatment planning; intermediate Therapeutic Radiology treatment planning;simple Therapeutic Radiology treatment planning; intermediate Continuing medical physics consultation Therapeutic Radiology treatment planning; complex Therapeutic Radiology treatment planning;simple Therapeutic Radiology treatment planning; complex Therapeutic Radiology treatment planning; intermediate Therapeutic Radiology treatment planning; complex Continuing medical physics consultation Therapeutic Radiology Simulation; simple Continuing medical physics consultation Therapeutic Radiology Simulation; intermediate Therapeutic Radiology Simulation; simple Therapeutic Radiology Simulation; intermediate Continuing medical physics consultation Therapeutic Radiology Simulation; complex Therapeutic Radiology Simulation; simple Therapeutic Radiology Simulation; complex Therapeutic Radiology Simulation; intermediate Therapeutic Radiology Simulation; complex Continuing medical physics consultation Therapeutic Radiology Simulation 3-Dimensional CT guidance for placement of radiation therapy fields Therapeutic Radiology Simulation 3-Dimensional Therapeutic Radiology Simulation; simple Therapeutic Radiology Simulation 3-Dimensional Therapeutic Radiology Simulation; intermediate Therapeutic Radiology Simulation 3-Dimensional Therapeutic Radiology Simulation; complex Therapeutic Radiology Simulation 3-Dimensional Teletherapy isodose plan simple Updated 3/19/2012 1
2 Description Description Source Therapeutic Radiology Simulation 3-Dimensional Teletherapy isodose plan; intermediate Therapeutic Radiology Simulation 3-Dimensional Teletherapy Isodose plan; complex Therapeutic Radiology Simulation 3-Dimensional Continuing medical physics consultation Basic Radiation Dosimetry Special radiation dosimetry IMRT Planning Ultrasound Localization of Radiation Therapy Fields IMRT Planning CT guidance for placement of radiation therapy fields IMRT Planning Therapeutic Radiology treatment planning;simple IMRT Planning Therapeutic Radiology treatment planning; intermediate IMRT Planning Therapeutic Radiology treatment planning; complex IMRT Planning Therapeutic Radiology Simulation; simple IMRT Planning Therapeutic Radiology Simulation; intermediate IMRT Planning Therapeutic Radiology Simulation; complex IMRT Planning Therapeutic Radiology Simulation 3-Dimensional IMRT Planning Teletherapy isodose plan simple IMRT Planning Teletherapy isodose plan; intermediate IMRT Planning Teletherapy Isodose plan; complex IMRT Planning Special Teletherapy port plan, particles, hemibody, total body IMRT Planning Brachytherapy Isodose Plan; simple IMRT Planning Brachytherapy Isodose Plan; intermediate IMRT Planning Brachytherapy Isodose Plan; complex IMRT Planning Special radiation dosimetry IMRT Planning Treatment Devices; simple IMRT Planning Treatment Devices; intermediate IMRT Planning Treatment Devices; complex IMRT Planning Continuing medical physics consultation IMRT Planning Special medical physics consultation IMRT Planning Radiation treatment delivery; superficial and/or ortho voltage IMRT Planning IMRT Planning MeV Updated 3/19/2012 2
3 Description IMRT Planning IMRT Planning IMRT Planning IMRT Planning Description Source 10 MeV blocks; up blocks; 6-10 MeV IMRT Planning blocks; MeV IMRT Planning IMRT Planning IMRT Planning IMRT Planning IMRT Planning blocks; 20 MeV or greater rotational beam, compensators, electron beam; up greater IMRT Planning Therapeutic Radiology Port Films IMRT Planning stereoscopic x-ray guidance for localization of target volume IMRT Planning Neutron beam tx, simple IMRT Planning Neutron beam tx, complex IMRT Planning Radiation treatment management, five treatments IMRT Planning IMRT Planning therapy consisting of 1-2 fractions Stereotactic radiation treatment management cerebral lesion(s) complete course of treatment consisting of 1 session IMRT Planning IMRT Planning Stereotactic body radiation treatment management per treatment course; 1 or more lesions, including image guidance entire course not to exceed 5 fractions Special Treatment Procedure (eg. Total body radiation, hemibody radiation, per oral endocavity or intraoperative cone irradiation) IMRT Planning Proton treatment delivery, simple w/o compensation Updated 3/19/2012 3
4 Description Description Source IMRT Planning Proton treatment delivery, simple w/ compensation IMRT Planning Proton treatment delivery, intermediate IMRT Planning Proton treatment delivery, complex Teletherapy isodose plan simple CT guidance for placement of radiation therapy fields Teletherapy isodose plan simple Continuing medical physics consultation Teletherapy isodose plan; intermediate CT guidance for placement of radiation therapy fields Teletherapy isodose plan; intermediate Teletherapy isodose plan simple Teletherapy isodose plan; intermediate Continuing medical physics consultation Teletherapy Isodose plan; complex CT guidance for placement of radiation therapy fields Teletherapy Isodose plan; complex Teletherapy isodose plan simple Teletherapy Isodose plan; complex Teletherapy isodose plan; intermediate Teletherapy Isodose plan; complex Continuing medical physics consultation Special Teletherapy port plan, particles, hemibody, total body Teletherapy isodose plan simple Special Teletherapy port plan, particles, hemibody, total body Teletherapy isodose plan; intermediate Special Teletherapy port plan, particles, hemibody, total body Teletherapy Isodose plan; complex Special Teletherapy port plan, particles, hemibody, total body Continuing medical physics consultation Brachytherapy Isodose Plan; simple Continuing medical physics consultation Brachytherapy Isodose Plan; intermediate Brachytherapy Isodose Plan; simple Brachytherapy Isodose Plan; intermediate Continuing medical physics consultation Brachytherapy Isodose Plan; complex Brachytherapy Isodose Plan; simple Brachytherapy Isodose Plan; complex Brachytherapy Isodose Plan; intermediate Brachytherapy Isodose Plan; complex Continuing medical physics consultation Treatment Devices; simple Continuing medical physics consultation Treatment Devices; intermediate Treatment Devices; simple Treatment Devices; intermediate Continuing medical physics consultation Treatment Devices; complex Treatment Devices; simple Treatment Devices; complex Treatment Devices; intermediate Treatment Devices; complex Continuing medical physics consultation Continuing medical physics consultation Special medical physics consultation Multi-leaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction per IMRT plan 0073T Compensator-based IMRT delivery Updated 3/19/2012 4
5 Description Description Source Multi-leaf Collimator (MLC) device(s) for intensity modulated radiation theratpy (IMRT), design and construction per IMRT plan Treatment Devices; simple Multi-leaf Collimator (MLC) device(s) for intensity modulated radiation theratpy (IMRT), design and construction per IMRT plan Treatment Devices; intermediate Multi-leaf Collimator (MLC) device(s) for intensity modulated radiation theratpy (IMRT), design and construction per IMRT plan Treatment Devices; complex Cobalt 60 based Ultrasound Localization of Radiation Therapy Fields Cobalt 60 based CT guidance for placement of radiation therapy fields Cobalt 60 based Teletherapy isodose plan simple Cobalt 60 based Teletherapy isodose plan; intermediate Cobalt 60 based Teletherapy Isodose plan; complex Cobalt 60 based Brachytherapy Isodose Plan; simple Cobalt 60 based Brachytherapy Isodose Plan; intermediate Cobalt 60 based Brachytherapy Isodose Plan; complex Cobalt 60 based Treatment Devices; simple Cobalt 60 based Treatment Devices; intermediate Cobalt 60 based of treatment of cerebral lesion(s) 1 session, linac based Cobalt 60 based Radiation treatment delivery; superficial and/or ortho voltage Cobalt 60 based Updated 3/19/2012 5
6 Description Cobalt 60 based Cobalt 60 based Cobalt 60 based Cobalt 60 based Cobalt 60 based Cobalt 60 based Description Source 19 MeV 10 MeV blocks; up blocks; 6-10 MeV blocks; MeV Cobalt 60 based blocks; 20 MeV or greater Cobalt 60 based Cobalt 60 based Cobalt 60 based Cobalt 60 based rotational beam, compensators, electron beam; up greater Cobalt 60 based stereoscopic x-ray guidance for localization of target volume Cobalt 60 based Neutron beam tx, simple Cobalt 60 based Neutron beam tx, complex Cobalt 60 based Radiation treatment management, five treatments Cobalt 60 based Cobalt 60 based Cobalt 60 based therapy consisting of 1-2 fractions Stereotactic body radiation treatment management per treatment course; 1 or more lesions, including image guidance entire course not to exceed 5 fractions Special Treatment Procedure (eg. Total body radiation, hemibody radiation, per oral endocavity or intraoperative cone irradiation) Updated 3/19/2012 6
7 Description Cobalt 60 based Description g g p Source motion during delivery of radiation therapy (eg, 3D positional tracking, gating, 3D surface tracking), each fraction of 0197T treatment Cobalt 60 based G0251 Stereotactic, 2-5 Treatments Cobalt 60 based G0339 Robotic stereotactic surgery 1 session Cobalt 60 based G0340 Robotic stereotactic radiosugery 2 through 5 sessions of treatment of cerebral lesion(s) 1 session, linac based Ultrasound Localization of Radiation Therapy Fields of treatment of cerebral lesion(s) 1 session, linac based CT guidance for placement of radiation therapy fields of treatment of cerebral lesion(s) 1 session, linac based Teletherapy isodose plan simple of treatment of cerebral lesion(s) 1 session, linac based Teletherapy isodose plan; intermediate of treatment of cerebral lesion(s) 1 session, linac based Teletherapy Isodose plan; complex of treatment of cerebral lesion(s) 1 session, linac based Brachytherapy Isodose Plan; simple of treatment of cerebral lesion(s) 1 session, linac based Brachytherapy Isodose Plan; intermediate of treatment of cerebral lesion(s) 1 session, linac based Brachytherapy Isodose Plan; complex of treatment of cerebral lesion(s) 1 session, linac based Treatment Devices; simple of treatment of cerebral lesion(s) 1 session, linac based Treatment Devices; intermediate of treatment of cerebral lesion(s) 1 session, linac based Radiation treatment delivery; superficial and/or ortho voltage of treatment of cerebral lesion(s) 1 session, linac based of treatment of cerebral lesion(s) 1 session, linac based of treatment of cerebral lesion(s) 1 session, linac based of treatment of cerebral lesion(s) 1 session, linac based MeV 10 MeV blocks; up Updated 3/19/2012 7
8 Description of treatment of cerebral lesion(s) 1 session, linac based of treatment of cerebral lesion(s) 1 session, linac based of treatment of cerebral lesion(s) 1 session, linac based of treatment of cerebral lesion(s) 1 session, linac based of treatment of cerebral lesion(s) 1 session, linac based of treatment of cerebral lesion(s) 1 session, linac based Description Source blocks; 6-10 MeV blocks; MeV blocks; 20 MeV or greater y; p y; p y; p greater of treatment of cerebral lesion(s) 1 session, linac based stereoscopic x-ray guidance for localization of target volume of treatment of cerebral lesion(s) 1 session, linac based Neutron beam tx, simple of treatment of cerebral lesion(s) 1 session, linac based Neutron beam tx, complex of treatment of cerebral lesion(s) 1 session, linac based Radiation treatment management, five treatments of treatment of cerebral lesion(s) 1 session, linac based of treatment of cerebral lesion(s) 1 session, linac based of treatment of cerebral lesion(s) 1 session, linac based of treatment of cerebral lesion(s) 1 session, linac based 0197T therapy consisting of 1-2 fractions Stereotactic body radiation treatment management per treatment course; 1 or more lesions, including image guidance entire course not to exceed 5 fractions Special Treatment Procedure (eg. Total body radiation, hemibody radiation, per oral endocavity or intraoperative cone irradiation) g g p motion during delivery of radiation therapy (eg, 3D positional tracking, gating, 3D surface tracking), each fraction of treatment of treatment of cerebral lesion(s) 1 session, linac based G0251 Stereotactic, 2-5 Treatments of treatment of cerebral lesion(s) 1 session, linac based G0339 Robotic stereotactic surgery 1 session of treatment of cerebral lesion(s) 1 session, linac based G0340 Robotic stereotactic radiosugery 2 through 5 sessions fractions Ultrasound Localization of Radiation Therapy Fields fractions CT guidance for placement of radiation therapy fields Updated 3/19/2012 8
9 Description Description Source fractions Teletherapy isodose plan simple fractions Teletherapy isodose plan; intermediate fractions Teletherapy Isodose plan; complex fractions Brachytherapy Isodose Plan; simple fractions Brachytherapy Isodose Plan; intermediate fractions Brachytherapy Isodose Plan; complex fractions Treatment Devices; simple fractions Treatment Devices; intermediate fractions fractions Cobalt 60 based of treatment of cerebral lesion(s) 1 session, linac based fractions Radiation treatment delivery; superficial and/or ortho voltage fractions fractions fractions fractions fractions fractions fractions fractions MeV 10 MeV blocks; 6-10 MeV blocks; MeV blocks; 20 MeV or greater rotational beam, compensators, electron beam; up Updated 3/19/2012 9
10 Description fractions fractions fractions y; Description p Source y; p y; p greater fractions stereoscopic x-ray guidance for localization of target volume fractions Neutron beam tx, simple fractions Neutron beam tx, complex fractions Radiation treatment management, five treatments fractions fractions fractions fractions 0197T therapy consisting of 1-2 fractions Stereotactic radiation treatment management cerebral lesion(s) complete course of treatment consisting of 1 session Special Treatment Procedure (eg. Total body radiation, hemibody radiation, per oral endocavity or intraoperative cone irradiation) g g p motion during delivery of radiation therapy (eg, 3D positional tracking, gating, 3D surface tracking), each fraction of treatment fractions G0251 Stereotactic, 2-5 Treatments fractions G0339 Robotic stereotactic surgery 1 session fractions G0340 Robotic stereotactic radiosugery 2 through 5 sessions Radiation treatment delivery; superficial and/or ortho voltage Neutron beam tx, simple Radiation treatment delivery; superficial and/or ortho voltage 0073T Compensator-based IMRT delivery CPT/AMA Radiation treatment delivery; superficial and/or ortho voltage Neutron beam tx, simple 0073T Compensator-based IMRT delivery CPT/AMA Updated 3/19/
11 Description Description Source port or parallel opposed ports, simple blocks or no blocks; MeV 0073T Compensator-based IMRT delivery CPT/AMA 19 MeV Radiation treatment delivery; superficial and/or ortho voltage 19 MeV MeV Neutron beam tx, simple 19 MeV Proton treatment delivery, simple w/o compensation port or parallel opposed ports, simple blocks or no blocks; 6-10 MeV 0073T Compensator-based IMRT delivery CPT/AMA 10 MeV Radiation treatment delivery; superficial and/or ortho voltage 10 MeV MeV MeV 10 MeV Neutron beam tx, simple port or parallel opposed ports, simple blocks or no blocks; T Compensator-based IMRT delivery CPT/AMA Radiation treatment delivery; superficial and/or ortho voltage MeV 10 MeV Neutron beam tx, simple blocks; up 0073T Compensator-based IMRT delivery CPT/AMA blocks; up Radiation treatment delivery; superficial and/or ortho voltage blocks; up Updated 3/19/
12 Description blocks; up blocks; up blocks; up Description Source 19 MeV 10 MeV blocks; up Neutron beam tx, simple blocks; up Proton treatment delivery, simple w/o compensation blocks; 6-10 MeV 0073T Compensator-based IMRT delivery CPT/AMA blocks; 6-10 MeV Radiation treatment delivery; superficial and/or ortho voltage blocks; 6-10 MeV blocks; 6-10 MeV blocks; 6-10 MeV blocks; 6-10 MeV blocks; 6-10 MeV MeV 10 MeV blocks; up blocks; 6-10 MeV Neutron beam tx, simple blocks; MeV 0073T Compensator-based IMRT delivery CPT/AMA blocks; MeV Radiation treatment delivery; superficial and/or ortho voltage blocks; MeV blocks; MeV blocks; MeV blocks; MeV MeV 10 MeV Updated 3/19/
13 Description blocks; MeV blocks; MeV Description Source blocks; up blocks; 6-10 MeV blocks; MeV Neutron beam tx, simple blocks; 20 MeV or greater 0073T Compensator-based IMRT delivery CPT/AMA blocks; 20 MeV or greater Radiation treatment delivery; superficial and/or ortho voltage blocks; 20 MeV or greater blocks; 20 MeV or greater blocks; 20 MeV or greater MeV 10 MeV blocks; 20 MeV or greater blocks; 20 MeV or greater blocks; up blocks; 20 MeV or greater blocks; 6-10 MeV blocks; 20 MeV or greater blocks; MeV blocks; 20 MeV or greater Neutron beam tx, simple rotational beam, compensators, electron beam; up 0073T Compensator-based IMRT delivery CPT/AMA rotational beam, compensators, electron beam; up Radiation treatment delivery; superficial and/or ortho voltage rotational beam, compensators, electron beam; up Updated 3/19/
14 Description Description Source rotational beam, compensators, electron beam; up rotational beam, compensators, electron beam; up MeV 10 MeV rotational beam, compensators, electron beam; up rotational beam, compensators, electron beam; up blocks; up rotational beam, compensators, electron beam; up blocks; 6-10 MeV rotational beam, compensators, electron beam; up blocks; MeV rotational beam, compensators, electron beam; up blocks; 20 MeV or greater rotational beam, compensators, electron beam; up Neutron beam tx, simple rotational beam, compensators, electron beam; up Neutron beam tx, complex 0073T Compensator-based IMRT delivery CPT/AMA Radiation treatment delivery; superficial and/or ortho voltage MeV 10 MeV Updated 3/19/
15 Description Description Source blocks; up blocks; 6-10 MeV blocks; MeV blocks; 20 MeV or greater rotational beam, compensators, electron beam; up Neutron beam tx, simple Neutron beam tx, complex 0073T Compensator-based IMRT delivery CPT/AMA Radiation treatment delivery; superficial and/or ortho voltage MeV 10 MeV blocks; up blocks; 6-10 MeV Updated 3/19/
16 Description Description Source blocks; 20 MeV or greater rotational beam, compensators, electron beam; up Neutron beam tx, simple Neutron beam tx, complex greater 0073T Compensator-based IMRT delivery CPT/AMA greater Radiation treatment delivery; superficial and/or ortho voltage greater greater greater greater greater greater greater greater MeV 10 MeV blocks; up blocks; 6-10 MeV blocks; MeV blocks; 20 MeV or greater Updated 3/19/
17 Description greater greater greater Description Source rotational beam, compensators, electron beam; up greater Neutron beam tx, simple greater Neutron beam tx, complex IMRT Treatment Delivery; single or multiple fields/arcs, via dynamic MLC, per treatment session 0073T Compensator-based IMRT delivery CPT/AMA dynamic MLC, per treatment session Ultrasound guidance for interstitial radioelement application dynamic MLC, per treatment session Therapeutic Radiology treatment planning;simple dynamic MLC, per treatment session Therapeutic Radiology treatment planning; intermediate dynamic MLC, per treatment session Therapeutic Radiology treatment planning; complex dynamic MLC, per treatment session Teletherapy isodose plan simple dynamic MLC, per treatment session Teletherapy isodose plan; intermediate dynamic MLC, per treatment session Teletherapy Isodose plan; complex dynamic MLC, per treatment session Special Teletherapy port plan, particles, hemibody, total body dynamic MLC, per treatment session Brachytherapy Isodose Plan; simple Updated 3/19/
18 Description Description Source dynamic MLC, per treatment session Brachytherapy Isodose Plan; intermediate dynamic MLC, per treatment session Brachytherapy Isodose Plan; complex dynamic MLC, per treatment session Special radiation dosimetry IMRT Treatment Delivery; single or multiple fields/arcs, via dynamic MLC, per treatment session Treatment Devices; simple IMRT Treatment Delivery; single or multiple fields/arcs, via dynamic MLC, per treatment session Treatment Devices; intermediate IMRT Treatment Delivery; single or multiple fields/arcs, via dynamic MLC, per treatment session Treatment Devices; complex IMRT Treatment Delivery; single or multiple fields/arcs, via dynamic MLC, per treatment session Multi-leaf Collimator (MLC) device(s) for intensity modulated radiation theratpy (IMRT), design and construction per IMRT plan dynamic MLC, per treatment session Cobalt 60 based dynamic MLC, per treatment session of treatment of cerebral lesion(s) 1 session, linac based dynamic MLC, per treatment session fractions dynamic MLC, per treatment session Radiation treatment delivery; superficial and/or ortho voltage dynamic MLC, per treatment session dynamic MLC, per treatment session dynamic MLC, per treatment session MeV 10 MeV dynamic MLC, per treatment session Updated 3/19/
19 Description Description Source dynamic MLC, per treatment session blocks; up dynamic MLC, per treatment session blocks; 6-10 MeV dynamic MLC, per treatment session blocks; MeV dynamic MLC, per treatment session blocks; 20 MeV or greater dynamic MLC, per treatment session dynamic MLC, per treatment session dynamic MLC, per treatment session dynamic MLC, per treatment session rotational beam, compensators, electron beam; up greater dynamic MLC, per treatment session Neutron beam tx, simple dynamic MLC, per treatment session Neutron beam tx, complex dynamic MLC, per treatment session Stereotactic radiation treatment management cerebral lesion(s) complete course of treatment consisting of 1 session dynamic MLC, per treatment session Stereotactic body radiation treatment management per treatment course; 1 or more lesions, including image guidance entire course not to exceed 5 fractions dynamic MLC, per treatment session Special Treatment Procedure (eg. Total body radiation, hemibody radiation, per oral endocavity or intraoperative cone irradiation) dynamic MLC, per treatment session Proton treatment delivery, simple w/o compensation dynamic MLC, per treatment session Proton treatment delivery, simple w/ compensation Updated 3/19/
20 Description Description Source dynamic MLC, per treatment session Proton treatment delivery, intermediate dynamic MLC, per treatment session Proton treatment delivery, complex dynamic MLC, per treatment session 0073T Compensator-based IMRT delivery dynamic MLC, per treatment session G0339 Robotic stereotactic surgery 1 session dynamic MLC, per treatment session G0340 Robotic stereotactic radiosugery 2 through 5 sessions stereoscopic x-ray guidance for localization of target volume Ultrasound Localization of Radiation Therapy Fields stereoscopic x-ray guidance for localization of target volume 0197T Intra-fraction localization and tracking of target or patient motion during delivery of radiation therapy (eg, 3D positional tracking, gating, 3D surface tracking), each fraction of treatment Neutron beam tx, simple Proton treatment delivery, simple w/o compensation Neutron beam tx, complex Radiation treatment delivery; superficial and/or ortho voltage Neutron beam tx, complex Neutron beam tx, complex Neutron beam tx, complex MeV 10 MeV Neutron beam tx, complex Neutron beam tx, complex blocks; up Neutron beam tx, complex blocks; 6-10 MeV Updated 3/19/
21 Description Description Source Neutron beam tx, complex blocks; MeV Neutron beam tx, complex blocks; 20 MeV or greater Neutron beam tx, complex Neutron beam tx, simple Neutron beam tx, complex Proton treatment delivery, simple w/o compensation Radiation treatment management, five treatments Stereotactic radiation treatment management cerebral lesion(s) complete course of treatment consisting of 1 session Radiation treatment management, five treatments G0339 Robotic stereotactic surgery 1 session Radiation treatment management, five treatments G0340 Robotic stereotactic radiosugery 2 through 5 sessions therapy consisting of 1-2 fractions Ultrasound Localization of Radiation Therapy Fields therapy consisting of 1-2 fractions Radiation treatment management, five treatments therapy consisting of 1-2 fractions G0339 Robotic stereotactic surgery 1 session therapy consisting of 1-2 fractions Stereotactic radiation treatment management cerebral G0340 Robotic stereotactic radiosugery 2 through 5 sessions lesion(s) complete course of treatment consisting of 1 session stereoscopic x-ray guidance for localization of target volume Stereotactic radiation treatment management cerebral lesion(s) complete course of treatment consisting of 1 session therapy consisting of 1-2 fractions Stereotactic body radiation treatment management per treatment course; 1 or more lesions, including image guidance entire course not to exceed 5 fractions stereoscopic x-ray guidance for localization of target volume Stereotactic body radiation treatment management per treatment course; 1 or more lesions, including image guidance entire course not to exceed 5 fractions Radiation treatment management, five treatments Stereotactic body radiation treatment management per treatment course; 1 or more lesions, including image guidance entire course not to exceed 5 fractions therapy consisting of 1-2 fractions Stereotactic body radiation treatment management per treatment course; 1 or more lesions, including image guidance entire course not to exceed 5 fractions Stereotactic radiation treatment management cerebral lesion(s) complete course of treatment consisting of 1 session Stereotactic body radiation treatment management per treatment course; 1 or more lesions, including image guidance entire course not to exceed 5 fractions Special Treatment Procedure (eg. Total body radiation, hemibody radiation, per oral endocavity or intraoperative cone irradiation) Special Treatment Procedure (eg. Total body radiation, hemibody radiation, per oral endocavity or intraoperative cone irradiation) Stereotactic radiation treatment management cerebral lesion(s) complete course of treatment consisting of 1 session Special Treatment Procedure (eg. Total body radiation, hemibody radiation, per oral endocavity or intraoperative cone irradiation) G0339 Robotic stereotactic surgery 1 session Updated 3/19/
22 77470 Description Description Source Special Treatment Procedure (eg. Total body radiation, hemibody radiation, per oral endocavity or intraoperative cone irradiation) G0340 Robotic stereotactic radiosugery 2 through 5 sessions Proton treatment delivery, simple w/o compensation Cobalt 60 based Proton treatment delivery, simple w/o compensation of treatment of cerebral lesion(s) 1 session, linac based Proton treatment delivery, simple w/o compensation fractions Proton treatment delivery, simple w/o compensation Radiation treatment delivery; superficial and/or ortho voltage Proton treatment delivery, simple w/o compensation Proton treatment delivery, simple w/o compensation Proton treatment delivery, simple w/o compensation MeV 10 MeV Proton treatment delivery, simple w/o compensation Proton treatment delivery, simple w/o compensation blocks; up Proton treatment delivery, simple w/o compensation blocks; 6-10 MeV Proton treatment delivery, simple w/o compensation blocks; MeV Proton treatment delivery, simple w/o compensation blocks; 20 MeV or greater Proton treatment delivery, simple w/o compensation Proton treatment delivery, simple w/o compensation rotational beam, compensators, electron beam; up Updated 3/19/
23 Description Proton treatment delivery, simple w/o compensation Proton treatment delivery, simple w/o compensation Description Source greater Proton treatment delivery, simple w/o compensation G0251 Stereotactic, 2-5 Treatments Proton treatment delivery, simple w/o compensation G0339 Robotic stereotactic surgery 1 session Proton treatment delivery, simple w/o compensation G0340 Robotic stereotactic radiosugery 2 through 5 sessions Proton treatment delivery, simple w/ compensation Cobalt 60 based Proton treatment delivery, simple w/ compensation of treatment of cerebral lesion(s) 1 session, linac based Proton treatment delivery, simple w/ compensation fractions Proton treatment delivery, simple w/ compensation Radiation treatment delivery; superficial and/or ortho voltage Proton treatment delivery, simple w/ compensation Proton treatment delivery, simple w/ compensation Proton treatment delivery, simple w/ compensation MeV 10 MeV Proton treatment delivery, simple w/ compensation Proton treatment delivery, simple w/ compensation blocks; up Proton treatment delivery, simple w/ compensation blocks; MeV Proton treatment delivery, simple w/ compensation blocks; 20 MeV or greater Proton treatment delivery, simple w/ compensation rotational beam, compensators, electron beam; up Updated 3/19/
24 Description Proton treatment delivery, simple w/ compensation Proton treatment delivery, simple w/ compensation Proton treatment delivery, simple w/ compensation Description Source greater Proton treatment delivery, simple w/ compensation Proton treatment delivery, simple w/o compensation Proton treatment delivery, simple w/ compensation G0251 Stereotactic, 2-5 Treatments Proton treatment delivery, simple w/ compensation G0339 Robotic stereotactic surgery 1 session Proton treatment delivery, simple w/ compensation G0340 Robotic stereotactic radiosugery 2 through 5 sessions Proton treatment delivery, intermediate Cobalt 60 based Proton treatment delivery, intermediate of treatment of cerebral lesion(s) 1 session, linac based Proton treatment delivery, intermediate fractions Proton treatment delivery, intermediate Radiation treatment delivery; superficial and/or ortho voltage Proton treatment delivery, intermediate Proton treatment delivery, intermediate Proton treatment delivery, intermediate MeV 10 MeV Proton treatment delivery, intermediate Updated 3/19/
25 Description Description Source Proton treatment delivery, intermediate blocks; up Proton treatment delivery, intermediate blocks; 6-10 MeV Proton treatment delivery, intermediate blocks; MeV Proton treatment delivery, intermediate blocks; 20 MeV or greater Proton treatment delivery, intermediate Proton treatment delivery, intermediate Proton treatment delivery, intermediate Proton treatment delivery, intermediate rotational beam, compensators, electron beam; up greater Proton treatment delivery, intermediate Proton treatment delivery, simple w/o compensation Proton treatment delivery, intermediate Proton treatment delivery, simple w/ compensation Proton treatment delivery, intermediate G0251 Stereotactic, 2-5 Treatments Proton treatment delivery, intermediate G0339 Robotic stereotactic surgery 1 session Proton treatment delivery, intermediate G0340 Robotic stereotactic radiosugery 2 through 5 sessions Proton treatment delivery, complex Cobalt 60 based Proton treatment delivery, complex of treatment of cerebral lesion(s) 1 session, linac based Proton treatment delivery, complex fractions Proton treatment delivery, complex Radiation treatment delivery; superficial and/or ortho voltage Proton treatment delivery, complex Updated 3/19/
26 Description Description Source Proton treatment delivery, complex Proton treatment delivery, complex MeV 10 MeV Proton treatment delivery, complex Proton treatment delivery, complex blocks; up Proton treatment delivery, complex blocks; 6-10 MeV Proton treatment delivery, complex blocks; MeV Proton treatment delivery, complex blocks; 20 MeV or greater Proton treatment delivery, complex Proton treatment delivery, complex Proton treatment delivery, complex Proton treatment delivery, complex rotational beam, compensators, electron beam; up greater Proton treatment delivery, complex Proton treatment delivery, simple w/o compensation Proton treatment delivery, complex Proton treatment delivery, simple w/ compensation Proton treatment delivery, complex Proton treatment delivery, intermediate Proton treatment delivery, complex G0251 Stereotactic, 2-5 Treatments Proton treatment delivery, complex G0339 Robotic stereotactic surgery 1 session Proton treatment delivery, complex G0340 Robotic stereotactic radiosugery 2 through 5 sessions Hyperthermia treatment; externally generated, deep Therapeutic Radiology treatment planning;simple Hyperthermia treatment; externally generated, deep Therapeutic Radiology treatment planning; intermediate Hyperthermia treatment; externally generated, deep Therapeutic Radiology treatment planning; complex Hyperthermia treatment; externally generated, deep Basic Radiation Dosimetry Updated 3/19/
27 Description Description Source Hyperthermia treatment; externally generated, deep Special radiation dosimetry Hyperthermia treatment; externally generated, deep Treatment Devices; simple Hyperthermia treatment; externally generated, deep Treatment Devices; intermediate Hyperthermia treatment; externally generated, deep Treatment Devices; complex Hyperthermia treatment; externally generated, deep Continuing medical physics consultation Hyperthermia treatment; externally generated, deep Special medical physics consultation Hyperthermia treatment; externally generated, deep applicators Hyperthermia treatment; externally generated, deep Hyperthermia generated by interstitial probe(s); 5 or more applicators Hyperthermia treatment; externally generated, deep Hyperthermia generated by intracavitary probe(s) applicators Therapeutic Radiology treatment planning;simple applicators Therapeutic Radiology treatment planning; intermediate applicators Therapeutic Radiology treatment planning; complex applicators Basic Radiation Dosimetry applicators Special radiation dosimetry applicators Treatment Devices; simple applicators Treatment Devices; intermediate applicators Treatment Devices; complex applicators Continuing medical physics consultation applicators Special medical physics consultation Hyperthermia treatment; externally generated, superficial Hyperthermia treatment; externally generated, deep Hyperthermia treatment; externally generated, superficial Hyperthermia treatment; externally generated, superficial applicators Hyperthermia generated by interstitial probe(s); 5 or more applicators Hyperthermia treatment; externally generated, superficial Hyperthermia generated by intracavitary probe(s) applicators Therapeutic Radiology treatment planning;simple applicators Therapeutic Radiology treatment planning; intermediate applicators Therapeutic Radiology treatment planning; complex applicators Basic Radiation Dosimetry applicators Special radiation dosimetry applicators Treatment Devices; simple Updated 3/19/
28 Description Description Source applicators Treatment Devices; intermediate applicators Treatment Devices; complex applicators Continuing medical physics consultation applicators Special medical physics consultation applicators Hyperthermia treatment; externally generated, deep applicators Hyperthermia generated by intracavitary probe(s) Hyperthermia generated by interstitial probe(s); 5 or more applicators Therapeutic Radiology treatment planning;simple Hyperthermia generated by interstitial probe(s); 5 or more applicators Therapeutic Radiology treatment planning; intermediate Hyperthermia generated by interstitial probe(s); 5 or more applicators Therapeutic Radiology treatment planning; complex Hyperthermia generated by interstitial probe(s); 5 or more applicators Basic Radiation Dosimetry Hyperthermia generated by interstitial probe(s); 5 or more applicators Special radiation dosimetry Hyperthermia generated by interstitial probe(s); 5 or more applicators Treatment Devices; simple Hyperthermia generated by interstitial probe(s); 5 or more applicators Treatment Devices; intermediate Hyperthermia generated by interstitial probe(s); 5 or more applicators Treatment Devices; complex Hyperthermia generated by interstitial probe(s); 5 or more applicators Continuing medical physics consultation Hyperthermia generated by interstitial probe(s); 5 or more applicators Special medical physics consultation Hyperthermia generated by interstitial probe(s); 5 or more applicators applicators applicators Hyperthermia generated by intracavitary probe(s) Hyperthermia generated by intracavitary probe(s) Therapeutic Radiology treatment planning;simple Hyperthermia generated by intracavitary probe(s) Therapeutic Radiology treatment planning; intermediate Hyperthermia generated by intracavitary probe(s) Therapeutic Radiology treatment planning; complex Hyperthermia generated by intracavitary probe(s) Basic Radiation Dosimetry Hyperthermia generated by intracavitary probe(s) Special radiation dosimetry Hyperthermia generated by intracavitary probe(s) Treatment Devices; simple Hyperthermia generated by intracavitary probe(s) Treatment Devices; intermediate Hyperthermia generated by intracavitary probe(s) Treatment Devices; complex Hyperthermia generated by intracavitary probe(s) Continuing medical physics consultation Updated 3/19/
29 Description Description Source Hyperthermia generated by intracavitary probe(s) Special medical physics consultation Infusion or instillation of radioelement solution (includes 3- month follow-up care) Continuing medical physics consultation Infusion or instillation of radioelement solution (includes 3- month follow-up care) Radiation treatment management, five treatments Infusion or instillation of radioelement solution (includes 3- month follow-up care) Infusion or instillation of radioelement solution (includes 3- month follow-up care) Infusion or instillation of radioelement solution (includes 3- month follow-up care) Infusion or instillation of radioelement solution (includes 3- month follow-up care) therapy consisting of 1-2 fractions brachytherapy; 1 channel brachytherapy; 2-12 channels brachytherapy; over 12 channels Intracavitary radiation source application; simple Continuing medical physics consultation Intracavitary radiation source application; simple Radiation treatment management, five treatments Intracavitary radiation source application; simple Intracavitary radiation source application; simple Intracavitary radiation source application; simple Intracavitary radiation source application; simple therapy consisting of 1-2 fractions brachytherapy; 1 channel brachytherapy; 2-12 channels brachytherapy; over 12 channels Intracavitary radiation source application; simple 0182T High dose rate electronic brachytherapy, per fraction Intracavitary radiation source application; intermediate Continuing medical physics consultation Intracavitary radiation source application; intermediate Radiation treatment management, five treatments Intracavitary radiation source application; intermediate therapy consisting of 1-2 fractions Intracavitary radiation source application; intermediate Intracavitary radiation source application; simple Intracavitary radiation source application; intermediate Intracavitary radiation source application; intermediate Intracavitary radiation source application; intermediate brachytherapy; 1 channel brachytherapy; 2-12 channels brachytherapy; over 12 channels Intracavitary radiation source application; intermediate 0182T High dose rate electronic brachytherapy, per fraction Intracavitary radiation source application; complex Continuing medical physics consultation Intracavitary radiation source application; complex therapy consisting of 1-2 fractions Intracavitary radiation source application; complex Intracavitary radiation source application; simple Intracavitary radiation source application; complex Intracavitary radiation source application; intermediate Intracavitary radiation source application; complex brachytherapy; 1 channel Updated 3/19/
30 Description Intracavitary radiation source application; complex Intracavitary radiation source application; complex Description Source brachytherapy; 2-12 channels brachytherapy; over 12 channels Intracavitary radiation source application; complex 0182T High dose rate electronic brachytherapy, per fraction Interstitial radiation source; simple Continuing medical physics consultation Interstitial radiation source; simple Radiation treatment management, five treatments Interstitial radiation source; simple therapy consisting of 1-2 fractions Interstitial radiation source; simple Intracavitary radiation source application; simple Interstitial radiation source; simple Intracavitary radiation source application; intermediate Interstitial radiation source; simple Intracavitary radiation source application; complex Interstitial radiation source; simple Interstitial radiation source; simple Interstitial radiation source; simple brachytherapy; 1 channel brachytherapy; 2-12 channels brachytherapy; over 12 channels Interstitial radiation source; simple 0182T High dose rate electronic brachytherapy, per fraction Interstitial radiation source; intermediate Continuing medical physics consultation Interstitial radiation source; intermediate Radiation treatment management, five treatments Interstitial radiation source; intermediate therapy consisting of 1-2 fractions Interstitial radiation source; intermediate Intracavitary radiation source application; simple Interstitial radiation source; intermediate Intracavitary radiation source application; intermediate Interstitial radiation source; intermediate Intracavitary radiation source application; complex Interstitial radiation source; intermediate Interstitial radiation source; simple Interstitial radiation source; intermediate 0182T High dose rate electronic brachytherapy, per fraction Interstitial radiation source; complex Continuing medical physics consultation Interstitial radiation source; complex Radiation treatment management, five treatments Interstitial radiation source; complex therapy consisting of 1-2 fractions Interstitial radiation source; complex Intracavitary radiation source application; simple Interstitial radiation source; complex Intracavitary radiation source application; intermediate Interstitial radiation source; complex Intracavitary radiation source application; complex Updated 3/19/
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