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Date Printed: June 25, 2017: 01:30 PM

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This medical policy (medical coverage guideline) is Copyright 2017, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2017 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.

04-77260-24

Original Effective Date: 05/01/16

Reviewed: 10/19/16

Revised: 11/15/16

Subject: Special Treatment Procedure and Special Physics Consult

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

           
Position Statement Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines
           
Other References Update      
           

DESCRIPTION:

Special treatment procedure describes the extra time, effort and resources associated with complex radiation therapy procedures and situations which are not reimbursed by another CPT® code. Several of these procedures are specifically described in the CPT® code definition including total body irradiation, hemibody radiation and per oral or endocavitary radiation. This code may also be used to report additional work and effort when a patient receives brachytherapy or concurrent chemotherapy along with a course of external beam radiation therapy. This code should not be used to report the work effort which is specifically described another CPT® code including but not limited to intensity modulated radiation therapy (IMRT), stereotactic body radiotherapy (SBRT), stereotactic radiosurgery (SRS) or intraoperative radiation therapy (IORT).

Special physics consult describes work performed by a qualified medical physicist to address a specific question or problem related to a complex radiation therapy plan. This only applies when the question to the physicist is beyond the scope of the routine physics work effort associated with radiation therapy planning and delivery. In response to a physician request, the physicist prepares a customized written report specifically addressing the issue in question. A special physics consult may be appropriate in cases of brachytherapy where the physicist is directly involved or when an a composite plan is generated by the physicist to reflect cumulative doses from different radiation modalities such as photons, electrons, charges particles and gamma rays. A special physics consult is also medically necessary when radiation dose to a fetus or medical device such as pacemaker needs to be measured. Special physics consult is appropriate when the physicist performs a fusion multiple images sets with or without associated dose distributions to be used by the physician in the development or analysis of a treatment plan. Special physics consult should not be used when fusion is performed by a non-physicist. A special physics consult may also apply to other specific treatment related questions when ordered by the radiation oncologist and appropriate documentation is provided.

POSITION STATEMENT:

Special treatment procedure meets the definition of medical necessity when extra planning time and effort can be documented for any of the following:

• Concurrent intravenous (I.V.) chemotherapy

• Brachytherapy

• Per oral or endocavitary irradiation not described by another CPT code

• Proton, neutron or charged particle therapy

• Total body or hemibody radiation

• Pediatric patient requiring anesthesia

• Hyperthermia

Reconstruction of previous radiation plan

Stereotactic body radiation therapy (SBRT)

• Other (documentation of special circumstances or time consuming plan required)

Special physics consult meets the definition of medical necessity when requested by physician for any of the following:

• Brachytherapy

• Fusion of multiple image sets (CT, MRI, PET) when performed by the medical physicist

• Dosimetric analysis of previous radiation field overlapping or abutting current field

• Analysis of dose to a fetus

• Analysis of dose to a pacemaker

• Stereotactic body radiation therapy (SBRT) with report of dosimetric parameters and specific organ tolerances met or exceeded

• Other specific physics work not described by another CPT code, at request of radiation oncologist

BILLING/CODING INFORMATION:

CPT Code:

The following codes may be used to describe special treatment procedure and special physics consult.

77370

Special medical radiation physics consultation

77470

Special treatment procedure (eg, total body irradiation, hemibody radiation, per oral or endocavitary irradiation)

LOINC Codes:

The following information may be required documentation to support medical necessity: physician history and physical, physician progress notes, plan of treatment and reason for special treatment procedure and special physics consult.

Documentation Table

LOINC Codes

LOINC
Time Frame
Modifier Code

LOINC Time Frame Modifier Codes Narrative

Physician history and physical

28626-0

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Attending physician progress note

18741-9

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

Plan of treatment

18776-5

18805-2

Include all data of the selected type that represents observations made six months or fewer before starting date of service for the claim

REIMBURSEMENT INFORMATION:

Special treatment procedure and special physics consults may each only be billed once per course of therapy

Refer to section entitled POSITION STATEMENT.

PROGRAM EXCEPTIONS:

Note: Coverage for special treatment procedure and special physics consult performed and billed in an outpatient or office location will be handled through the Radiation Oncology program for select products. AIM Specialty Health will determine coverage for special treatment procedure and special physics consult for select products. Refer to member's contract benefits.

Federal Employee Program (FEP): Follow FEP guidelines.

State Account Organization (SAO): Follow SAO guidelines.

Medicare Advantage products:

No National Coverage Determination (NCD) and/or Local Coverage Determination (LCD) were found at the time of the last guideline reviewed date.

DEFINITIONS:

No guideline specific definitions apply.

RELATED GUIDELINES:

None applicable.

OTHER:

None applicable.

REFERENCES:

  1. AIM Specialty Health Clinical Appropriateness Guideline: Radiation Oncology Special Treatment Procedure and Special Physics Consult, 11/16.

COMMITTEE APPROVAL:

This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 10/19/16.

GUIDELINE UPDATE INFORMATION:

05/01/16

New Medical Coverage Guideline.

08/15/16

Updated program exceptions.

11/15/16

Revision; revised position statement. Updated references.

Date Printed: June 25, 2017: 01:30 PM