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Intensity-Modulated Radiation Therapy (IMRT) Reimbursement Policy

As part of our continued efforts to reinforce accurate coding practices for timely claim processing and proper reimbursement, We will be implementing a new Intensity-Modulated Radiation Therapy (IMRT) claims and payment policy. 

This policy will have the following Medicare effective dates:

  • July 1, 2019 – CA, CT, FL, GA, HI, IL, LA, NJ, NY, SC
  • July 1, 2019 – UAM – ME, TX
  • October 1, 2019 – AL, AR, MS, TN, TX

This policy will have the following Medicaid effective dates:

  • July 1, 2019 – MO, SC
  • August 1, 2019 – FL, GA, NJ, NY
  • September 1, 2019 –  HI , NE                                                                                                                                                                                                                                                                                                                                                                                             

What does this mean for providers?

Our claims team will enforce the new Claims and Payment Policy (Policy Number: 108) for Intensity Modulated Radiation Therapy (IMRT). IMRT, delivers radiation with focused intensity to preserve adjoining healthy tissue. It is typically provided in two treatment phases, planning and delivery. Per the Centers for Medicare & Medicaid Services (CMS), CPT codes 77014, 77280, 77285, 77290, 77295, 77306, 77307, 77316, 77317, 77318, 77321, 77331 and 77370 are included in the payment for CPT code 77301 (IMRT Planning). Providers should not report these codes in addition to CPT code 77301, when provided prior to, or as part of, the development of the IMRT plan.

We  are aligning with CMS Guidelines by including the payment for CPT codes 77014, 77280, 77285, 77290, 77295, 77306, 77307, 77316, 77317, 77318, 77321, 77331 and 77370, in the payment for IMRT planning CPT code – 77301, even if the individual services associated with IMRT planning are performed on date of service other than the date on which CPT code 77301 is reported. These services are considered incidental to IMRT planning and thus Providers should not be reporting them in addition to CPT code 77301, on either the same or different date of service.

Why is this necessary?

  • To ensure that members receive the appropriate frequency of services established by coding guidelines and in accordance with CMS policy.
  • To manage and coordinate care throughout the duration of service.
  • To ensure that radiation therapy facilities receive appropriate payment for services based on authorized intensity of care while aligning with accepted coding guidelines.

Please review the complete policy on our website, https://www.ohanahealthplan.com/. Click on Providers, visit the Claims page and look under Payment Policy.

We are here to help. If you need further information, please contact us at 1-888-846-4262, Monday–Friday, 7:45 a.m.–4:30 p.m.

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Last Updated On: 5/31/2019