The requirements for IMRT have been consistent for quite some time but there is still much confusion in the field as to what exactly is necessary in order to use this form of treatment.  The two main requirements, as stated in most LCD’s, are: 1) the need for a statement of medical necessity by the physician for the use of IMRT, and 2) dose constraints and goals for critical structures. 

This medical necessity statement would not only indicate why IMRT is needed but also why it is necessary over conventional forms of treatment like 3D.  This should be provided up front prior to any planning being performed and in many cases is needed for any pre-authorizations required by the payer.  Many physicians do not include this statement of medical necessity in each medical record until they are requested by a payer after the treatment has been concluded.  There is another misconception that this information doesn’t need to be included for prostate IMRT planning and treatment since the efficacy of IMRT is widely published. 

The dose constraints, or organ goals, are another item commonly not found in the medical records reviewed.  Most centers believe that the information contained within the treatment plan is sufficient, but technically the plan cannot be generated without these constraints and goals being established.  This information is typically relayed to the dosimetrists but not always documented in the medical record.  Due to the IMRT requirements in most LCD’s it is necessary for the physician to provide this information prior to planning and is recommended at the time the plan is ordered.

Below is a quote from Highmark Medicare Services, Inc., and Trailblazer Health Enterprises, LLC.  The verbiage from both LCD’s is identical and these 2 MAC’s cover multiple states throughout the country.

• The prescription must define the goals and requirements of the treatment plan, 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 3-dimensional treatment planning and delivery.
• A signed IMRT inverse plan that meets prescribed dose constraints for the planning target volume (PTV) and surrounding normal tissue using either dynamic multi-leaf collimator (DMLC), segmented multi-leaf collimator (SMLC) (average number of "steps" required to meet IMRT delivery is 5), or inverse planned IMRT solid compensators to achieve intensity modulation radiation delivery.

Review your specific MAC’s documentation and medical necessity requirements and ensure that this information can be clearly identified in your medical record for each patient undergoing IMRT planning and IMRT treatment delivery. 

Compliant coding and achieving proper payment for BID HDR treatments and ancillary codes can be very tricky; careful attention must be paid to ensure accuracy.  When billing for any procedure code twice a day, once in the AM and again in the PM, there is a potential risk of the payer denying as a duplicate charge.  Modifiers, such as 76 Repeat Procedure or Service by Same Physician, can be utilized to indicate to the payer that this is not a duplicate charge.  Unfortunately, you may find that different payers may demand different or even multiple modifiers in order to receive payment.  There are even some Medicaid programs that do not recognize the -76 modifier.

In addition, there are other radiation oncology procedure codes that may be used BID during HDR treatment.  The “old school” rule of only one simulation per date of service may be disregarded if the physician orders AM and PM simulations on HDR patients.  The same holds true for the 77014 CT Guidance code.  The radiation oncology specialty societies have fought hard to ensure that the Medically Unlikely Edits (MUE’s) are reflective of the procedures commonly performed.  When you reference the MUE’s for these procedure codes you will find that both of these codes have an MUE of two, meaning there may be the possibility of two simulations or two CT’s on one date of service.  However, just because the MUE’s are set at two for these procedure codes does not mean that we have carte blanche to bill these in multiples for all cases.  The MUE’s were set at two specifically for BID HDR. 

It is imperative that physicians order all procedures providing medical necessity and thorough documentation when performing BID HDR.  This along with the use of appropriate modifiers and referencing MUE’s is central to ensuring proper payment for BID HDR services.