Radiation oncology services, Medicare

Applies to: 

Medicare plans

Definition

Radiation therapy uses high-energy radiation to shrink tumors and kill cancer cells. X-rays, gamma rays, and charged particles are types of radiation used for cancer treatment. The radiation may be delivered by a machine outside the body (external-beam radiation therapy), or it may come from radioactive material placed in the body near cancer cells (internal radiation therapy, also called brachytherapy). - from cancer.gov

Coverage for radiation oncology services

Priority Health Medicare follows WPS-Medicare Local Coverage Determination (LCD) L30316, which includes coverage, billing and coding rules for radiation oncology services.

Member cost-sharing for weekly radiation oncology services

Many providers and members confuse the daily copayments applied to weekly radiation oncology services with the 20% coinsurance applied by Original Medicare to total amount billed. They believe members are paying more in copayments than they would under Original Medicare.

However, the member's out-of-pocket maximum protects the member from paying out more than he/she would have paid under Original Medicare. Once a member reaches his/her out-of-pocket maximum, services are covered at 100% by Priority Health.

77261, 77262, 77263, Tumor mapping and clinical treatment planning:

One time only charge. Radiation copay applies.

77280 - 77295, Therapeutic radiology stimulation:

Radiation copay applies.

77427, Weekly physician management services:

One copay per day. Specialist copay applies.

77425 and 77431, Weekly therapeutic services:

One copay per day. Radiation copay applies.

77300-77399, Radiation physics:

One copay per day. Radiation copayapplies.

77014, Profesional component, modifier 26:

Not billable. No copay applies.

77014 and 77336, CT guidance:

Not billable. No copay applies.

77241, Steroscopic X-ray:

Not billable. No copay applies.

Billing for weekly radiation services

The Centers for Medicare and Medicaid Services (CMS) require that weekly billing for radiation services for physician management (77427) and therapeutic (77425 and 77431) services be billed with a unit of 1.

Billing by fractions of a week

One weekly unit of treatment management is equal to five fractions or treatment sessions. The unit of 1 represents one week's service.

If, at the final billing of the treatment course, there are fractions beyond the multiples of five that equal treatment weeks: 

  • Three or four fractions are paid for as a full week unit of 1.
  • One or two fractions are considered as having been paid through prior payments.

For more information see the Medicare Claims Processing Manual, Chapter 13, Radiology Services and Other Diagnostic Procedures.