Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-1 Radiation Oncology Center Manual Transmittal Letter ROC-1 Date 06/01/11 601 Introduction MassHealth pays for the services represented by the codes listed in Subchapter 6, in effect at the time of service subject to all conditions and limitations in MassHealth regulations at 130 CMR 436.000 and 450.000. A provider may request prior authorization for any medically necessary service reimbursable under the federal Medicaid Act in accordance with 130 CMR 450.144, 42 U.S.C. 1396d(a), and 42 U.S.C. 1396d(r)(5) for a MassHealth Standard or CommonHealth member younger than 21 years of age, even if it is not designated as covered or payable in Subchapter 6 of the Radiation Oncology Center Manual. 602 Service Codes and Descriptions Service Code Service Description Computed Tomography Guidance 77014 Computed tomography guidance for placement of radiation therapy fields Radiation Oncology Clinical Treatment Planning 77261 Therapeutic radiology treatment planning; simple 77262 intermediate 77263 complex 77280 Therapeutic radiology simulation-aided field setting; simple 77285 intermediate 77290 complex 77295 3-dimensional 77299 Unlisted procedure, therapeutic radiology clinical treatment planning Medical Radiation Physics, Dosimetry, Treatment Devices, and Special Services 77300 Basic radiation dosimetry calculation, central axis depth dose calculation, TDF, NSD, gap calculation, off axis factor, tissue inhomogeneity factors, calculation of non-ionizing radiation surface and depth dose, as required during course of treatment, only when prescribed by the treating physician 77301 Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specifications 77305 Teletherapy, isodose plan (whether hand or computer calculated); simple (1 or 2 parallel opposed unmodified ports directed to a single area of interest) 77310 intermediate (3 or more treatment ports directed to a single area of interest) 77315 complex (mantle or inverted Y, tangential ports, the use of wedges, compensators, complex blocking, rotational beam, or special beam considerations) 77321 Special teletherapy port plan, particles, hemibody, total body 77326 Brachytherapy isodose plan; simple (calculation made from single plane, 1 to 4 sources/ribbon application, remote afterloading brachytherapy, 1 to 8 sources) 77327 intermediate (multiplane dosage calculations, application involving 5 to 10 sources/ribbons, remote afterloading brachytherapy, 9 to 12 sources) 77328 complex (multiplane isodose plan, volume implant calculations, over 10 sources/ribbons used, special spatial reconstruction, remote afterloading bracytherapy, over 12 sources) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-2 Radiation Oncology Center Manual Transmittal Letter ROC-1 Date 06/01/11 77331 Special dosimetry (e.g., TLD, microdosimetry) (specify), only when prescribed by the treating physician 77332 Treatment devices, design and construction; simple (simple block, simple bolus) 77333 intermediate (multiple blocks, stents, bite blocks, special bolus) 77334 complex (irregular blocks, special shields, compensators, wedges, molds or casts) 77336 Continuing medical physics consultation, including assessment of treatment parameters, quality assurance of dose delivery, and review of patient treatment documentation in support of the radiation oncologist, reported per week of therapy 77338 Multi-leaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction per IMRT plan 77370 Special medical radiation physics consultation Sterotactic Radiation Treatment Delivery 77371 Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based 77372 linear accelerator based 77373 Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions Other Procedures 77399 Unlisted procedure, medical radiation physics, dosimetry and treatment devices, and special services (I.C.) Radiation Treatment Delivery 77401 Radiation treatment delivery, superficial and/or ortho voltage 77402 Radiation treatment delivery, single treatment area, single port or parallel opposed ports, simple blocks or no blocks; up to 5 MeV 77403 6-10 MeV 77404 11-19 MeV 77406 20 MeV or greater 77407 Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks; up to 5 MeV 77408 6-10 MeV 77409 11-19 MeV 77411 20 MeV or greater 77412 Radiation treatment delivery, 3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; up to 5 MeV 77413 6-10 MeV 77414 11-19 MeV 77416 20 MeV or greater 77417 Therapeutic radiology port film(s) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-3 Radiation Oncology Center Manual Transmittal Letter ROC-1 Date 06/01/11 77418 Intensity modulated treatment delivery, single or multiple fields/arcs, via narrow spatially and temporally modulated beams, binary, dynamic MLC, per treatment session 77421 Stereoscopic X-ray guidance for localization of target volume for the delivery of radiation therapy Neutron Beam Treatment Delivery 77422 High energy neutron radiation treatment delivery; single treatment area using a single port or parallel-opposed ports with no blocks or simple blocking 77423 1 or more isocenter(s) with coplanar or non-coplanar geometry with blocking and/or wedge, and/or compensator(s) Radiation Treatment Management 77427 Radiation treatment management, 5 treatments 77431 Radiation therapy management with complete course of therapy consisting of 1 or 2 fractions only 77432 Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session) 77435 Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions 77470 Special treatment procedure (e.g., total body irradiation, hemibody radiation, per oral, endocavitary or intraoperative cone irradiation) 77499 Unlisted procedure, therapeutic radiology treatment management (I.C.) Hyperthermia 77600 Hyperthermia, externally generated; superficial (i.e., heating to a depth of 4 cm or less) 7760577610 de Hyperthermia generated by interstitial probe(s); 5 or fewer interstitial applicators ep (i.e., heating to more than 5 interstitial applicators 77615 depths greater than 4 cm) Clinical Intracavity Hyperthermia 77620 Hyperthermia generated by intracavitary probe(s) Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-4 Radiation Oncology Center Manual Transmittal Letter ROC-1 Date 06/01/11 Clinical Brachytherapy 77750 Infusion or instillation of radioelement solution (includes 3-month follow-up care) 77761 Intracavitary radiation source application; simple 77762 intermediate 77763 complex 77776 Interstitial radiation source application; simple 77777 intermediate 77778 complex 77785 Remote afterloading high dose rate radionuclide brachytherapy; 1 channel 77786 2-12 channels 77787 over 12 channels 77789 Surface application of radiation source 77799 Unlisted procedure, clinical brachytherapy Evaluation and Management Office or Other Outpatient Services 99201 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: . A problem focused history; . A problem focused examination; . Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family. 99202 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: . An expanded problem focused history; . An expanded problem focused examination; . Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 20 minutes face-to-face with the patient and/or family. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-5 Radiation Oncology Center Manual Transmittal Letter ROC-1 Date 06/01/11 99203 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: . A detailed focused history; . A detailed examination; . Medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family. 99204 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: . A comprehensive history; . A comprehensive examination; . Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 45 minutes face-to-face with the patient and/or family. 99205 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: . A comprehensive history; . A comprehensive examination; . Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 60 minutes face-to-face with the patient and/or family. Established Patient 99211 Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services. Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 6. Service Codes and Descriptions Page 6-6 Radiation Oncology Center Manual Transmittal Letter ROC-1 Date 06/01/11 99212 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: . A problem focused history; . A problem focused examination; . Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family. 99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: . An expanded problem focused history; . An expanded problem focused examination; . Medical decision making of low complexity. Counseling and coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of low to moderate severity. Physicians typically spend 15 minutes face-to-face with the patient and/or family. 99214 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: . A detailed focused history; . A detailed examination; . Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family. 99215 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: . A comprehensive focused history; . A comprehensive examination; . Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family. Commonwealth of Massachusetts MassHealth Provider Manual Series Radiation Oncology Center Manual Subchapter Number and Title 6. Service Codes and Descriptions Page 6-7 Transmittal Letter ROC-2 Date 07/01/12 603 Modifiers The following service code modifiers are allowed for billing under MassHealth. Modifier Modifier Description 26 Professional Component TC Technical Component The following modifiers are for Provider Preventable Conditions (PPCs) that are National Coverage Determinations. Modifier Modifier Description PA Surgical or other invasive procedure on wrong body part PB Surgical or other invasive procedure on wrong patient PC Wrong surgery or other invasive procedure on patient For more information on the use of these modifiers, see Appendix V of your provider manual. Commonwealth of Massachusetts MassHealth Provider Manual Series Radiation Oncology Center Manual Subchapter Number and Title 6. 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