Radiation therapy

Horizon NJ Medicaid and FIDE-SNP Radiation Therapy Code List
Code Code Description
19294Preparation of tumor cavity, with placement of radiation therapy applicator for intraoperative radiation therapy (IORT), concurrent with partial mastectomy
19296Placement of radiotherapy afterloading expandable catheter (single or multichannel) into the breast for interstitial radioelement application following partial mastectomy, includes imaging guidance; on date separate from partial mastectomy
19297Placement of radiotherapy afterloading expandable catheter (single or multichannel) into the breast for interstitial radioelement application following partial mastectomy, includes imaging guidance; concurrent with partial mastectomy (List separately in addition to code for primary procedure)
19298Placement of radiotherapy after loading brachytherapy catheters (multiple tube and button type) into the breast for interstitial radioelement application following (at the time of or subsequent to) partial mastectomy, includes imaging guidance
31643Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with placement of catheter(s) for intracavitary radioelement application
32553Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), percutaneous, intra-thoracic, single or multiple
41019Placement of needles, catheters, or other device(s) into the head and/or neck region (percutaneous, transoral, or transnasal) for subsequent interstitial radioelement application
49411Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), percutaneous, intra-abdominal, intra-pelvic (except prostate), and/or retroperitoneum, single or multiple
49412Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), open, intra-abdominal, intrapelvic, and/or retroperitoneum, including image guidance, if performed, single or multiple (List separately in addition to code for primary procedure)
55875Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without cystoscopy
55876Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), prostate (via needle, any approach), single or multiple
55920Placement of needles or catheters into pelvic organs and/or genitalia (except prostate) for subsequent interstitial radioelement application
57155Insertion of uterine tandem and/or vaginal ovoids for clinical brachytherapy
57156Insertion of a vaginal radiation afterloading apparatus for clinical brachytherapy
58346Insertion of Heyman capsules for clinical brachytherapy
61796Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1
simple cranial lesion
61797Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each
additional cranial lesion, simple (List separately in addition to code for primary
procedure)
61798Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1
complex cranial lesion
61799Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each
additional cranial lesion, complex (List separately in addition to code for primary
procedure)
61800Application of stereotactic headframe for stereotactic radiosurgery (List
separately in addition to code for primary procedure)
76873Ultrasound, transrectal; prostate volume study for brachytherapy treatment planning (separate procedure)
76965Ultrasonic guidance for interstitial radioelement application
77014Computed tomography guidance for placement of radiation therapy fields
77261Therapeutic radiology treatment planning; simple
77262Therapeutic radiology treatment planning; intermediate
77263Therapeutic radiology treatment planning; complex
77280Therapeutic radiology simulation-aided field setting; simple
77285Therapeutic radiology simulation-aided field setting; intermediate
77290Therapeutic radiology simulation-aided field setting; complex
77293Respiratory motion management simulation (List separately in addition to code for primary procedure)
772953-dimensional radiotherapy plan, including dose-volume histograms
77299Unlisted procedure, therapeutic radiology clinical treatment planning
77300Basic 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, onl
77301Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specifications
77306Teletherapy isodose plan; simple (1 or 2 unmodified ports directed to a single area of interest), includes basic dosimetry calculation(s)
77307Teletherapy isodose plan; complex (multiple treatment areas, tangential ports, the use of wedges, blocking, rotational beam, or special beam considerations), includes basic dosimetry calculation(s)
77316Brachytherapy isodose plan; simple (calculation[s] made from 1 to 4 sources, or remote afterloading brachytherapy, 1 channel), includes basic dosimetry calculation(s)
77317Brachytherapy isodose plan; intermediate (calculation[s] made from 5 to 10 sources, or remote afterloading brachytherapy, 2-12 channels), includes basic dosimetry calculation(s)
77318Brachytherapy isodose plan; complex (calculation[s] made from over 10 sources, or remote afterloading brachytherapy, over 12 channels), includes basic dosimetry calculation(s)
77321Special teletherapy port plan, particles, hemibody, total body
77331Special dosimetry (eg, TLD, microdosimetry) (specify), only when prescribed by the treating physician
77332Treatment devices, design and construction; simple (simple block, simple bolus)
77333Treatment devices, design and construction; intermediate (multiple blocks, stents, bite blocks, special bolus)
77334Treatment devices, design and construction; complex (irregular blocks, special shields, compensators, wedges, molds or casts)
77336Continuing 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
77338Multi-leaf collimator (MLC) device(s) for intensity modulated radiation therapy (IMRT), design and construction per IMRT plan
77370Special medical radiation physics consultation
77371Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; multi-source Cobalt 60 based
77372Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; linear accelerator based
77373Stereotactic body radiation therapy, treatment delivery, per fraction to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions
77385Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; simple
77386Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; complex
77387Guidance for localization of target volume for delivery of radiation treatment, includes intrafraction tracking, when performed
77399Unlisted procedure, medical radiation physics, dosimetry and treatment devices, and special services
77401Radiation treatment delivery, superficial and/or ortho voltage, per day
77402Radiation treatment delivery, >1 MeV; simple
77407Radiation treatment delivery; two separate treatment areas; three or more ports on a single treatment area; or three or more simple blocks;>=1 MeV; intermediate
77412Radiation treatment delivery; three or more separate treatment areas; custom blocking; tangential ports; wedges; rotational beam; field-in-field or other tissue compensation that does not meet IMRT guidelines; or electron beam; >=1 MeV; complex
77417Therapeutic radiology port image(s)
77423High energy neutron radiation treatment delivery; 1 or more isocenter(s) with coplanar or non-coplanar geometry with blocking and/or wedge, and/or compensator(s)
77424Intraoperative radiation treatment delivery, x-ray, single treatment session
77425Intraoperative radiation treatment delivery, electrons, single treatment session
77427Radiation treatment management, 5 treatments
77431Radiation therapy management with complete course of therapy consisting of 1 or 2 fractions only
77432Stereotactic radiation treatment management of cranial lesion(s) (complete course of treatment consisting of 1 session)
77435Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions
77469Intraoperative radiation treatment management
77470Special treatment procedure (eg, total body irradiation, hemibody radiation, per oral or endocavitary irradiation)
77499Unlisted procedure, therapeutic radiology treatment management
77520Proton treatment delivery; simple, without compensation
77522Proton treatment delivery; simple, with compensation
77523Proton treatment delivery; intermediate
77525Proton treatment delivery; complex
77600Hyperthermia, externally generated; superficial (ie, heating to a depth of 4 cm or less)
77605Hyperthermia, externally generated; deep (ie, heating to depths greater than 4 cm)
77610Hyperthermia generated by interstitial probe(s); 5 or fewer interstitial applicators
77615Hyperthermia generated by interstitial probe(s); more than 5 interstitial applicators
77620Hyperthermia generated by intracavitary probe(s)
77750Infusion or instillation of radioelement solution (includes 3-month follow-up care)
77761Intracavitary radiation source application; simple
77762Intracavitary radiation source application; intermediate
77763Intracavitary radiation source application; complex
77767HDR radionuclide skin surface brachytherapy; lesion diameter up to 2.0 cm or 1 channel
77768HDR radionuclide skin surface brachytherapy; lesion diameter over 2.0 cm and 2 or more channels, or multiple lesions
77770HDR radionuclide interstitial or intracavitary brachytherapy; 1 channel
77771HDR radionuclide rate interstitial or intracavitary brachytherapy; 2 to 12 channels
77772HDR radionuclide interstitial or intracavitary brachytherapy; over 12 channels
77778Interstitial radiation source application, complex, includes supervision, handling, loading of radiation source when performed
77789Surface application of low dose rate radionuclide source
77790Supervision, handling, loading of radiation source
77799Unlisted procedure, clinical brachytherapy
79005Radiopharmaceutical therapy, by oral administration; used for I-131 treatment
79101Radiopharmaceutical therapy, by intravenous administration
79403Radiopharmaceutical therapy, radiolabeled monoclonal antibody by intravenous
infusion
0394THDR electronic brachytherapy, skin surface application, per fraction
0395THDR electronic brachytherapy, interstitial or intracavitary treatment, per fraction
A9606Radium ra-223 dichloride, therapeutic, per microcurie (Xofigo)
C2616Brachytherapy source, nonstranded, yttrium-90, per source
G0339Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session or first session of fractionated treatment
G0340Image guided robotic linear accelerator-based stereotactic radiosurgery, delivery including collimator changes and custom plugging, fractionated treatment, all lesions, per session, second through fifth sessions, maximum 5 sessions per course of treatment
G6001Ultrasonic guidance for placement of radiation therapy fields
G6002Stereoscopic x-ray guidance for localization of target volume for the delivery of radiation therapy
G6003Radiation treatment delivery, single treatment area,single port or parallel opposed ports, simple blocks or no blocks: up to 5mev
G6004Radiation treatment delivery, single treatment area,single port or parallel opposed ports, simple blocks or no blocks: 6-10mev
G6005Radiation treatment delivery, single treatment area,single port or parallel opposed ports, simple blocks or no blocks: 11-19mev
G6006Radiation treatment delivery, single treatment area,single port or parallel opposed ports, simple blocks or no blocks: 20mev or greater
G6007Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: up to 5mev
G6008Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: 6-10mev
G6009Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: 11-19mev
G6010Radiation treatment delivery, 2 separate treatment areas, 3 or more ports on a single treatment area, use of multiple blocks: 20 mev or greater
G6011Radiation treatment delivery,3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; up to 5mev
G6012Radiation treatment delivery,3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 6-10mev
G6013Radiation treatment delivery,3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 11-19mev
G6014Radiation treatment delivery,3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 20mev or greater
G6015Intensity modulated treatment delivery, single or multiple fields/arcs,via narrow spatially and temporally modulated beams, binary, dynamic mlc, per treatment session
G6016Compensator-based beam modulation treatment delivery of inverse planned treatment using 3 or more high resolution (milled or cast) compensator, convergent beam modulated fields, per treatment session
G6017Intra-fraction localization and tracking of target or patient motion during delivery of radiation therapy (eg, 3d positional tracking, gating, 3d surface tracking), each fraction of treatment