Radiation Therapy
Select a code category below to review the codes included as part of the Horizon NJ Medicaid and FIDE-SNP Radiation Therapy Program. This listing was last revised onDecember 19, 2022and may be subject to change.
| Code | Code Description |
|---|---|
| 19294 | Preparation of tumor cavity, with placement of radiation therapy applicator for intraoperative radiation therapy (IORT), concurrent with partial mastectomy |
| 19296 | Placement 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 |
| 19297 | Placement 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) |
| 19298 | Placement 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 |
| 31643 | Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with placement of catheter(s) for intracavitary radioelement application |
| 32553 | Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), percutaneous, intra-thoracic, single or multiple |
| 41019 | Placement of needles, catheters, or other device(s) into the head and/or neck region (percutaneous, transoral, or transnasal) for subsequent interstitial radioelement application |
| 49411 | Placement 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 |
| 49412 | Placement 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) |
| 55875 | Transperineal placement of needles or catheters into prostate for interstitial radioelement application, with or without cystoscopy |
| 55876 | Placement of interstitial device(s) for radiation therapy guidance (eg, fiducial markers, dosimeter), prostate (via needle, any approach), single or multiple |
| 55920 | Placement of needles or catheters into pelvic organs and/or genitalia (except prostate) for subsequent interstitial radioelement application |
| 57155 | Insertion of uterine tandem and/or vaginal ovoids for clinical brachytherapy |
| 57156 | Insertion of a vaginal radiation afterloading apparatus for clinical brachytherapy |
| 58346 | 插入海曼胶囊临床brachytherapy |
| 61796 | Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 simple cranial lesion |
| 61797 | Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional cranial lesion, simple (List separately in addition to code for primary procedure) |
| 61798 | Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); 1 complex cranial lesion |
| 61799 | Stereotactic radiosurgery (particle beam, gamma ray, or linear accelerator); each additional cranial lesion, complex (List separately in addition to code for primary procedure) |
| 61800 | Application of stereotactic headframe for stereotactic radiosurgery (List separately in addition to code for primary procedure) |
| 76873 | Ultrasound, transrectal; prostate volume study for brachytherapy treatment planning (separate procedure) |
| 76965 | Ultrasonic guidance for interstitial radioelement application |
| 77014 | Computed tomography guidance for placement of radiation therapy fields |
| 77261 | Therapeutic radiology treatment planning; simple |
| 77262 | Therapeutic radiology treatment planning; intermediate |
| 77263 | Therapeutic radiology treatment planning; complex |
| 77280 | Therapeutic radiology simulation-aided field setting; simple |
| 77285 | Therapeutic radiology simulation-aided field setting; intermediate |
| 77290 | Therapeutic radiology simulation-aided field setting; complex |
| 77293 | Respiratory motion management simulation (List separately in addition to code for primary procedure) |
| 77295 | 3-dimensional radiotherapy plan, including dose-volume histograms |
| 77299 | Unlisted procedure, therapeutic radiology clinical treatment planning |
| 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, onl |
| 77301 | Intensity modulated radiotherapy plan, including dose-volume histograms for target and critical structure partial tolerance specifications |
| 77306 | Teletherapy isodose plan; simple (1 or 2 unmodified ports directed to a single area of interest), includes basic dosimetry calculation(s) |
| 77307 | Teletherapy isodose plan; complex (multiple treatment areas, tangential ports, the use of wedges, blocking, rotational beam, or special beam considerations), includes basic dosimetry calculation(s) |
| 77316 | Brachytherapy isodose plan; simple (calculation[s] made from 1 to 4 sources, or remote afterloading brachytherapy, 1 channel), includes basic dosimetry calculation(s) |
| 77317 | Brachytherapy isodose plan; intermediate (calculation[s] made from 5 to 10 sources, or remote afterloading brachytherapy, 2-12 channels), includes basic dosimetry calculation(s) |
| 77318 | Brachytherapy isodose plan; complex (calculation[s] made from over 10 sources, or remote afterloading brachytherapy, over 12 channels), includes basic dosimetry calculation(s) |
| 77321 | Special teletherapy port plan, particles, hemibody, total body |
| 77331 | Special dosimetry (eg, TLD, microdosimetry) (specify), only when prescribed by the treating physician |
| 77332 | Treatment devices, design and construction; simple (simple block, simple bolus) |
| 77333 | Treatment devices, design and construction; intermediate (multiple blocks, stents, bite blocks, special bolus) |
| 77334 | Treatment devices, design and construction; 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 |
| 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 | Radiation treatment delivery, stereotactic radiosurgery (SRS), complete course of treatment of cranial lesion(s) consisting of 1 session; 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 |
| 77385 | Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; simple |
| 77386 | Intensity modulated radiation treatment delivery (IMRT), includes guidance and tracking, when performed; complex |
| 77387 | Guidance for localization of target volume for delivery of radiation treatment, includes intrafraction tracking, when performed |
| 77399 | Unlisted procedure, medical radiation physics, dosimetry and treatment devices, and special services |
| 77401 | Radiation treatment delivery, superficial and/or ortho voltage, per day |
| 77402 | Radiation treatment delivery, >1 MeV; simple |
| 77407 | Radiation treatment delivery; two separate treatment areas; three or more ports on a single treatment area; or three or more simple blocks;>=1 MeV; intermediate |
| 77412 | Radiation 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 |
| 77417 | Therapeutic radiology port image(s) |
| 77423 | High 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) |
| 77424 | Intraoperative radiation treatment delivery, x-ray, single treatment session |
| 77425 | Intraoperative radiation treatment delivery, electrons, single treatment session |
| 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 |
| 77469 | Intraoperative radiation treatment management |
| 77470 | Special treatment procedure (eg, total body irradiation, hemibody radiation, per oral or endocavitary irradiation) |
| 77499 | Unlisted procedure, therapeutic radiology treatment management |
| 77520 | Proton treatment delivery; simple, without compensation |
| 77522 | Proton treatment delivery; simple, with compensation |
| 77523 | Proton treatment delivery; intermediate |
| 77525 | Proton treatment delivery; complex |
| 77600 | Hyperthermia, externally generated; superficial (ie, heating to a depth of 4 cm or less) |
| 77605 | Hyperthermia, externally generated; deep (ie, heating to depths greater than 4 cm) |
| 77610 | Hyperthermia generated by interstitial probe(s); 5 or fewer interstitial applicators |
| 77615 | Hyperthermia generated by interstitial probe(s); more than 5 interstitial applicators |
| 77620 | Hyperthermia generated by intracavitary probe(s) |
| 77750 | 注入或滴注法of radioelement solution (includes 3-month follow-up care) |
| 77761 | Intracavitary radiation source application; simple |
| 77762 | Intracavitary radiation source application; intermediate |
| 77763 | Intracavitary radiation source application; complex |
| 77767 | HDR radionuclide skin surface brachytherapy; lesion diameter up to 2.0 cm or 1 channel |
| 77768 | HDR radionuclide skin surface brachytherapy; lesion diameter over 2.0 cm and 2 or more channels, or multiple lesions |
| 77770 | HDR radionuclide interstitial or intracavitary brachytherapy; 1 channel |
| 77771 | HDR radionuclide rate interstitial or intracavitary brachytherapy; 2 to 12 channels |
| 77772 | HDR radionuclide interstitial or intracavitary brachytherapy; over 12 channels |
| 77778 | Interstitial radiation source application, complex, includes supervision, handling, loading of radiation source when performed |
| 77789 | Surface application of low dose rate radionuclide source |
| 77790 | Supervision, handling, loading of radiation source |
| 77799 | Unlisted procedure, clinical brachytherapy |
| 79005 | Radiopharmaceutical therapy, by oral administration; used for I-131 treatment |
| 79101 | Radiopharmaceutical therapy, by intravenous administration |
| 79403 | Radiopharmaceutical therapy, radiolabeled monoclonal antibody by intravenous infusion |
| Code | Code Description |
|---|---|
| 0394T | HDR electronic brachytherapy, skin surface application, per fraction |
| 0395T | HDR电子近距离放射疗法,间质或intracavitary treatment, per fraction |
| 0745T | Cardiac focal ablation utilizing radiation therapy for arrhythmia; noninvasive arrhythmia localization and mapping of arrhythmia site (nidus), derived from anatomical image data (eg, CT, MRI, or myocardial perfusion scan) and electrical data (eg, 12-lead ECG data), and identification of areas of avoidance |
| 0746T | Conversion of arrhythmia localization and mapping of arrhythmia site (nidus) into a multidimensional radiation treatment plan |
| 0747T | Delivery of radiation therapy, arrhythmia |
Recent/Upcoming Updates
- Effective January 18, 2023, eviCore will also review services represented by0745T, 0746Tand0747Tas part of this program.
| Code | Code Description |
|---|---|
| A9606 | Radium ra-223 dichloride, therapeutic, per microcurie (Xofigo) |
| A9607 | Lutetium lu 177 vipivotide tetraxetan, therapeutic, 1 millicurie |
| A9699 | Radiopharmaceutical, therapeutic, not otherwise classified |
| C2616 | Brachytherapy source, nonstranded, yttrium-90, per source |
| G0339 | Image guided robotic linear accelerator-based stereotactic radiosurgery, complete course of therapy in one session or first session of fractionated treatment |
| G0340 | Image 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 |
| G6001 | Ultrasonic guidance for placement of radiation therapy fields |
| G6002 | Stereoscopic x-ray guidance for localization of target volume for the delivery of radiation therapy |
| G6003 | Radiation treatment delivery, single treatment area,single port or parallel opposed ports, simple blocks or no blocks: up to 5mev |
| G6004 | Radiation treatment delivery, single treatment area,single port or parallel opposed ports, simple blocks or no blocks: 6-10mev |
| G6005 | Radiation treatment delivery, single treatment area,single port or parallel opposed ports, simple blocks or no blocks: 11-19mev |
| G6006 | Radiation treatment delivery, single treatment area,single port or parallel opposed ports, simple blocks or no blocks: 20mev or greater |
| G6007 | 放射治疗交付2单独的混乱关系atment areas, 3 or more ports on a single treatment area, use of multiple blocks: up to 5mev |
| G6008 | 放射治疗交付2单独的混乱关系atment areas, 3 or more ports on a single treatment area, use of multiple blocks: 6-10mev |
| G6009 | 放射治疗交付2单独的混乱关系atment areas, 3 or more ports on a single treatment area, use of multiple blocks: 11-19mev |
| G6010 | 放射治疗交付2单独的混乱关系atment areas, 3 or more ports on a single treatment area, use of multiple blocks: 20 mev or greater |
| G6011 | Radiation treatment delivery,3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; up to 5mev |
| G6012 | Radiation treatment delivery,3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 6-10mev |
| G6013 | Radiation treatment delivery,3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 11-19mev |
| G6014 | Radiation treatment delivery,3 or more separate treatment areas, custom blocking, tangential ports, wedges, rotational beam, compensators, electron beam; 20mev or greater |
| G6015 | Intensity modulated treatment delivery, single or multiple fields/arcs,via narrow spatially and temporally modulated beams, binary, dynamic mlc, per treatment session |
| G6016 | Compensator-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 |
| G6017 | Intra-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 |
Recent/Upcoming Updates
- Effective August 1, 2022, eviCore will review services represented byA9699as part of this program.
- Effective October 1, 2022, eviCore will review services represented byA9607as part of this program.