19294
HCPCS/CPT
Prior Authorization
Prior Auth Required
Conditional coverage; review criteria to confirm PA need (medium confidence)
Medicare Pricing
Work RVU
2.93
Facility
$147.97
Non-Facility
$147.97
Documentation Required
- ICD-10-CM diagnosis codes supporting medical necessity must be submitted with each claim; include any additional medical records or forms required by LCD L37779.
- Pre-procedural documentation must include a complete initial evaluation with history, focused physical examination, and review of relevant pathology and imaging results.
- Treatment plans developed with other providers (e.g., medical oncologist, surgeon, tumor board) should be included when they support that the procedure is reasonable and necessary.
- The procedure note must be legible and document mode of radiation delivery, anatomic sites irradiated, radiation dose in Gray, and any necessary pre- and post-procedural assessments, with legible signature, time, and date.
Key Coverage Criteria
- Intraoperative radiation therapy (IORT) claims are covered when submitted with ICD-10-CM diagnosis codes that support medical necessity per applicable clinical criteria (see LCD L37779).
- Intraoperative radiation (IORT) is covered when therapeutic radiation is initiated after surgical exposure of the tumor or tumor bed and is completed prior to the patient leaving the operating room.
- IORT is covered when surgical resection is reasonable and necessary for treatment of the patient’s malignancy based on available information at the time the decision for surgery is made.
- IORT for breast cancer is covered only for patients in whom there is a reasonable expectation at the time of surgery that Accelerated Partial Breast Irradiation (APBI) may be appropriate per NCCN candidacy criteria.
- IORT for breast cancer is covered in a woman meeting all of: age >= 50 years; invasive ductal carcinoma; negative margins >= 2 mm; no lymphovascular invasion; estrogen receptor positive; BRCA negative.
- IORT for breast cancer is covered in a woman meeting all of: low or intermediate nuclear grade; screen-detected ductal carcinoma in situ (DCIS); tumor size as appropriate per NCCN; negative margins >= 3 mm.
4 Active Policies
A56684 — Billing and Coding: Intraoperative Radiation Therapy
L37779 — Intraoperative Radiation Therapy
CARELON-radiation-therapy-excludes-proton-2025-03-23 — Radiation Therapy Excludes Proton
EVICORE-RADIATION-ONCOLOGY-CODING-MANUAL — EviCore Radiation Oncology Coding Manual
Related Codes
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