Does 55876 require prior authorization?

Yes, 55876 requires prior authorization (medium confidence). Conditional coverage; review criteria to confirm PA need.

What is the Medicare reimbursement rate for 55876?

Medicare facility rate: $90.85. Non-facility rate: $151.31. Work RVU: 1.69.

HCPCS/CPT

Prior Auth Required

Conditional coverage; review criteria to confirm PA need (medium confidence)

Work RVU

1.69

Facility

$90.85

Non-Facility

$151.31

Clinical treatment planning: "Documentation is required to report clinical treatment planning. Necessary documentation includes the diagnosis, treatment site, treatment intent, treatment dose, treatment technique and any special circumstances unique to the individual."
General: "The radiation oncologist is responsible for documentation of IGRT directives, supervision, and review of all images."
Simulation: "Appropriate documentation for simulation services includes: the treatment site, type of images, if a clinical simulation is performed, and any immobilization devices that are constructed. The documentation should be signed and dated by the physician."
Respiratory simulation (+77293): "Documentation should include the medical necessity of reporting CPT® code +77293 and describe the work that was performed."

Clinical treatment planning (CPT® 77261, 77262, 77263): One unit of CPT® 77261, 77262, or 77263 is necessary for an episode of care (clinical treatment planning is performed after the initial consultation and before simulation).
Simulation (CPT® 77280, 77285, 77290): For non-IMRT plans, one unit of CPT® 77280, 77285, or 77290 is allowed per phase of treatment; verification simulation reported with one unit of CPT® 77280. (+77293 respiratory motion management simulation is allowed when treatment area moves with continuous respiration and requires acquisition of multiple data sets.)
Respiratory motion management simulation (CPT® +77293): Performed when the treatment area moves with continuous respiration; +77293 is an add-on code, allowed once per episode of care and only on same date of service as primary procedure (e.g., with 77295, 77301).
Teletherapy isodose planning (CPT® 77306, 77307): One unit allowed for each treatment site approved when a teletherapy isodose plan has been authorized.
3-D conformal planning (CPT® 77295): One unit allowed per episode of care when 3-D conformal has been authorized.
Special teletherapy plan (CPT® 77321): Allowed when an electron plan is performed.

HUMANA-INTENSITY-MODULATED-RADIATION-THERAPY-MA — Intensity Modulated Radiation Therapy - Medicare Advantage

HUMANA-BENIGN-PROSTATIC-HYPERPLASIA-TREATMENTS-MA — Benign Prostatic Hyperplasia Treatments - Medicare Advantage

HUMANA-BRACHYTHERAPY-MA — Brachytherapy - Medicare Advantage

EVICORE-RADIATION-ONCOLOGY-CODING-MANUAL — EviCore Radiation Oncology Coding Manual

Ask Verity about documentation requirements, denial risks, or coverage in your state.