A9590, Iodine i-131, iobenguane, 1 millicurie
HCPCS/CPT
Prior Authorization
Prior Auth Required
Code explicitly requires prior authorization (high confidence)
Medicare Pricing
Work RVU
0.00
Facility
N/A
Non-Facility
N/A
Documentation Required
- 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."
Key Coverage Criteria
- Coverage of injectable oncology medications is based on NCCN Compendium Categories of Evidence and Consensus (1, 2A, 2B = proven/medically necessary; 3 = unproven/not medically necessary); if NCCN is unavailable, base decisions on FDA labeling.
- 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.
11 Active Policies
EVICORE-RADIATION-ONCOLOGY-CODING-MANUAL, EviCore Radiation Oncology Coding Manual
UHC-POL-oncology-medication-clinical-coverage-policy, Oncology Medication Clinical Coverage
RAD604.012, Myocardial Sympathetic Innervation Imaging in Individuals With Heart Failure
BCBSIL-RAD604.012, Myocardial Sympathetic Innervation Imaging in Individuals With Heart Failure
Related Codes
Have a follow-up question?
Ask Verity about documentation requirements, denial risks, or coverage in your state.