A9606, Radium ra-223 dichloride, therapeutic, per microcurie
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
- Narrative field or electronic equivalent on the claim must state 'visceral metastases are absent'.
- Submit HCPCS code A9606 on the claim for radium Ra 223 dichloride (Xofigo).
- Diagnosis codes on the claim must include ICD-10 C61 (malignant neoplasm of prostate) and either C79.51 (secondary malignant neoplasm of bone) or C79.52 (secondary malignant neoplasm of bone marrow).
- 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."
Key Coverage Criteria
- Treatment of patients with castration-resistant prostate cancer with symptomatic bone metastases and no known visceral metastatic disease.
- 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.
13 Active Policies
EVICORE-RADIATION-ONCOLOGY-CODING-MANUAL, EviCore Radiation Oncology Coding Manual
A54559, Billing and Coding: Xofigo Billing Instructions
UHC-POL-oncology-medication-clinical-coverage-policy, Oncology Medication Clinical Coverage
UMR-POL-UMR-oncology-medication-clinical-coverage-policy, Oncology Medication Clinical Coverage
Related Codes
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