Billing and Coding: Proton Beam Therapy

This policy provides billing and coding guidance for proton beam therapy: technical delivery codes (CPT 77520/77522/77523/77524) are facility-billed technical components with code selection based on treatment complexity, while physician work is billed under planning and management codes. Thorough, legible documentation supporting medical necessity and the selected diagnosis/CPT codes is required; clinical trial claims must include trial identifiers (8-digit NCT and 7-character IDE placement), use modifiers Q0/Q1 as appropriate with diagnosis Z00.6 and condition code 30 when applicable, and claims missing required diagnosis or trial identifiers will be returned. An ABN with modifier GA is required if the patient elects proton therapy that does not clearly meet coverage criteria.

"Proton beam therapy is covered when the medical record documents that the service is reasonable and necessary per LCD L36658 and supports the selected diagnosis codes and planned course of therapy."