Billing and Coding: Proton Beam Therapy

This billing and coding guidance for proton beam therapy complements the related LCD and requires that coverage follow the LCD's medical necessity criteria and be supported by detailed documentation. Claims must include a valid ICD-10-CM diagnosis code and, when applicable, the referring/ordering physician's name and NPI; procedure codes may be subject to NCCI and OPPS edits that can affect payment.

"Proton beam therapy is covered when the service meets the medical necessity criteria specified in the related Local Coverage Determination (LCD) and those criteria are documented in the medical rec..."

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