LCD/NCD Portal

L28892

 

INTENSITY MODULATED RADIATION THERAPY (IMRT)

 

11/29/2012

 

Indications and Limitations of Coverage and/or Medical Necessity

• IMRT is not a replacement therapy for conventional radiation therapy methods.

• IMRT will be considered reasonable and necessary when at least one or more of the following five conditions is documented:

o The target volume is in close proximity to critical structures that must be protected.

o The volume of interest must be covered with narrow margins to adequately protect immediately adjacent structures.

o An immediately adjacent area has been previously irradiated and abutting portals must be established with high precision.

o The target volume is concave or convex, and critical normal tissues are within or around that that convexity or concavity.

o Dose escalation is planned to deliver radiation doses in excess of those commonly utilized for similar tumors with conventional treatment.

• The most common sites that currently support the use of IMRT include:

o Primary, metastatic or benign tumors of the central nervous system, including the brain, brain stem and spinal cord.

o Primary metastatic tumors of the spine where spinal cord tolerance may be exceeded by conventional treatment.

o Primary, metastatic or benign lesions to the head and neck area including orbits, sinuses, skull base, aerodigestive tract and salivary glands.

o Carcinoma of the prostate.

o Selected cases of thoracic and abdominal malignancies.

o Selected cases of left breast tumors due to risk to immediately adjacent cardiac and pericardial structures, and selected right breast cases in larger volume breasts and larger chest wall separation distances.

o Other pelvic and retroperitoneal tumors that meet the requirements for medical necessity

o Reirradiation that meets the requirements for medical necessity.

• Patient-Specific IMRT Treatment Verification

o Per the American Society for Therapeutic Radiology and Oncology (ASTRO)/The American College of Radiology (ACR) Guidelines, verification of the patient treatment plan includes documentation of all of the elements associated with implementation as well as images of treatment portals and physical dose measurements.

 Each facility may derive its own means to document and ensure communication of the exact details required to achieve daily, ongoing correlation between the image-based IMRT plan and dose delivery.

 However, the following critical information must be contained in the treatment verification elements.

 Documentation must exist that the qualified medical physicist has appropriately commissioned the IMRT planning and delivery system, has authorized the system for clinical use, and has established the quality assurance (QA) program to monitor the IMRT planning and delivery systems.

 This documentation is generally not contained in individual patients’ medical records.

 There are various valid commissioning and performance monitoring protocols for IMRT planning and delivery systems.

 Qualified medical physicists should refer to the appropriate American Association of Physicists in Medicine (AAPM) recommendations or ACR practice guideline for IMRT.

• Use of Clinical Treatment Planning in IMRT (CPT Code 77263) Prior to the Specific IMRT Treatment Plan (77301)

o Clinical treatment planning includes interpretation of special testing, tumor localization, treatment volume determinations, treatment time/dosage determinations, choice of treatment modality(ies), selection of appropriate treatment devices and other procedures such as concurrent or sequential chemotherapy or surgery.

o A separate charge for clinical treatment planning may be appropriately claimed when based on separately documented work itemizing the specific services provided.

o Review of records, pathology reports and/or imaging studies are typically part of the basis for claiming either a higher-level E/M service preceding treatment planning, or as a component of this code, but this same work should not be counted as a basis for both services.

o The need for IMRT should justify complex treatment planning.

• Use of Simulation-Aided Field Setting in IMRT (CPT Code 77290)

o Simulation-aided field setting complex (CPT code 77290) during a course of IMRT is appropriate for the initial setup of the patient where an immobilization device may be constructed, isocenter(s) and volume of interest are determined, and CT or other imaging is obtained for subsequent reconstruction of target(s) and critical structure(s).

o Documentation should include patient positioning and immobilization device, target verification, possible utilizing radiographic studies and a description of the physician’s work.

• Use of Intensity Modulated Radiotherapy Plan (CPT Code 77301), Including Dose Volume Histograms for Target and Critical Structure Partial Tolerance Specification

o Intensity-modulated radiotherapy plan (CPT code 77301) is a separate and distinct step in the process of care whose product is the computerized plan developed by the physician, medical physicist and dosimetrist, and is required for the delivery of IMRT.

 Only one unit of CPT code 77301 (Radiotherapy dose plan, IMRT) can be billed per course of therapy, even if there is a planned “cone down” treatment feature or change in field size.

 In that case, coding for conventional treatment should be used. A second unit of CPT code 77301 can only be billed if changes in patient anatomy during treatment requires repeat planning CT scanning.

 Such a change must be documented.

 Similarly, CPT code 77295 (Set radiation therapy field) cannot be billed during the same course of treatment unless required by a change in patient anatomy.

o Documentation for IMRT planning must include the following:

 Review (signed and dated) by the radiation oncologist of the CT or MRI based images of the target and all critical structures with representative isodose distributions that characterize the three-dimensional dose.

 Radiation oncologist review of dose-volume histograms for all targets and critical structures.

 Description of the number and location of each treatment step/rotation or portal to accomplish the treatment plan.

 Documentation of dosimetric verification of treatment setup and delivery, signed by both the radiation oncologist and the medical physicist.

 For compensator-based IMRT, the unique compensator design should be documented for east step or portal.

• Use of Basic Radiation Dosimetry Calculation, Central Axis Depth Dose Calculation, TDF, NSD, Gap Calculation, Off-Axis Factor, Tissue Inhomogeneity Factors, Calculation of Non-Ionizing Radiation Surface and Depth Dose, As Required During Course of Treatment, Only When Prescribed by the Treating Physician (CPT Code 77300) in IMRT

o Basic radiation dosimetry is a separate service from CPT code 77301 (Radiation dose plan, IMRT). CPT code 77300 (Radiation therapy dose plan) is used to report dosimetry calculations that arrive at the relationship between monitor units (or time) and dose, and the physician’s verification, review and approval of this.

 The documentation should contain the independent check for each field, separate from the computer-generated IMRT plan.

• Use of Teletherapy Isodose Plan in IMRT (CPT Codes 77305–77321)

o A claim for a separate teletherapy isodose plan during a course of IMRT is appropriate only when the claim applies to another modality (e.g., an accompanying “boost” with external beam).

• Use of Brachytherapy Isodose Plan in IMRT (CPT Codes 77326–77328)

o A claim for a separate brachytherapy isodose plan during a course of IMRT is appropriate only when the claim applies to a separate, accompanying brachytherapy modality.

• Use of Special Dosimetry in IMRT (CPT Code 77331)

o Dosimetry performed as part of plan verification is part of the work and practice expense of CPT code 77301 and cannot be billed separately.

• Use of Treatment Devices (e.g., “Blocks”) in IMRT (CPT Codes 77332–77334)

o It would not be expected to see providers billing frequently for the design and construction of devices that are separate and distinct from the “device” derived from the computerized IMRT plan.

 The Correct Coding Initiative (CCI) bundles the device CPT codes 77332–77334 into CPT code 77301.

 In cases where these separate devices are billed, the medical record must clearly demonstrate the medical necessity and rationale for the service.

o When a provider designs and constructs a treatment or immobilization device separate and distinct from the “device” derived from the computerized IMRT plan, the provider may then report 77332-77334, as appropriate, with modifier - 59.

 The medical record must have documentation to support this use of modifier -59. A treatment device could also be appropriate where it applies to another modality (e.g. an accompanying “boost” with external beam).

o Additionally, to compensate for the physician work and practice expense (largely physicist and dosimetrist) associated with the calculations, review and oversight necessary for the multileaf collimator, a claim for “Treatment Device” may be made for each gantry stop, up to a maximum of six, using the professional-service-only modifier (-26).

 It is not appropriate to bill a Treatment Device for these services without the professional-service-only modifier, since the large portion of the technical component is being paid in the treatment delivery code.

 Using the professional-service-only modifier likely undervalues the practice expense component somewhat and correspondingly may over value the work expense component for these services, but the net effect would be to allow a reasonably fair and functional way to value these services until more specific, updated codes are developed.

• Use of Continuing Medical Physics Consultation in IMRT (Weekly Physics QA: CPT Code 77336)

o Continuing medical physics is appropriate for the weekly continuing medical physics process and reports the work and oversight of the medical physicist in the care of the IMRT patient.

 It is not appropriately reported for work associated with the creation of the IMRT plan.

• Use of Special Medical Radiation Physics Consultation in IMRT (CPT Code 77370)

o A claim for special medical radiation physics consultation during a course of IMRT is appropriate only where the need for and use of the consultation are carefully documented and occur at a time other than that necessary as a part of IMRT planning (e.g., a special physics assessment requested when already into a course of therapy).

 A medical physics consultation could also be appropriate where it applies to another modality (e.g., an accompanying “boost“with external beam).

• Use of Other Radiation Treatment Delivery on the Same Day as IMRT Treatment Delivery (CPT Codes 77418, 0073T)

o Radiation treatment delivery CPT codes 77401–77416, 77422–77423 and 0082T may not be used on the same date of service as IMRT treatment delivery (CPT code 0073T or 77418).

 These other delivery codes may be used prior to or subsequent to an IMRT treatment course for treatment with a different modality.

• Radiation Treatment Management (CPT Code 77427)

o Radiation treatment management (CPT code 77427) is reported by the physician for the weekly (defined as five-fraction) management of patients receiving radiation therapy, including IMRT.

• Use of “Special Treatment Procedure” in IMRT (CPT Code 77470)

o A claim for “special treatment procedure” (e.g., total body irradiation, hemibody radiation, per oral, endocavitary or intraoperative cone irradiation) would not be appropriate for services that are a necessary part of IMRT planning, but might rarely be appropriate during a course of IMRT when the respective treatment is being delivered as a separate therapy.

 Providers are cautioned that the use of this code implies a special treatment procedure with moderate physician work and very considerable practice expense (such as in Total Body Irradiation (TBI)).

 This service is not to be claimed for much less significant “special procedures” that would more appropriately use CPT code 77499 or are a regular variant of IMRT or regular combination with IMRT.

• Image Guided Radiation Therapy (IGRT) Codes (CPT codes 76950,77014,77421)

o IGRT is a form of adaptive radiation therapy, which utilizes imaging technology to guide action(s) that modifies the treatment in reference to the intended target,

o In IGRT, the external beam radiation treatment setup is accomplished with direct visualization of the target volume, implanted fiducial markers or adjacent anatomical structures.

 These guidance images are compared to the designated target(s) as delineated on the treatment isodose plan.

 An adjustment may then be required to achieve an accurate concordance of dose distribution with the original plan.

 IGRT is used in patients whose tumors are directly adjacent to critical structures and where conventional means of targeting are deemed to be inadequate.

o IGRT must be performed by the radiation oncologist, medical physicist or trained radiation therapist under the supervision of the radiation oncologist.

 The physician must supervise and review the procedure, as the guidance may show a shift beyond standard tolerances.

o The current supervision requirements for the technical component of the IGRT procedure codes are as follows: CPT code 76950 requires general supervision, CPT code 77014 requires direct supervision and CPT code 77421 requires direct supervision.

• General supervision means the procedure is furnished under the physician’s overall direction and control, but the physician’s presence is not required during the performance of the procedure.

• Direct supervision in the office setting means the physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure.

It does not mean that the physician must be present in the room when the procedure is performed.

• Personal supervision means a physician must be in attendance in the room during the performance of the procedure.

Coding Information

 

Bill Type Codes

• Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service.

• Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type.

• Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

 

 

 

12x Hospital Inpatient (Medicare Part B only)

13x Hospital Outpatient

85x Critical Access Hospital

 

Revenue Codes

• Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service.

• In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination.

• Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

 

 

0333 Radiology - Therapeutic and/or Chemotherapy Administration - Radiation Therapy

 

 

CPT/HCPCS Codes

 

 

0073T COMPENSATOR-BASED BEAM MODULATION TREATMENT DELIVERY OF INVERSE PLANNED TREATMENT USING 3 OR MORE HIGH RESOLUTION (MILLED OR CAST) COMPENSATOR CONVERGENT BEAM MODULATED FIELDS, PER TREATMENT SESSION

77301 INTENSITY MODULATED RADIOTHERAPY PLAN, INCLUDING DOSE-VOLUME HISTOGRAMS FOR TARGET AND CRITICAL STRUCTURE PARTIAL TOLERANCE SPECIFICATIONS

77418 INTENSITY MODULATED TREATMENT DELIVERY, SINGLE OR MULTIPLE FIELDS/ARCS, VIA NARROW SPATIALLY AND TEMPORALLY MODULATED BEAMS, BINARY, DYNAMIC MLC, PER TREATMENT SESSION

 

 

ICD-9 Codes that Support Medical Necessity

 

 

The following limited coverage is established for CPT/HCPCS codes 0073T, 77301 and 77418:

 

Covered for:

 

141.0 MALIGNANT NEOPLASM OF BASE OF TONGUE

141.1 MALIGNANT NEOPLASM OF DORSAL SURFACE OF TONGUE

141.2 MALIGNANT NEOPLASM OF TIP AND LATERAL BORDER OF TONGUE

141.3 MALIGNANT NEOPLASM OF VENTRAL SURFACE OF TONGUE

141.4 MALIGNANT NEOPLASM OF ANTERIOR TWO-THIRDS OF TONGUE PART UNSPECIFIED

141.5 MALIGNANT NEOPLASM OF JUNCTIONAL ZONE OF TONGUE

141.6 MALIGNANT NEOPLASM OF LINGUAL TONSIL

141.8 MALIGNANT NEOPLASM OF OTHER SITES OF TONGUE

141.9 MALIGNANT NEOPLASM OF TONGUE UNSPECIFIED

142.0 MALIGNANT NEOPLASM OF PAROTID GLAND

142.1 MALIGNANT NEOPLASM OF SUBMANDIBULAR GLAND

142.2 MALIGNANT NEOPLASM OF SUBLINGUAL GLAND

142.8 MALIGNANT NEOPLASM OF OTHER MAJOR SALIVARY GLANDS

142.9 MALIGNANT NEOPLASM OF SALIVARY GLAND UNSPECIFIED

144.0 MALIGNANT NEOPLASM OF ANTERIOR PORTION OF FLOOR OF MOUTH

144.1 MALIGNANT NEOPLASM OF LATERAL PORTION OF FLOOR OF MOUTH

144.8 MALIGNANT NEOPLASM OF OTHER SITES OF FLOOR OF MOUTH

144.9 MALIGNANT NEOPLASM OF FLOOR OF MOUTH PART UNSPECIFIED

145.0 MALIGNANT NEOPLASM OF CHEEK MUCOSA

145.1 MALIGNANT NEOPLASM OF VESTIBULE OF MOUTH

145.2 MALIGNANT NEOPLASM OF HARD PALATE

145.3 MALIGNANT NEOPLASM OF SOFT PALATE

145.4 MALIGNANT NEOPLASM OF UVULA

145.5 MALIGNANT NEOPLASM OF PALATE UNSPECIFIED

145.6 MALIGNANT NEOPLASM OF RETROMOLAR AREA

145.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED PARTS OF MOUTH

145.9 MALIGNANT NEOPLASM OF MOUTH UNSPECIFIED

146.0 MALIGNANT NEOPLASM OF TONSIL

146.1 MALIGNANT NEOPLASM OF TONSILLAR FOSSA

146.2 MALIGNANT NEOPLASM OF TONSILLAR PILLARS (ANTERIOR) (POSTERIOR)

146.3 MALIGNANT NEOPLASM OF VALLECULA EPIGLOTTICA

146.4 MALIGNANT NEOPLASM OF ANTERIOR ASPECT OF EPIGLOTTIS

146.5 MALIGNANT NEOPLASM OF JUNCTIONAL REGION OF OROPHARYNX

146.6 MALIGNANT NEOPLASM OF LATERAL WALL OF OROPHARYNX

146.7 MALIGNANT NEOPLASM OF POSTERIOR WALL OF OROPHARYNX

146.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF OROPHARYNX

146.9 MALIGNANT NEOPLASM OF OROPHARYNX UNSPECIFIED SITE

147.0 MALIGNANT NEOPLASM OF SUPERIOR WALL OF NASOPHARYNX

147.1 MALIGNANT NEOPLASM OF POSTERIOR WALL OF NASOPHARYNX

147.2 MALIGNANT NEOPLASM OF LATERAL WALL OF NASOPHARYNX

147.3 MALIGNANT NEOPLASM OF ANTERIOR WALL OF NASOPHARYNX

147.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF NASOPHARYNX

147.9 MALIGNANT NEOPLASM OF NASOPHARYNX UNSPECIFIED SITE

148.0 MALIGNANT NEOPLASM OF POSTCRICOID REGION OF HYPOPHARYNX

148.1 MALIGNANT NEOPLASM OF PYRIFORM SINUS

148.2 MALIGNANT NEOPLASM OF ARYEPIGLOTTIC FOLD HYPOPHARYNGEAL ASPECT

148.3 MALIGNANT NEOPLASM OF POSTERIOR HYPOPHARYNGEAL WALL

148.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF HYPOPHARYNX

148.9 MALIGNANT NEOPLASM OF HYPOPHARYNX UNSPECIFIED SITE

149.0 MALIGNANT NEOPLASM OF PHARYNX UNSPECIFIED

149.1 MALIGNANT NEOPLASM OF WALDEYER'S RING

149.8 MALIGNANT NEOPLASM OF OTHER SITES WITHIN THE LIP AND ORAL CAVITY

149.9 MALIGNANT NEOPLASM OF ILL-DEFINED SITES WITHIN THE LIP AND ORAL CAVITY

150.0 MALIGNANT NEOPLASM OF CERVICAL ESOPHAGUS

150.1 MALIGNANT NEOPLASM OF THORACIC ESOPHAGUS

150.2 MALIGNANT NEOPLASM OF ABDOMINAL ESOPHAGUS

150.3 MALIGNANT NEOPLASM OF UPPER THIRD OF ESOPHAGUS

150.4 MALIGNANT NEOPLASM OF MIDDLE THIRD OF ESOPHAGUS

150.5 MALIGNANT NEOPLASM OF LOWER THIRD OF ESOPHAGUS

150.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED PART OF ESOPHAGUS

150.9 MALIGNANT NEOPLASM OF ESOPHAGUS UNSPECIFIED SITE

151.0 MALIGNANT NEOPLASM OF CARDIA

151.1 MALIGNANT NEOPLASM OF PYLORUS

151.2 MALIGNANT NEOPLASM OF PYLORIC ANTRUM

151.3 MALIGNANT NEOPLASM OF FUNDUS OF STOMACH

151.4 MALIGNANT NEOPLASM OF BODY OF STOMACH

151.5 MALIGNANT NEOPLASM OF LESSER CURVATURE OF STOMACH UNSPECIFIED

151.6 MALIGNANT NEOPLASM OF GREATER CURVATURE OF STOMACH UNSPECIFIED

151.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF STOMACH

151.9 MALIGNANT NEOPLASM OF STOMACH UNSPECIFIED SITE

153.0 MALIGNANT NEOPLASM OF HEPATIC FLEXURE

153.1 MALIGNANT NEOPLASM OF TRANSVERSE COLON

153.2 MALIGNANT NEOPLASM OF DESCENDING COLON

153.3 MALIGNANT NEOPLASM OF SIGMOID COLON

153.4 MALIGNANT NEOPLASM OF CECUM

153.5 MALIGNANT NEOPLASM OF APPENDIX VERMIFORMIS

153.6 MALIGNANT NEOPLASM OF ASCENDING COLON

153.7 MALIGNANT NEOPLASM OF SPLENIC FLEXURE

153.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF LARGE INTESTINE

153.9 MALIGNANT NEOPLASM OF COLON UNSPECIFIED SITE

154.0 MALIGNANT NEOPLASM OF RECTOSIGMOID JUNCTION

154.1 MALIGNANT NEOPLASM OF RECTUM

154.2 MALIGNANT NEOPLASM OF ANAL CANAL

154.3 MALIGNANT NEOPLASM OF ANUS UNSPECIFIED SITE

154.8 MALIGNANT NEOPLASM OF OTHER SITES OF RECTUM RECTOSIGMOID JUNCTION AND ANUS

155.0 MALIGNANT NEOPLASM OF LIVER PRIMARY

155.1 MALIGNANT NEOPLASM OF INTRAHEPATIC BILE DUCTS

155.2 MALIGNANT NEOPLASM OF LIVER NOT SPECIFIED AS PRIMARY OR SECONDARY

156.0 MALIGNANT NEOPLASM OF GALLBLADDER

156.1 MALIGNANT NEOPLASM OF EXTRAHEPATIC BILE DUCTS

156.2 MALIGNANT NEOPLASM OF AMPULLA OF VATER

156.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF GALLBLADDER AND EXTRAHEPATIC BILE DUCTS

156.9 MALIGNANT NEOPLASM OF BILIARY TRACT PART UNSPECIFIED SITE

157.0 MALIGNANT NEOPLASM OF HEAD OF PANCREAS

157.1 MALIGNANT NEOPLASM OF BODY OF PANCREAS

157.2 MALIGNANT NEOPLASM OF TAIL OF PANCREAS

157.3 MALIGNANT NEOPLASM OF PANCREATIC DUCT

157.4 MALIGNANT NEOPLASM OF ISLETS OF LANGERHANS

157.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF PANCREAS

157.9 MALIGNANT NEOPLASM OF PANCREAS PART UNSPECIFIED

158.0 MALIGNANT NEOPLASM OF RETROPERITONEUM

158.8 MALIGNANT NEOPLASM OF SPECIFIED PARTS OF PERITONEUM

158.9 MALIGNANT NEOPLASM OF PERITONEUM UNSPECIFIED

160.0 MALIGNANT NEOPLASM OF NASAL CAVITIES

160.1 MALIGNANT NEOPLASM OF AUDITORY TUBE MIDDLE EAR AND MASTOID AIR CELLS

160.2 MALIGNANT NEOPLASM OF MAXILLARY SINUS

160.3 MALIGNANT NEOPLASM OF ETHMOIDAL SINUS

160.4 MALIGNANT NEOPLASM OF FRONTAL SINUS

160.5 MALIGNANT NEOPLASM OF SPHENOIDAL SINUS

160.8 MALIGNANT NEOPLASM OF OTHER ACCESSORY SINUSES

160.9 MALIGNANT NEOPLASM OF ACCESSORY SINUS UNSPECIFIED

161.0 MALIGNANT NEOPLASM OF GLOTTIS

161.1 MALIGNANT NEOPLASM OF SUPRAGLOTTIS

161.2 MALIGNANT NEOPLASM OF SUBGLOTTIS

161.3 MALIGNANT NEOPLASM OF LARYNGEAL CARTILAGES

161.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF LARYNX

161.9 MALIGNANT NEOPLASM OF LARYNX UNSPECIFIED

162.0 MALIGNANT NEOPLASM OF TRACHEA

162.2 MALIGNANT NEOPLASM OF MAIN BRONCHUS

162.3 MALIGNANT NEOPLASM OF UPPER LOBE BRONCHUS OR LUNG

162.4 MALIGNANT NEOPLASM OF MIDDLE LOBE BRONCHUS OR LUNG

162.5 MALIGNANT NEOPLASM OF LOWER LOBE BRONCHUS OR LUNG

162.8 MALIGNANT NEOPLASM OF OTHER PARTS OF BRONCHUS OR LUNG

162.9 MALIGNANT NEOPLASM OF BRONCHUS AND LUNG UNSPECIFIED

163.0 MALIGNANT NEOPLASM OF PARIETAL PLEURA

163.1 MALIGNANT NEOPLASM OF VISCERAL PLEURA

163.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF PLEURA

163.9 MALIGNANT NEOPLASM OF PLEURA UNSPECIFIED

164.0 MALIGNANT NEOPLASM OF THYMUS

164.1 MALIGNANT NEOPLASM OF HEART

164.2 MALIGNANT NEOPLASM OF ANTERIOR MEDIASTINUM

164.3 MALIGNANT NEOPLASM OF POSTERIOR MEDIASTINUM

164.8 MALIGNANT NEOPLASM OF OTHER PARTS OF MEDIASTINUM

164.9 MALIGNANT NEOPLASM OF MEDIASTINUM PART UNSPECIFIED

171.0 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF HEAD FACE AND NECK

171.2 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF UPPER LIMB INCLUDING SHOULDER

171.3 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF LOWER LIMB INCLUDING HIP

171.4 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF THORAX

171.5 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF ABDOMEN

171.6 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF PELVIS

171.7 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE OF TRUNK UNSPECIFIED

171.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF CONNECTIVE AND OTHER SOFT TISSUE

171.9 MALIGNANT NEOPLASM OF CONNECTIVE AND OTHER SOFT TISSUE SITE UNSPECIFIED

174.0 MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF FEMALE BREAST

174.1 MALIGNANT NEOPLASM OF CENTRAL PORTION OF FEMALE BREAST

174.2 MALIGNANT NEOPLASM OF UPPER-INNER QUADRANT OF FEMALE BREAST

174.3 MALIGNANT NEOPLASM OF LOWER-INNER QUADRANT OF FEMALE BREAST

174.4 MALIGNANT NEOPLASM OF UPPER-OUTER QUADRANT OF FEMALE BREAST

174.5 MALIGNANT NEOPLASM OF LOWER-OUTER QUADRANT OF FEMALE BREAST

174.6 MALIGNANT NEOPLASM OF AXILLARY TAIL OF FEMALE BREAST

174.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF FEMALE BREAST

174.9 MALIGNANT NEOPLASM OF BREAST (FEMALE) UNSPECIFIED SITE

175.0 MALIGNANT NEOPLASM OF NIPPLE AND AREOLA OF MALE BREAST

175.9 MALIGNANT NEOPLASM OF OTHER AND UNSPECIFIED SITES OF MALE BREAST

179 MALIGNANT NEOPLASM OF UTERUS-PART UNS

180.0 MALIGNANT NEOPLASM OF ENDOCERVIX

180.1 MALIGNANT NEOPLASM OF EXOCERVIX

180.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF CERVIX

180.9 MALIGNANT NEOPLASM OF CERVIX UTERI UNSPECIFIED SITE

182.0 MALIGNANT NEOPLASM OF CORPUS UTERI EXCEPT ISTHMUS

182.1 MALIGNANT NEOPLASM OF ISTHMUS

182.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF BODY OF UTERUS

183.0 MALIGNANT NEOPLASM OF OVARY

183.2 MALIGNANT NEOPLASM OF FALLOPIAN TUBE

183.3 MALIGNANT NEOPLASM OF BROAD LIGAMENT OF UTERUS

183.4 MALIGNANT NEOPLASM OF PARAMETRIUM

183.5 MALIGNANT NEOPLASM OF ROUND LIGAMENT OF UTERUS

183.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF UTERINE ADNEXA

183.9 MALIGNANT NEOPLASM OF UTERINE ADNEXA UNSPECIFIED SITE

184.0 MALIGNANT NEOPLASM OF VAGINA

184.1 MALIGNANT NEOPLASM OF LABIA MAJORA

184.2 MALIGNANT NEOPLASM OF LABIA MINORA

184.3 MALIGNANT NEOPLASM OF CLITORIS

184.4 MALIGNANT NEOPLASM OF VULVA UNSPECIFIED SITE

184.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF FEMALE GENITAL ORGANS

184.9 MALIGNANT NEOPLASM OF FEMALE GENITAL ORGAN SITE UNSPECIFIED

185 MALIGNANT NEOPLASM OF PROSTATE

188.0 MALIGNANT NEOPLASM OF TRIGONE OF URINARY BLADDER

188.1 MALIGNANT NEOPLASM OF DOME OF URINARY BLADDER

188.2 MALIGNANT NEOPLASM OF LATERAL WALL OF URINARY BLADDER

188.3 MALIGNANT NEOPLASM OF ANTERIOR WALL OF URINARY BLADDER

188.4 MALIGNANT NEOPLASM OF POSTERIOR WALL OF URINARY BLADDER

188.5 MALIGNANT NEOPLASM OF BLADDER NECK

188.6 MALIGNANT NEOPLASM OF URETERIC ORIFICE

188.7 MALIGNANT NEOPLASM OF URACHUS

188.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF BLADDER

188.9 MALIGNANT NEOPLASM OF BLADDER PART UNSPECIFIED

189.0 MALIGNANT NEOPLASM OF KIDNEY EXCEPT PELVIS

189.1 MALIGNANT NEOPLASM OF RENAL PELVIS

189.2 MALIGNANT NEOPLASM OF URETER

189.3 MALIGNANT NEOPLASM OF URETHRA

189.4 MALIGNANT NEOPLASM OF PARAURETHRAL GLANDS

189.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF URINARY ORGANS

189.9 MALIGNANT NEOPLASM OF URINARY ORGAN SITE UNSPECIFIED

190.0 MALIGNANT NEOPLASM OF EYEBALL EXCEPT CONJUNCTIVA CORNEA RETINA AND CHOROID

190.1 MALIGNANT NEOPLASM OF ORBIT

190.2 MALIGNANT NEOPLASM OF LACRIMAL GLAND

190.3 MALIGNANT NEOPLASM OF CONJUNCTIVA

190.4 MALIGNANT NEOPLASM OF CORNEA

190.5 MALIGNANT NEOPLASM OF RETINA

190.6 MALIGNANT NEOPLASM OF CHOROID

190.7 MALIGNANT NEOPLASM OF LACRIMAL DUCT

190.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF EYE

190.9 MALIGNANT NEOPLASM OF EYE PART UNSPECIFIED

191.0 MALIGNANT NEOPLASM OF CEREBRUM EXCEPT LOBES AND VENTRICLES

191.1 MALIGNANT NEOPLASM OF FRONTAL LOBE

191.2 MALIGNANT NEOPLASM OF TEMPORAL LOBE

191.3 MALIGNANT NEOPLASM OF PARIETAL LOBE

191.4 MALIGNANT NEOPLASM OF OCCIPITAL LOBE

191.5 MALIGNANT NEOPLASM OF VENTRICLES

191.6 MALIGNANT NEOPLASM OF CEREBELLUM NOS

191.7 MALIGNANT NEOPLASM OF BRAIN STEM

191.8 MALIGNANT NEOPLASM OF OTHER PARTS OF BRAIN

191.9 MALIGNANT NEOPLASM OF BRAIN UNSPECIFIED SITE

192.0 MALIGNANT NEOPLASM OF CRANIAL NERVES

192.1 MALIGNANT NEOPLASM OF CEREBRAL MENINGES

192.2 MALIGNANT NEOPLASM OF SPINAL CORD

192.3 MALIGNANT NEOPLASM OF SPINAL MENINGES

192.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES OF NERVOUS SYSTEM

192.9 MALIGNANT NEOPLASM OF NERVOUS SYSTEM PART UNSPECIFIED

193 MALIGNANT NEOPLASM OF THYROID GLAND

194.0 MALIGNANT NEOPLASM OF ADRENAL GLAND

194.1 MALIGNANT NEOPLASM OF PARATHYROID GLAND

194.5 MALIGNANT NEOPLASM OF CAROTID BODY

194.6 MALIGNANT NEOPLASM OF AORTIC BODY AND OTHER PARAGANGLIA

195.0 MALIGNANT NEOPLASM OF HEAD FACE AND NECK

195.1 MALIGNANT NEOPLASM OF THORAX

195.2 MALIGNANT NEOPLASM OF ABDOMEN

195.3 MALIGNANT NEOPLASM OF PELVIS

195.4 MALIGNANT NEOPLASM OF UPPER LIMB

195.5 MALIGNANT NEOPLASM OF LOWER LIMB

195.8 MALIGNANT NEOPLASM OF OTHER SPECIFIED SITES

198.3 SECONDARY MALIGNANT NEOPLASM OF BRAIN AND SPINAL CORD

198.5 SECONDARY MALIGNANT NEOPLASM OF BONE AND BONE MARROW

201.00 HODGKIN'S PARAGRANULOMA UNSPECIFIED SITE

201.01 HODGKIN'S PARAGRANULOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK

201.02 HODGKIN'S PARAGRANULOMA INVOLVING INTRATHORACIC LYMPH NODES

201.03 HODGKIN'S PARAGRANULOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES

201.04 HODGKIN'S PARAGRANULOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

201.05 HODGKIN'S PARAGRANULOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

201.06 HODGKIN'S PARAGRANULOMA INVOLVING INTRAPELVIC LYMPH NODES

201.07 HODGKIN'S PARAGRANULOMA INVOLVING SPLEEN

201.08 HODGKIN'S PARAGRANULOMA INVOLVING LYMPH NODES OF MULTIPLE SITES

201.10 HODGKIN'S GRANULOMA UNSPECIFIED SITE

201.11 HODGKIN'S GRANULOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK

201.12 HODGKIN'S GRANULOMA INVOLVING INTRATHORACIC LYMPH NODES

201.13 HODGKIN'S GRANULOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES

201.14 HODGKIN'S GRANULOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

201.15 HODGKIN'S GRANULOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

201.16 HODGKIN'S GRANULOMA INVOLVING INTRAPELVIC LYMPH NODES

201.17 HODGKIN'S GRANULOMA INVOLVING SPLEEN

201.18 HODGKIN'S GRANULOMA INVOLVING LYMPH NODES OF MULTIPLE SITES

201.20 HODGKIN'S SARCOMA UNSPECIFIED SITE

201.21 HODGKIN'S SARCOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK

201.22 HODGKIN'S SARCOMA INVOLVING INTRATHORACIC LYMPH NODES

201.23 HODGKIN'S SARCOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES

201.24 HODGKIN'S SARCOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

201.25 HODGKIN'S SARCOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

201.26 HODGKIN'S SARCOMA INVOLVING INTRAPELVIC LYMPH NODES

201.27 HODGKIN'S SARCOMA INVOLVING SPLEEN

201.28 HODGKIN'S SARCOMA INVOLVING LYMPH NODES OF MULTIPLE SITES

201.40 HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE UNSPECIFIED SITE

201.41 HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING LYMPH NODES OF HEAD FACE AND NECK

201.42 HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING INTRATHORACIC LYMPH NODES

201.43 HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING INTRA-ABDOMINAL LYMPH NODES

201.44 HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

201.45 HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

201.46 HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING INTRAPELVIC LYMPH NODES

201.47 HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING SPLEEN

201.48 HODGKIN'S DISEASE LYMPHOCYTIC-HISTIOCYTIC PREDOMINANCE INVOLVING LYMPH NODES OF MULTIPLE SITES

201.50 HODGKIN'S DISEASE NODULAR SCLEROSIS UNSPECIFIED SITE

201.51 HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING LYMPH NODES OF HEAD FACE AND NECK

201.52 HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING INTRATHORACIC LYMPH NODES

201.53 HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING INTRA-ABDOMINAL LYMPH NODES

201.54 HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

201.55 HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

201.56 HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING INTRAPELVIC LYMPH NODES

201.57 HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING SPLEEN

201.58 HODGKIN'S DISEASE NODULAR SCLEROSIS INVOLVING LYMPH NODES OF MULTIPLE SITES

201.60 HODGKIN'S DISEASE MIXED CELLULARITY UNSPECIFIED SITE

201.61 HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING LYMPH NODES OF HEAD FACE AND NECK

201.62 HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING INTRATHORACIC LYMPH NODES

201.63 HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING INTRA-ABDOMINAL LYMPH NODES

201.64 HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

201.65 HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

201.66 HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING INTRAPELVIC LYMPH NODES

201.67 HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING SPLEEN

201.68 HODGKIN'S DISEASE MIXED CELLULARITY INVOLVING LYMPH NODES OF MULTIPLE SITES

201.70 HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION UNSPECIFIED SITE

201.71 HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING LYMPH NODES OF HEAD FACE AND NECK

201.72 HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING INTRATHORACIC LYMPH NODES

201.73 HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING INTRA-ABDOMINAL LYMPH NODES

201.74 HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

201.75 HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

201.76 HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING INTRAPELVIC LYMPH NODES

201.77 HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING SPLEEN

201.78 HODGKIN'S DISEASE LYMPHOCYTIC DEPLETION INVOLVING LYMPH NODES OF MULTIPLE SITES

201.90 HODGKIN'S DISEASE UNSPECIFIED TYPE UNSPECIFIED SITE

201.91 HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING LYMPH NODES OF HEAD FACE AND NECK

201.92 HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING INTRATHORACIC LYMPH NODES

201.93 HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING INTRA-ABDOMINAL LYMPH NODES

201.94 HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

201.95 HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

201.96 HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING INTRAPELVIC LYMPH NODES

201.97 HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING SPLEEN

201.98 HODGKIN'S DISEASE UNSPECIFIED TYPE INVOLVING LYMPH NODES OF MULTIPLE SITES

202.00 NODULAR LYMPHOMA UNSPECIFIED SITE

202.01 NODULAR LYMPHOMA INVOLVING LYMPH NODES OF HEAD FACE AND NECK

202.02 NODULAR LYMPHOMA INVOLVING INTRATHORACIC LYMPH NODES

202.03 NODULAR LYMPHOMA INVOLVING INTRA-ABDOMINAL LYMPH NODES

202.04 NODULAR LYMPHOMA INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

202.05 NODULAR LYMPHOMA INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

202.06 NODULAR LYMPHOMA INVOLVING INTRAPELVIC LYMPH NODES

202.07 NODULAR LYMPHOMA INVOLVING SPLEEN

202.08 NODULAR LYMPHOMA INVOLVING LYMPH NODES OF MULTIPLE SITES

202.10 MYCOSIS FUNGOIDES UNSPECIFIED SITE

202.11 MYCOSIS FUNGOIDES INVOLVING LYMPH NODES OF HEAD FACE AND NECK

202.12 MYCOSIS FUNGOIDES INVOLVING INTRATHORACIC LYMPH NODES

202.13 MYCOSIS FUNGOIDES INVOLVING INTRA-ABDOMINAL LYMPH NODES

202.14 MYCOSIS FUNGOIDES INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

202.15 MYCOSIS FUNGOIDES INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

202.16 MYCOSIS FUNGOIDES INVOLVING INTRAPELVIC LYMPH NODES

202.17 MYCOSIS FUNGOIDES INVOLVING SPLEEN

202.18 MYCOSIS FUNGOIDES INVOLVING LYMPH NODES OF MULTIPLE SITES

202.20 SEZARY'S DISEASE UNSPECIFIED SITE

202.21 SEZARY'S DISEASE INVOLVING LYMPH NODES OF HEAD FACE AND NECK

202.22 SEZARY'S DISEASE INVOLVING INTRATHORACIC LYMPH NODES

202.23 SEZARY'S DISEASE INVOLVING INTRA-ABDOMINAL LYMPH NODES

202.24 SEZARY'S DISEASE INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

202.25 SEZARY'S DISEASE INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

202.26 SEZARY'S DISEASE INVOLVING INTRAPELVIC LYMPH NODES

202.27 SEZARY'S DISEASE INVOLVING SPLEEN

202.28 SEZARY'S DISEASE INVOLVING LYMPH NODES OF MULTIPLE SITES

202.30 MALIGNANT HISTIOCYTOSIS UNSPECIFIED SITE

202.31 MALIGNANT HISTIOCYTOSIS INVOLVING LYMPH NODES OF HEAD FACE AND NECK

202.32 MALIGNANT HISTIOCYTOSIS INVOLVING INTRATHORACIC LYMPH NODES

202.33 MALIGNANT HISTIOCYTOSIS INVOLVING INTRA-ABDOMINAL LYMPH NODES

202.34 MALIGNANT HISTIOCYTOSIS INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

202.35 MALIGNANT HISTIOCYTOSIS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

202.36 MALIGNANT HISTIOCYTOSIS INVOLVING INTRAPELVIC LYMPH NODES

202.37 MALIGNANT HISTIOCYTOSIS INVOLVING SPLEEN

202.38 MALIGNANT HISTIOCYTOSIS INVOLVING LYMPH NODES OF MULTIPLE SITES

202.40 LEUKEMIC RETICULOENDOTHELIOSIS UNSPECIFIED SITE

202.41 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF HEAD FACE AND NECK

202.42 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING INTRATHORACIC LYMPH NODES

202.43 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING INTRA-ABDOMINAL LYMPH NODES

202.44 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF AXILLA AND UPPER ARM

202.45 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

202.46 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING INTRAPELVIC LYMPH NODES

202.47 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING SPLEEN

202.48 LEUKEMIC RETICULOENDOTHELIOSIS INVOLVING LYMPH NODES OF MULTIPLE SITES

202.50 LETTERER-SIWE DISEASE UNSPECIFIED SITE

202.51 LETTERER-SIWE DISEASE INVOLVING LYMPH NODES OF HEAD FACE AND NECK

202.52 LETTERER-SIWE DISEASE INVOLVING INTRATHORACIC LYMPH NODES

202.53 LETTERER-SIWE DISEASE INVOLVING INTRA-ABDOMINAL LYMPH NODES

202.54 LETTERER-SIWE DISEASE INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

202.55 LETTERER-SIWE DISEASE INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

202.56 LETTERER-SIWE DISEASE INVOLVING INTRAPELVIC LYMPH NODES

202.57 LETTERER-SIWE DISEASE INVOLVING SPLEEN

202.58 LETTERER-SIWE DISEASE INVOLVING LYMPH NODES OF MULTIPLE SITES

202.60 MALIGNANT MAST CELL TUMORS UNSPECIFIED SITE

202.61 MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF HEAD FACE AND NECK

202.62 MALIGNANT MAST CELL TUMORS INVOLVING INTRATHORACIC LYMPH NODES

202.63 MALIGNANT MAST CELL TUMORS INVOLVING INTRA-ABDOMINAL LYMPH NODES

202.64 MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

202.65 MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

202.66 MALIGNANT MAST CELL TUMORS INVOLVING INTRAPELVIC LYMPH NODES

202.67 MALIGNANT MAST CELL TUMORS INVOLVING SPLEEN

202.68 MALIGNANT MAST CELL TUMORS INVOLVING LYMPH NODES OF MULTIPLE SITES

202.70 PERIPHERAL T CELL LYMPHOMA, UNSPECIFIED SITE, EXTRANODAL AND SOLID ORGAN SITES

202.71 PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF HEAD, FACE, AND NECK

202.72 PERIPHERAL T CELL LYMPHOMA, INTRATHORACIC LYMPH NODES

202.73 PERIPHERAL T CELL LYMPHOMA, INTRA-ABDOMINAL LYMPH NODES

202.74 PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF AXILLA AND UPPER LIMB

202.75 PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

202.76 PERIPHERAL T CELL LYMPHOMA, INTRAPELVIC LYMPH NODES

202.77 PERIPHERAL T CELL LYMPHOMA, SPLEEN

202.78 PERIPHERAL T CELL LYMPHOMA, LYMPH NODES OF MULTIPLE SITES

202.80 OTHER MALIGNANT LYMPHOMAS UNSPECIFIED SITE

202.81 OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF HEAD FACE AND NECK

202.82 OTHER MALIGNANT LYMPHOMAS INVOLVING INTRATHORACIC LYMPH NODES

202.83 OTHER MALIGNANT LYMPHOMAS INVOLVING INTRA-ABDOMINAL LYMPH NODES

202.84 OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

202.85 OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

202.86 OTHER MALIGNANT LYMPHOMAS INVOLVING INTRAPELVIC LYMPH NODES

202.87 OTHER MALIGNANT LYMPHOMAS INVOLVING SPLEEN

202.88 OTHER MALIGNANT LYMPHOMAS INVOLVING LYMPH NODES OF MULTIPLE SITES

202.90 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE UNSPECIFIED SITE

202.91 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES OF HEAD FACE AND NECK

202.92 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING INTRATHORACIC LYMPH NODES

202.93 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING INTRA-ABDOMINAL LYMPH NODES

202.94 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES OF AXILLA AND UPPER LIMB

202.95 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES OF INGUINAL REGION AND LOWER LIMB

202.96 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING INTRAPELVIC LYMPH NODES

202.97 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING SPLEEN

202.98 OTHER AND UNSPECIFIED MALIGNANT NEOPLASMS OF LYMPHOID AND HISTIOCYTIC TISSUE INVOLVING LYMPH NODES OF MULTIPLE SITES

225.1 BENIGN NEOPLASM OF CRANIAL NERVES

225.2 BENIGN NEOPLASM OF CEREBRAL MENINGES

227.3 BENIGN NEOPLASM OF PITUITARY GLAND AND CRANIOPHARYNGEAL DUCT

227.4 BENIGN NEOPLASM OF PINEAL GLAND

227.6 BENIGN NEOPLASM OF AORTIC BODY AND OTHER PARAGANGLIA

233.0 CARCINOMA IN SITU OF BREAST

747.81 CONGENITAL ANOMALIES OF CEREBROVASCULAR SYSTEM

 

 

Documentation Requirements

• Medical record documentation maintained by the provider must indicate the medical necessity for IMRT, and include all of the following for IMRT planning and delivery:

o The treatment plan/prescription must define the goals and requirements of the treatment, including the specific dose constraints for the target(s) and nearby critical structures.

o A statement by the treating physician documenting the special need for performing IMRT on the patient in question, rather than performing conventional or three-dimensional treatment planning and delivery.

 The physician must address the other organs at risk and/or adjacent critical structures.

o Review (signed and dated) by the radiation oncologist of the CT or MRI based images of the target and all critical structures with representative isodose distributions that characterize the three-dimensional dose.

o Radiation oncologist review of dose-volume histograms for all targets and critical structures.

o Description of the number and location of each treatment step/rotation or portal to accomplish the treatment plan.

o Documentation of dosimetric verification of treatment setup and delivery, signed by both the radiation oncologist and the medical physicist.

o For compensator-based IMRT, the unique compensator design should be documented for east step or portal.

• Other procedures performed during the episode of care must have documentation that supports the professional and technical components as applicable by identifying

o The place of service.

o The date of service.

o The supervising physician.

o Proof of work.

 

Utilization Guidelines

• It is expected that these services would be performed as indicated by current medical literature and/or medical standards of practice.

o When services are performed in excess of established parameters, they may be subject to review for medical necessity.

• Procedures billed should be consistent with CPT code descriptors and Medicare valuation.

o The frequency of such procedures in the episode of care and the units on a given day must meet standards of care.

Treatment Logic

• Intensity Modulated Radiation Therapy (IMRT) is a computer-based method of planning for, and delivery of patient specific, spatially modulated beams of radiation to solid tumors within a patient.

• IMRT planning and delivery uses an approach for obtaining the highly conformal dose distributions needed to irradiate complex targets positioned near, or invaginated by, sensitive normal tissues, thus improving the therapeutic ratios.

• IMRT delivers a more precise radiation dose to the tumor while sparing the surrounding normal tissues by using non-uniform radiation beam intensities determined by various computer-based optimization techniques.

• The decision process for using IMRT requires an understanding of accepted practices that take into account the risks and benefits of such therapy compared to conventional treatment techniques.

• While IMRT technology may empirically offer advances over conventional or three-dimensional conformal radiation, a comprehensive understanding of all consequences is required before applying this technology.

 

Sources of Information and Basis for Decision

 

American College of Radiology, American Society for Therapeutic Radiology and Oncology (2001). Model Policy on Intensity Modulated Radiation Therapy. Fairfax, VA. This source supports the appropriate indication for use.

 

American Society Therapeutic Radiation Oncology/American College Radiology Guide to Radiation Oncology Coding. (2007).

 

American Society Therapeutic Radiation Oncology/American College Radiology Guide to Radiation Oncology Coding. (2008 Supplement).

 

Bradley, J., Graham, M., Winter, K., Purdy, J., Komaki, R., Roa, W., Ryu, J., Bosch, W., & Emami, B. (2005). Toxicity and outcome results of RTOG 9311: A phase I-II dose-escalation study using three-dimensional conformal radiotherapy in patients with inoperable non-small-cell lung carcinoma. Int . J. Radiation Oncology Bio. Phys., 61(2), 318-328.

 

Chen, M., Hayman, J., Haken, R., Tatro, D., Fernando, S., & Kong, F. (2006). Long-term results of high-dose conformal radiotherapy for patients with medically inoperable T1-3N0 non-small-cell lung cancer: is low incidence of regional failure due to incidental nodal irradiation. Int . J. Radiation Oncology Bio. Phys., 64(1), 120-126.

 

FCSO LCD 29200, Intensity Modulated Radiation Therapy (IMRT), 11/29/2012. The official local coverage determination (LCD) is the version on the Medicare coverage database at www.cms.gov/medicare-coverage-database/.

 

Freedman, G., Li, T., Nicolaou, N. Chen, Y., Ma, C., & Anderson, P. (2009). Breast intensity-modulated radiation therapy reduces time spent with acute dermatitis for women of all breast sizes during radiation. Int. J. Radiation Oncology Biol. Pys., 74(3), 689-694.

 

Intensity-Modulated Radiotherapy Collaborative Working Group. (2001). Intensity-modulated radiotherapy: current status and issues of interest. International Journal of Radiation Oncology, Biology, Physics, 54(4), 880-914. This source supports the appropriate indication for use.

 

Mell, L., Schomas, D., Salama, J., Devisetty, K., Aydogan, B., Miller, R., Jani, A., Kindler, H., Mundt, A., Roeske, J., & Chmura, S. (2008).Association between bone marrow dosimetric parameters and acute hematologic toxicity in anal cancer patients treated with concurrent chemotherapy and intensity-modulated radiotherapy. Int . J. Radiation Oncology Bio. Phys., 70(5), 1431-1437.

 

Milano, M., Chmura, S., Garofalo, M., Rash, C., Roeske, J., Connell, P., Kwon, O., Jani, A., & Heimann, R. (2004). Intensity-modulated radiotherapy in treatment of pancreatic and bile duct malignancies: Toxicity and clinical outcome. Int . J. Radiation Oncology Bio. Phys., 59(2), 445-453.

 

Nutting, C.M., Convery, D.J., Cosgrove, V.P., et al. (2000). Reduction of small and large bowel irradiation using an optimized intensity modulated pelvic radiotherapy technique in-patients with prostate cancer. International Journal of Radiation Oncology, Biology, Physics, 48 (3), 649-656. This source supports the appropriate indication for use.

 

Pirzkall, A., Carol, M., Lohr, F., et al. (2000). Comparison of intensity modulated radiotherapy with conventional conformal radiotherapy for complex-shaped tumors. International Journal of Radiation Oncology, Biology, Physics, 48(5), 1371-1380. This source supports the appropriate indication for use.

 

Salama, J., Mell, L., Schomas, D., Miller, R., Devisetty, K., Jani, A., Mundt, A., Roeske, J., Liauw, S., & Chmura, S. (2007). Concurrent chemotherapy and intensity-modulated radiation therapy for anal canal cancer patients: A multicenter experience. Journal of Clinical Oncology, 25(29), 4581-4586.

 

Shu, H.G., Lee, T, Vigneault, E., et al. (2001). Toxicity following high-dose 3-dimensional and intensity-modulated radiation therapy for clinically localized prostate cancer. Urology, 57(1), 102-107. This source provides a description of services and provides indications for the appropriate use.

 

Sura, S., Gupta, V., Yorke, E., Jackson, A., Amols, H., & Rosenzweig, K. (2008). Intensity-modulated radiation therapy (IMRT) for inoperable non-small cell lung cancer: The Memorial Sloan-Kettering Cancer Center (MSKCC) experience. Radiotherapy and Oncology.87, 17-23.

 

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Xia, P., Fu, K., Wong, G., et al. (2000). Comparison of treatment plans involving intensity modulated radiotherapy for nasopharyngeal carcinoma. International Journal of Radiation Oncology, Biology, Physics, 48 (2), 329-337. This source supports the appropriate indication for use.

 

Yom, S., Liao, Z., Liu, H., Tucker, S., Hu, C., Wei, X., Wang, X., Wang, S., Mohan, R., Cox, J., & Komaki, R. (2007). Initial evaluation of treatment-related pneumonitis in advanced-stage non-small-cell lung cancer patients treated with concurrent chemotherapy and intensity-modulated radiotherapy. Int. J. Radiation Oncology Bio. Phys., 68(1), 94-102.

 

Zelefsky, M. J., Fuks, Z., et al (2000). Clinical experiences with intensity modulated radiation therapy (IMRT) in prostate cancer. Radiotherapy Oncology, 55(3), 241-249. This source supports the appropriate indication for use.

 

 

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