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Official Description

Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions

© Copyright 2025 American Medical Association. All rights reserved.

Common Language Description

Stereotactic body radiation therapy (SBRT) treatment management is a specialized form of radiation therapy that is utilized for the precise targeting of one or more lesions within the body. This procedure is characterized by its ability to deliver high doses of radiation to a specific area while minimizing exposure to surrounding healthy tissues. The treatment course is structured to not exceed five fractions, or sessions, which allows for a concentrated delivery of radiation over a defined period. The process begins with advanced imaging techniques, such as MRI or CT scans, which are employed to accurately locate the lesions in three-dimensional space. This imaging is crucial for the computer-aided planning that follows, ensuring that the radiation is directed precisely at the target. During the treatment, patients are immobilized using removable frames, masks, or fitted casts to limit movement, thereby enhancing the accuracy of radiation delivery. The management of SBRT involves several critical components, including the calculation and review of dosimetry, which determines the appropriate radiation dose for each session. Additionally, treatment management encompasses pre-treatment setup, which involves positioning the patient correctly and assessing the placement of immobilization devices, as well as any necessary radiation blocks or wedges. Throughout the course of treatment, healthcare professionals coordinate the patient's care, monitor their response to therapy, and review relevant lab tests and imaging films to ensure optimal outcomes.

© Copyright 2025 Coding Ahead. All rights reserved.

1. Indications

The indications for stereotactic body radiation therapy (SBRT) treatment management include the following conditions:

  • Localized Tumors SBRT is indicated for the treatment of localized tumors that are accessible and can be targeted precisely with radiation.
  • Metastatic Lesions This therapy is often used for patients with metastatic lesions in the body, where traditional treatment options may not be suitable.
  • Inoperable Tumors SBRT is indicated for tumors that are deemed inoperable due to their location or the patient's overall health status.
  • Recurrence of Cancer It is also indicated for patients experiencing a recurrence of cancer in previously treated areas.

2. Procedure

The procedure for stereotactic body radiation therapy (SBRT) treatment management involves several key steps that ensure the accurate delivery of radiation to the targeted lesions:

  • Step 1: Imaging and Planning The first step involves obtaining detailed imaging of the lesions using MRI or CT scans. This imaging is essential for the computer-aided planning process, which allows for precise localization of the target area in three-dimensional space.
  • Step 2: Patient Positioning Once the planning is complete, the patient is positioned accurately on the treatment table. This may involve the use of removable frames, masks, or fitted casts to ensure that the patient remains still during the procedure, thereby minimizing movement that could affect treatment accuracy.
  • Step 3: Dosimetry Calculation The next step is the calculation and review of dosimetry, which determines the appropriate radiation dose to be delivered during each fraction of treatment. This calculation is critical to ensure that the radiation is delivered safely and effectively.
  • Step 4: Treatment Delivery During the treatment sessions, a focused external beam of radiation is delivered to the targeted lesions. The treatment is conducted over a course that does not exceed five fractions, allowing for a concentrated dose of radiation.
  • Step 5: Monitoring and Evaluation Throughout the treatment course, the healthcare team monitors the patient's response to therapy. This includes reviewing lab tests and imaging films to assess the effectiveness of the treatment and make any necessary adjustments.

3. Post-Procedure

After the completion of stereotactic body radiation therapy (SBRT), patients may require follow-up care to monitor their recovery and response to treatment. This may involve additional imaging studies to evaluate the effectiveness of the therapy and to check for any potential side effects. Patients are typically advised on post-treatment care, which may include managing any discomfort or side effects that arise from the radiation therapy. Ongoing communication with the healthcare team is essential to address any concerns and to ensure that the patient's overall health is monitored during the recovery period.

Short Descr SBRT MANAGEMENT
Medium Descr STEREOTACTIC BODY RADIATION MANAGEMENT
Long Descr Stereotactic body radiation therapy, treatment management, per treatment course, to 1 or more lesions, including image guidance, entire course not to exceed 5 fractions
Status Code Active Code
Global Days XXX - Global Concept Does Not Apply
PC/TC Indicator (26, TC) 2 - Professional Component Only Code
Multiple Procedures (51) 0 - No payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50) 0 - 150% payment adjustment for bilateral procedures does NOT apply.
Physician Supervisions 09 - Concept does not apply.
Assistant Surgeon (80, 82) 0 - Payment restriction for assistants at surgery applies to this procedure...
Co-Surgeons (62) 0 - Co-surgeons not permitted for this procedure.
Team Surgery (66) 0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family 99 - Concept Does Not Apply
APC Status Indicator Items and Services Packaged into APC Rates
ASC Payment Indicator Packaged service/item; no separate payment made.
Type of Service (TOS) 6 - Therapeutic Radiology
Berenson-Eggers TOS (BETOS) I4B - Imaging/procedure - other
MUE 1
CCS Clinical Classification 211 - Therapeutic radiology
GC This service has been performed in part by a resident under the direction of a teaching physician
Q1 Routine clinical service provided in a clinical research study that is in an approved clinical research study
Q6 Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
AQ Physician providing a service in an unlisted health professional shortage area (hpsa)
59 Distinct procedural service: under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. modifier 59 is used to identify procedures/services, other than e/m services, that are not normally reported together, but are appropriate under the circumstances. documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. however, when another already established modifier is appropriate it should be used rather than modifier 59. only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. note: modifier 59 should not be appended to an e/m service. to report a separate and distinct e/m service with a non-e/m service performed on the same date, see modifier 25.
X4 Episodic/focused services: for reporting services by clinicians who provide focused care on particular types of treatment limited to a defined period and circumstance; the patient has a problem, acute or chronic, that will be treated with surgery, radiation, or some other type of generally time-limited intervention; reporting clinician service examples include but are not limited to, the orthopedic surgeon performing a knee replacement and seeing the patient through the postoperative period
X5 Diagnostic services requested by another clinician: for reporting services by a clinician who furnishes care to the patient only as requested by another clinician or subsequent and related services requested by another clinician; this modifier is reported for patient relationships that may not be adequately captured by the above alternative categories; reporting clinician service examples include but are not limited to, the radiologist's interpretation of an imaging study requested by another clinician
XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service
XE Separate encounter, a service that is distinct because it occurred during a separate encounter
24 Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period: the physician or other qualified health care professional may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure. this circumstance may be reported by adding modifier 24 to the appropriate level of e/m service.
26 Professional component: certain procedures are a combination of a physician or other qualified health care professional component and a technical component. when the physician or other qualified health care professional component is reported separately, the service may be identified by adding modifier 26 to the usual procedure number.
76 Repeat procedure or service by same physician or other qualified health care professional: it may be necessary to indicate that a procedure or service was repeated by the same physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 76 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
77 Repeat procedure by another physician or other qualified health care professional: it may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. this circumstance may be reported by adding modifier 77 to the repeated procedure or service. note: this modifier should not be appended to an e/m service.
79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period: the individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. this circumstance may be reported by using modifier 79. (for repeat procedures on the same day, see modifier 76.)
95 Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system: synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located at a distant site from the physician or other qualified health care professional. the totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that would be sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction. modifier 95 may only be appended to the services listed in appendix p. appendix p is the list of cpt codes for services that are typically performed face-to-face, but may be rendered via a real-time (synchronous) interactive audio and video telecommunications system.
CC Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)
CR Catastrophe/disaster related
GV Attending physician not employed or paid under arrangement by the patient's hospice provider
GW Service not related to the hospice patient's terminal condition
GZ Item or service expected to be denied as not reasonable and necessary
PN Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital
Q0 Investigational clinical service provided in a clinical research study that is in an approved clinical research study
Q5 Service furnished under a reciprocal billing arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
RT Right side (used to identify procedures performed on the right side of the body)
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
Date
Action
Notes
2013-01-01 Changed Guideline information changed.
2009-01-01 Changed Code description changed
2007-01-01 Added First appearance in code book in 2007.
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