CPT 77290Radiology

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CPT 77290 covers the planning session (simulation) for complex radiation therapy treatment, where specialized imaging and computer calculations determine exactly where to aim radiation beams. This is the detailed preparation work done before any actual radiation treatment begins.

Showing rates for

National Average

Base Medicare rate

$427.62

This calculator gives a typical-case estimate using standard Medicare modifier rules. Actual payment depends on payer policies, documentation, code-specific CMS status indicators, and locality. Verify before billing.

RVU breakdown

Work RVU

1.56

PE RVU (NF)

11.57

MP RVU

0.09

Total RVU

13.22

Conversion factor: 32.3465 · Source: CMS MPFS RVU25A · Confidence: High

NCCI bundling edits

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Billing tips

Ensure simulation complexity matches code selection - 77290 requires three or more treatment areas, custom blocking, or advanced techniques; simpler simulations should use 77280 or 77285
Impact: Incorrect code selection accounts for 30-40% of radiation oncology denials; downcoding from 77290 to 77285 results in approximately $100-150 payment reduction per case
Document all elements that establish complexity: number of treatment ports, use of custom blocking, wedge angles, field-within-field techniques, or rotational beam approaches in the simulation report
Impact: Missing complexity documentation is the #1 reason for downcoding; comprehensive documentation prevents $100+ reimbursement loss and reduces audit risk
Bill simulation codes only once per treatment course unless re-simulation is medically necessary due to tumor changes, significant weight loss, or treatment plan modification
Impact: Repeat simulations without proper justification face 85%+ denial rates; when justified with documentation, modifier 76 allows full $427.62 reimbursement for necessary re-planning
Verify treatment planning codes (77295, 77300, 77301) are billed separately as these are distinct from simulation and represent different professional work
Impact: Failure to bill planning codes separately results in leaving $150-400 on the table per case; these are complementary services, not bundled with 77290
Submit claims within 30 days of simulation date and ensure simulation precedes any treatment delivery codes chronologically in the billing sequence
Impact: Claims submitted with simulation after treatment dates face automatic denials; proper sequencing ensures clean claims processing and prevents payment delays of 30-60 days

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Frequently asked questions

What is the Medicare reimbursement rate for CPT 77290 in 2025?

Medicare pays $427.62 for CPT 77290 in 2025 (both facility and non-facility rates are identical). This is based on 13.22 total RVUs (1.56 work RVU + 11.57 practice expense RVU + 0.09 malpractice RVU) multiplied by the 2025 conversion factor of 32.3465.

What is the difference between CPT 77290 and 77295?

CPT 77290 is the simulation procedure where treatment fields and patient positioning are established, while CPT 77295 is the 3D dosimetry treatment planning that follows simulation. Both are separately billable services - 77290 covers the physical simulation process, and 77295 covers the computational planning work. They are typically performed on different dates and represent distinct professional services.

How many times can you bill CPT 77290 during a course of radiation treatment?

CPT 77290 is typically billed once per treatment course. A second simulation can be billed with modifier 76 if medically necessary due to tumor changes, significant anatomical changes (such as weight loss), treatment plan modifications, or initial simulation inadequacies. Documentation must clearly justify why re-simulation is required.

What makes a radiation simulation 'complex' enough to bill 77290?

A simulation qualifies as complex (77290) when it involves three or more treatment areas, custom blocking, tangential ports, wedges or other beam modification devices, rotational beams, field-within-field techniques, or electron arc therapy. If the simulation involves fewer than three ports and no special beam arrangements, use 77285 (intermediate) or 77280 (simple) instead.

Can CPT 77290 be billed with a professional component modifier 26?

While modifier 26 can technically be appended to 77290, the facility and non-facility rates are identical ($427.62), and the RVU distribution shows this is already structured as a predominantly professional service. Split billing with 26/TC is rarely appropriate for this code. Verify your specific payer's policy before splitting components.

What documentation is required to support billing CPT 77290?

Required documentation includes: identification of treatment areas with anatomic detail, number of treatment ports/fields, specifications for custom blocking or beam shaping, beam modification devices used (wedges, compensators), patient positioning and immobilization methods, treatment volume determination, physician supervision notes, and medical necessity justification linking the simulation complexity to the diagnosis and treatment plan.

Is prior authorization required for CPT 77290?

Prior authorization requirements vary by payer and state. Medicare typically does not require prior authorization for 77290, but many Medicare Advantage plans and commercial insurers do require authorization for radiation therapy services including simulation. Always verify with the specific payer before performing the simulation to avoid denial. Some states have radiation oncology programs enrolled in prior authorization demonstration projects.