Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Breast brachytherapy is the direct treatment of breast cancer by placing radioactive substances into the exact portion of the breast from which an early cancer was removed. This is also known as a Mammosite procedure. After limited breast surgery for an early cancer, a reservoir (like a balloon) is placed in the portion of the breast from which the cancer was removed. Liquid preparations of radioactive substances are placed into the reservoir for defined amounts of time to irradiate the local tissues in an effort to reduce recurrence of the cancer.

2)    This treatment is covered by QualChoice.

1)    There are three stages to the Mammosite procedure: insertion of the balloon, evaluation and set up for treatment, and treatment sessions. The treatment course is either one or two per day of therapy for a 5-day course.
QualChoice will recognize and compensate these sections of the process as follows:

a)    Insertion of the Balloon:

i)     One code in the range 19296-19298

b)    Initial radiation therapy evaluation and set up for treatment – one each of the following codes:

i)     77326; AND (code 77326 del 01/01/2015 and replaced by 77316)

ii)    77336; AND

iii)   77370

c)    Per treatment:

i)     Use modifier 76 if more than one treatment per day

ii)    77790 AND

iii)   One of 77761-77763

iv)   Plus appropriate HCPCS codes for the radioactive substance used.

Codes Used In This BI:

Addendum:

Effective 01/01/2017: Removed deleted codes 77326 and code range 77781 – 77784 from Claim Statement section. These codes are no longer valid codes.