September 28, 2026 · Team ALH.

How independent radiation oncology practices rebuild delivery coding, IGRT claims, and Noridian JF documentation after the CY 2026 Medicare reset.

Independent radiation oncology practices did not get a soft landing in calendar year (CY) 2026. The Centers for Medicare & Medicaid Services (CMS) deleted the freestanding Healthcare Common Procedure Coding System (HCPCS) G6001–G6017 delivery and image-guided radiation therapy (IGRT) set, deleted intensity-modulated radiation therapy (IMRT) delivery codes 77385 and 77386, and replaced megavoltage external beam radiation therapy (EBRT) delivery with complexity-based Current Procedural Terminology (CPT) codes 77402, 77407, and 77412. Technical IGRT sits inside those delivery codes. Separately payable IGRT is limited to the professional component of 77387. A new superficial / orthovoltage family (77436–77439) replaced legacy skin codes. Payment methodology shifted toward Outpatient Prospective Payment System (OPPS)–informed practice expense (PE) assumptions and a −2.5% efficiency adjustment on many non–time-based work relative value units (RVUs).

That package is FINAL for dates of service (DOS) on or after January 1, 2026. It is not a proposal you can wait out. By March 2026, an American Society for Radiation Oncology (ASTRO) member survey was already reporting frequent Level 3 (77412) downcoding and double-digit revenue stress in freestanding settings. Practices that still map "IMRT equals the high code," still drop 77387-TC, or still treat Washington as Jurisdiction E (JE) are leaving clean claims on the table.

This post is for radiation oncology (RO) practice managers, physicists, therapists, and billing leads who need the full 2026 package in one place: leveled delivery definitions, IGRT bundling, payment and hospital outpatient APC context, the new superficial radiation therapy (SRT) codes and Noridian Local Coverage Determination (LCD) L40176 / Billing and Coding article A60181, modifiers that matter, a Washington Jurisdiction F (JF) geography correction, a practical checklist, and labeled claim examples. It is RO-only. It does not rehash a single-code 77412 deep dive or an IGRT-only primer. Where CY 2027 conversion-factor (CF) pressure or the Radiation Oncology (RO) Model appears, those items are labeled PROPOSED or unconfirmed—not current mandatory billing rules for Woodland or Vancouver, Washington clinics.

Why CY 2026 is an operational reset, not a rumor

For years, freestanding centers and hospital outpatient departments often spoke different coding languages for the same megavoltage fraction. Freestanding sites used G-codes. Hospitals used CPT delivery codes. IMRT had its own delivery pair. CT guidance (77014) and various imaging lines sat beside delivery. That structure no longer matched how departments treat patients: 3D, IMRT/volumetric modulated arc therapy (VMAT), surface guidance, gating, breath-hold, multi-isocenter plans, mixed electron/photon setups, and TSET can appear in the same clinic.

CMS finalized the CY 2026 Medicare Physician Fee Schedule (PFS) rule (CMS-1832-F) on October 31, 2025, with policies effective January 1, 2026. The CMS fact sheet and MLN Matters MM14315 both emphasize use of OPPS hospital data to set relative rates and cost assumptions for radiation treatment services under the PFS, plus the −2.5% efficiency adjustment. ASTRO's Final Rule Summary and Winter 2026 ASTROnews translate the clinical coding story: technique-agnostic leveled delivery, IGRT technical bundling, professional 77387, and the new SRT family.

Treat January 1, 2026 as a hard cutover for charge masters, electronic health record (EHR) maps, prior authorization (PA) templates, and therapist documentation. "We will fix it when commercial catches up" is how Level 3 appeals pile up.

FINAL coding map: what was deleted and what replaced it

The following is FINAL / CURRENT for CY 2026 coding (effective January 1, 2026 unless noted). Sources: ASTRO Winter 2026 ASTROnews, ASTRO 2026 MPFS Final Rule Summary, and the Noridian JF Radiation Oncology specialty page (last updated January 19, 2026).

Important vocabulary note: Noridian education pages sometimes shorthand the leveled codes. Your staff training should use CPT / ASTRO treatment-delivery descriptors, not informal "placement guidance" labels.

Stereotactic body radiation therapy (SBRT) and stereotactic radiosurgery (SRS) families were not the focus of the 2026 delivery overhaul. Keep existing rules for codes such as 77373 (SBRT delivery, once per day, image guidance included) and course management codes such as 77435. Do not double-bill SBRT delivery and the leveled EBRT delivery codes on the same day (Noridian JF billing tips).

Level 3 is a criterion test—not an IMRT badge

ASTRO and practical coding guidance (including Jahraus et al., Cureus/PMC) are consistent on the pivot: the codes no longer distinguish 3D versus IMRT as the primary driver. Complexity does.

Level 1 — CPT 77402

Radiation treatment delivery; Level 1 (for example, single electron field, multiple electron fields, or 2D photons), including imaging guidance, when performed.

Level 2 — CPT 77407

Radiation treatment delivery; Level 2, single isocenter (e.g., 3D or IMRT), photons, including imaging guidance, when performed.

Level 3 — CPT 77412

Radiation treatment delivery; Level 3 when any one of the following is true for that delivery, including imaging guidance when performed:

1. Multiple isocenters with photon therapy; or
2. Single-isocenter photon therapy with active motion management; or
3. Total skin electrons; or
4. Mixed electron/photon field(s).

Any one criterion is enough. You do not need multiple isocenters and AMM and mixed fields. Single-isocenter IMRT or 3D without AMM is typically 77407, not 77412.

What "active motion management" is—and is not

AMM is where freestanding denials concentrate. Image guidance (cone-beam computed tomography (CBCT), planar imaging, surface monitoring used only for setup) is not automatically AMM. AMM means a documented modality that actively manages motion during delivery—examples commonly discussed in specialty materials include deep inspiration breath hold (DIBH), respiratory gating, surface-guided radiation therapy (SGRT) used for motion management, and four-dimensional (4D) approaches when they meet the active-management definition your payer recognizes.

Documentation that wins appeals names the criterion and shows it in the plan and treatment record for the fraction billed. ASTRO's March 2026 survey identified payer interpretation of definitions as the top denial driver (reported by a large majority of respondents). Modifier 59 is not a Level 3 unlock. Noridian JF billing tips warn: never append modifier 59 when billing evaluation and management (E/M) or weekly radiation management codes on the same day.

IGRT bundling: technical inside delivery, professional as 77387

Under Medicare's 2026 alignment:

• Technical imaging guidance is included in 77402 / 77407 / 77412 when performed.
• Separately payable IGRT work is the professional component of 77387 (physician image review / localization-tracking professional work), commonly billed with modifier 26.
• The technical component of 77387 is not separately payable (CMS procedure status B packaging). Noridian JF states you cannot bill 77387 with the -TC modifier for payment—it is tracking only and not separately payable.
• Legacy 77014 freestanding habits must stop for DOS on or after January 1, 2026.

Commercial payers may still mishandle globals or packaging. Map each major plan separately. Do not invent a house rule that "everyone still pays 77387-TC."

Payment context: OPPS-informed PE, efficiency adjustment, APCs, and the ASTRO survey

What CMS finalized (FINAL)

From the CMS CY 2026 PFS final fact sheet, MM14315, and ASTRO's Final Rule Summary:

• CMS uses OPPS hospital data to inform relative rates / cost assumptions for radiation treatment services under the PFS.
• An efficiency adjustment of −2.5% applies to work RVUs (and corresponding intraservice time) for many non–time-based codes, with recurrence every three years going forward.
• CMS did not adopt the American Medical Association (AMA) Physician Practice Information / Clinical Practice Information (PPI/CPI) PE/hour survey path that ASTRO described as risking a modeled ~40% RO PE/hour cut—an advocacy win that still sits beside the efficiency cut.
• CMS published dual conversion factors for 2026 (qualifying participant (QP) versus non-QP), including a statutory one-year +2.50% CF bump. ASTRO's Final Rule Summary publishes illustrative final CF figures (QP approximately $33.5675; non-QP approximately $33.4009). The CMS specialty impact table showed roughly −1% allowed charges for radiation oncology; ASTRO notes statutory CF pieces outside budget neutrality can leave many services net positive relative to a pure table reading. Use your locality PFS file for contract math.

Hospital outpatient APCs (FINAL)

ASTRO's 2026 Hospital Outpatient Prospective Payment System (HOPPS) Final Rule Summary reports the finalized Ambulatory Payment Classification (APC) crosswalk:

• 77402 → APC 5621
• 77407 → APC 5622
• 77412 → APC 5623 (final reassignment; the proposed rule had kept 77412 with 77407 in 5622)

Hospital partners should verify current OPPS addenda before pricing. Freestanding sites should not copy hospital APC dollars onto a PFS claim.

ASTRO illustrative RVUs (not your locality allowables)

ASTRO's Winter 2026 ASTROnews published illustrative national MPFS approximations used for specialty education at the start of 2026 (for example, 77402 ≈ 2.38 RVUs; 77407 ≈ 9.51 RVUs; 77412 ≈ 11.72 RVUs). CMS also finalized utilization assumptions of roughly 55% 77407 / 35% 77412 (ASTRO had preferred a 50%/45% RUC mix). Treat published dollar examples as historical illustrations. Pull the current PFS locality file and OPPS addenda before you price a contract, a write-off, or an appeal.

March 2026 ASTRO survey (cite carefully)

ASTRO's Executive Summary of the March 2026 coding-change survey (about 160 respondents) reports that large majorities of members saw double-digit facility and/or nonfacility revenue declines, with frequent 77412 downcoding after appeal—especially in freestanding settings—and payer definition disputes as the leading denial theme. That is survey evidence of industry stress, not a promise that every Washington clinic lost the same percentage. Use it to justify documentation SOPs and commercial PA rebuilds, not as a guaranteed revenue claim.

New SRT family and Noridian L40176 / A60181 (March 1, 2026)

Effective for coding on January 1, 2026, CMS/CPT introduced:

Legacy 77401 and 0394T are deleted after December 31, 2025.

Coverage is not the same as coding

For NMSC SRT under Noridian (JE and JF contractor set), LCD L40176 and Billing and Coding article A60181 apply for DOS on or after March 1, 2026. High-level coverage themes from the LCD/article (always read the live documents for the DOS):

• Limited coverage for SRT of NMSC in nonsurgical candidates meeting policy criteria.
• Not reasonable and necessary as first-line therapy in surgical candidates, for several advanced/high-risk scenarios, or when size/depth and morphology limits in the LCD are exceeded.
• Electronic brachytherapy (EBT) is not covered under this LCD.
• High-resolution ultrasound (HRUS) guidance is not reasonable and necessary under the LCD framing.
• Article A60181 requires modifier KX on covered 77437 when medical-policy requirements are met, and points to ICD-10 Group 1 lists. GY/GZ pathways exist for intentionally noncovered Part B billing—compliance-sensitive; do not use them casually.
• A60181-R1 removed older draft language that said SRT was "only payable in the non-facility setting." Do not overclaim an office-only setting limit from deleted text.

If your clinic offers SRT for NMSC, rebuild PA and documentation for nonsurgical candidacy and shared decision-making before the March 1, 2026 DOS window—not after the first medical-necessity denial.

Modifiers that matter in 2026 (and one that does not unlock Level 3)

Virtual direct supervision via real-time audio-visual technology is a policy definition change finalized for applicable services (with stated exceptions such as global 010/090 packages)—not a new modifier. Always check current National Correct Coding Initiative (NCCI) and Medically Unlikely Edit (MUE) files; Noridian flags MUE MAI=2 as a date-of-service policy edit.

Payer-variable note: Commercial plans may still demand different imaging packaging, different Level 3 definitions, or different SRT edits. Keep a payer grid separate from Medicare JF logic.

Geography: Washington is Noridian JF Part B 02402—not JE

ALH Billing Solutions sits in the Woodland / Vancouver, Washington area. For Medicare Part B:

• Washington = Noridian Jurisdiction F (JF), Part B contract 02402.
• JE is California, Hawaii, and Nevada (and territories)—not Washington.

National CY 2026 PFS/OPPS coding and packaging rules apply the same in Washington as elsewhere. Local education and SRT coverage still come through the JF Radiation Oncology specialty page (updated January 19, 2026) plus LCD L40176 / article A60181. Bookmark:

• JF Part B RO specialty page: https://med.noridianmedicare.com/web/jfb/specialties/radiation-oncology
• LCD L40176 and article A60181 on the Medicare Coverage Database

If you also serve California / Nevada / Hawaii clients, point those teams to the JE specialty page—do not blur JE into the Washington lede.

Practical checklist for independent RO practices

1. Charge master / EHR / revenue cycle maps: Remove G6001–G6017, 77385, 77386, 77014, 77401, and 0394T. Activate 77402 / 77407 / 77412, 77387 professional, and 77436–77439.
2. Leveling SOP: Train therapists, dosimetrists, and coders on Level 3 criteria. Require discrete documentation of AMM modality, second isocenter same day, mixed modality, or TSET.
3. IGRT billing: Stop 77387-TC / 77014 habits. Bill physician image review as 77387 professional when performed. Confirm delivery already includes technical imaging.
4. SBRT / EBRT same day: Do not double-bill SBRT delivery and leveled EBRT delivery codes the same day (Noridian).
5. Weekly management (77427): Still document on-treatment visits and fraction narratives. Verify telehealth-list status from the official CMS list before any remote on-treatment visit claims—do not rely on tribal memory.
6. SRT / NMSC (if offered): For DOS on or after March 1, 2026, follow L40176 limitations; append KX to covered 77437; match ICD-10 Group 1 in A60181.
7. Prior auth / commercial: Rebuild PA templates for leveled codes; expect aggressive 77412 scrutiny (ASTRO survey).
8. Financial model: Re-forecast freestanding technical revenue with final PFS RVUs and your real utilization mix. Hospital partners verify APC 5621–5623.
9. WA / JF: Bookmark the JF RO page and L40176/A60181; re-check NCCI/MUE monthly.
10. Advocacy watch: Efficiency adjustment recurrence every three years; CY 2027 CF cliff when the temporary +2.50% expires (PROPOSED pressure in the July 2026 fact sheet—not a second delivery rewrite headline).

Claim scenario examples

Examples below are educational patterns, not guarantees of payment. Always follow current CMS, Noridian JF, and payer rules for the date of service.

Example A (Level 2 single-isocenter IMRT, no AMM): Freestanding clinic delivers single-isocenter prostate IMRT without active motion management. Chart shows single isocenter and setup imaging only. Bill 77407 (imaging guidance technical included). If the radiation oncologist performs separately identifiable image review/localization professional work, consider 77387-26—not 77387-TC.

Example B (Level 3 with DIBH): Left-breast plan uses deep inspiration breath hold as active motion management on a single isocenter. Chart names DIBH as AMM and shows it on the treatment record for the fraction. Bill 77412. Do not add modifier 59 to "prove" Level 3.

Example C (legacy habits that fail in 2026): Same fraction drops deleted 77386 plus 77014 plus 77387-TC. Expect reject/deny patterns under Medicare 2026 edits and packaging.

Example D (SRT with KX): After March 1, 2026, a nonsurgical NMSC candidate receives covered superficial delivery ≤150 kV meeting L40176. Bill 77437 with KX and a Group 1 ICD-10 from A60181, with candidacy and shared decision-making documented.

Example E (SRT without policy fit): Surgical candidate treated first-line with SRT contrary to LCD limitations, or EBT billed under the SRT LCD logic. Coverage risk is medical necessity / LCD—not fixed by appending KX.

Example F (wrong MAC bookmark): Washington biller follows JE education only and misses JF specialty updates or JF article notices for L40176. National codes may still be right while local documentation tips and article revisions are missed.

Looking ahead: label PROPOSED and unconfirmed clearly

CY 2027 PFS proposed rule (fact sheet dated July 14, 2026): Statutory CF updates and expiration of the 2026 temporary +2.50% create downside pressure. The fact sheet does not headline another RO delivery-code rewrite. Treat 2027 payment paragraphs as PROPOSED until a final rule issues. Pair any RO-specific 2027 claims with ASTRO's 2027 summary before publishing operational guarantees.

Radiation Oncology (RO) Model: The CMS Innovation Center page has emphasized delayed implementation and future rulemaking. Do not claim active mandatory RO Model episode billing for Woodland / Vancouver clinics without a fresh Innovation Center confirmation for your Core-Based Statistical Area (CBSA).

Proton delivery: National PFS RVUs for proton delivery were still MAC-priced in materials reviewed for this brief, with comment solicitation only—do not invent national proton rates.

FAQ

1. Does IMRT automatically mean CPT 77412?

No. Single-isocenter IMRT or 3D without active motion management is typically 77407. 77412 needs an explicit Level 3 criterion (multiple isocenters, AMM, TSET, or mixed electron/photon fields).

2. Can we still bill IGRT technically with CBCT?

Under Medicare 2026 rules, technical IGRT is bundled into 77402 / 77407 / 77412. Separately payable IGRT is the professional component of 77387. Do not expect payment for 77387-TC.

3. What documentation wins a 77412 appeal?

Name the Level 3 criterion met (AMM type, second isocenter, mixed fields, or TSET) and show it in the plan and treatment record. ASTRO's March 2026 survey found payer definition disputes were the leading denial driver.

4. Are SBRT codes part of the new leveled set?

No. SBRT/SRS families were not the focus of the 2026 rewrite. Continue to follow existing SBRT delivery and management rules (for example, 77373 once per day with image guidance included).

5. What changed for skin / superficial radiation?

New codes 77436–77439 replace deleted 77401 / 0394T. For NMSC under Noridian, LCD L40176 and article A60181 apply for DOS on or after March 1, 2026, including KX on covered 77437.

6. Is Washington under Noridian JE?

No. Washington Part B is Noridian JF, contract 02402. JE covers California, Hawaii, and Nevada. National coding is the same; cite JF URLs and JF article notices for Washington clinics.

Final takeaway

Radiation oncology billing in 2026 is a full operational package: leveled delivery (77402 / 77407 / 77412), IGRT technical bundling with professional 77387, OPPS-informed PE and efficiency-adjustment payment context, hospital APC 5623 for Level 3, a new SRT family with a March 1, 2026 Noridian coverage article, and a geography check that puts Washington under JF 02402. Level 3 is a documented criterion, not an IMRT slogan. 77387-TC is not a Medicare payment line. SRT needs LCD discipline and KX when covered. Keep CY 2027 CF talk and the RO Model in the PROPOSED / unconfirmed column until primary sources say otherwise. Independent RO practices that rebuild maps, SOPs, and payer grids now protect remittances better than practices that wait for the next denial dashboard spike.

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Sources

• CMS CY 2026 PFS Final Rule fact sheet (CMS-1832-F) — cms.gov fact sheet
• MLN Matters MM14315 — MM14315 PDF
• CMS CY 2027 PFS Proposed Rule fact sheet — cms.gov 2027 proposed
• ASTRO 2026 MPFS Final Rule Summary; Winter 2026 ASTROnews code-change article; March 2026 coding survey executive summary; 2026 HOPPS Final Rule Summary
• Noridian JF Radiation Oncology specialty page; LCD L40176; article A60181
• Jahraus et al. practical coding paper (PMC12842826)