Radiation Therapy Documentation Requirements

It is expected that patient's medical records reflect the need for care/services provided. The listing of records is not all inclusive. Providers must ensure all necessary records are submitted to support services rendered. They may include:

Check Brief Description

 

Legible handwritten physician and/or clinician signatures

 

Valid electronic physician and/or clinician signatures

 

Physician or Non-Physician Practitioner (NPP) order for date(s) of service, if applicable

 

Documentation of clinical treatment planning written, signed and dated by physician that includes some or all of the following elements:

  • Diagnosis and extent of disease
  • Treatment site
  • Target anatomical structures
  • Identification of any organs at risk in or adjacent to the treatment fields
  • Intent of treatment
  • Specialized tests interpreted to determine target volume
  • Treatment modality and interaction with chemotherapy, if applicable
  • Planning considerations and justification for modality and technique planned
  • Use of anesthesia or specific patient related immobilization challenges

 

Legible radiation therapy records/procedure reports for date(s) of service to allow reconstruction of modality and technique used

  • Simulation-aided field setting
  • Use of treatment devices/blocks
  • Position stabilization
  • Imaging for localization
  • Radiation treatment delivery

 

Dosimetry calculation records, if applicable

  • Isodose plan
  • Special dosimetry

 

Records of patient's condition before, during and after this billing period to support medical necessity and reason service was provided

  • Most recent physician clinic/ER/progress notes pertaining to diagnosis/reason radiation is being performed
  • Clinical treatment planning
  • Radiotherapy plan
  • Radiation treatment management
  • Medical physics consultation

 

Diagnostic test results/reports, including imaging and/or laboratory reports, including those prior to claim date(s) of service if related, to support medical necessity and reason for radiation therapy, if applicable

  • When no official imaging report is available, the following components must be present within medical records: date(s) imaging was completed, type(s) of imaging/exam and detailed findings

 

Itemization of services

 

Office visit and/or evaluation and management (E&M) documentation if billed on same date(s) of service under medical review

 

Documentation to support indications and/or criteria as specified in Local Coverage Determinations (LCDs), National Coverage Determinations (NCDs) or coverage article for service(s) billed, if applicable

 

Advance Beneficiary Notice of Noncoverage (ABN), if applicable

 

Multiple CMS contractors are charged with completing reviews of medical records. See Identifying Which Entity Completed a Part A Claim Review for detailed information about each of these contractors. 

Documentation Submission

Once a provider compiles all the necessary documentation, it is important to submit them to the appropriate contractor according to the request received. Select the request below to view the appropriate submission instructions. 

View the Outpatient Prospective Payment System (OPPS) webpage for additional information and resources.

 

Last Updated Feb 08, 2019

Documentation Requirements Disclaimer

The documentation requirements contents/references provided within this section were prepared as educational tools and are not intended to grant rights or impose obligations. Use of these documents are not intended to take the place of either written law or regulations.

The listing of records is not all inclusive. Providers must ensure all necessary records are submitted to support services rendered.

Important that physician intent, physician decision and physician recommendation to provide services derived clearly from the medical record and properly authenticated.

The submission of these records shall not guarantee payment as all applicable coverage requirements must be met.