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:
|Correct Beneficiary and Date of Service|
|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: |
| Legible radiation therapy records/procedure reports for date(s) of service to allow reconstruction of modality and technique used |
| Dosimetry calculation records, if applicable |
| Records of patient's condition before, during and after this billing period to support medical necessity and reason service was provided |
| 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|
| Legible handwritten physician and/or clinician signatures |
| Valid electronic physician and/or clinician signatures |
Multiple CMS contractors are charged with completing reviews of medical records. See Identifying Which Entity Completed a Part B Claim Review for detailed information about each of these contractors.
Once a provider/supplier 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.
- Noridian Medical Review - Automated Development System (ADS) Letter
- Comprehensive Error Rate Testing (CERT) - CID Request
- Level One Appeal - Redeterminations Request
View the Radiation Oncology webpage for additional information and resources.
Last Updated Aug 06, 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.