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
  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:
  • Diagnosis and extent of disease
  • Treatment site
  • Target anatomical structures
  • Identification of any organs at risk in or adjacent to 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
  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.

Documentation Submission

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.

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.