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
All radiation therapy documentation for the treatment course
Practitioner, nurse, and ancillary progress notes
Documentation of dosimetric verification of treatment setup and delivery, signed by both the radiation oncologist and the medical physicist
Diagnostic tests and results
Physician / Non Physician (NPP) order or evidence of intent to order
Documentation to support IMRT delivery
A statement by the treating physician documenting the special need for performing IMRT on the beneficiary in question, rather than performing conventional or three-dimensional treatment planning and delivery. The physician must address the other organs at risk and/or adjacent critical structures
Documentation to support Stereotactic Radiosurgery (SRS)/Stereotactic Body Radiation Therapy (SBRT)
Review (signed and dated) by the radiation oncologist of the CT or MRI based images of the target and all critical structures with representative isodose distributions that characterize the three-dimensional dose
Radiation oncologist review of dose-volume histograms for all targets and critical structures
Description of the number and location of each treatment step/rotation or portal to accomplish the treatment plan
Beneficiary name and date of service on all documentation
Documentation as required in LCD or NCD
Any additional documentation to support the reasonable necessity of the service(s) performed
Advance Beneficiary Notice
Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services)
Signature attestation and credentials of all personnel providing services
If an electronic health record is utilized, include your facility's process of how the electronic signature is created. Include an example of how the electronic signature displays once signed by the physician

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 23 , 2024

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.