Nine Elements of Clinical Treatment Planning Documentation

ASTRO’s Nine Elements of Clinical Treatment Planning Documentation for Optimum Coding

What is Clinical Treatment Planning Documentation?

Radiation oncology billing requires documentation of clinical treatment planning which consists of a written note or individualized form signed and dated by the radiation oncologist that includes diagnosis, treatment site, the target anatomical structures (e.g., primary and regional lymph nodes or primary site only), identification of any organs at risk in or adjacent to the treatment fields, intent of treatment, special tests interpreted, modality and interaction with chemotherapy and technique contemplated (e.g., conventional, three-dimensional, IMRT, SRS, SBRT or brachytherapy).

What are ASTRO’s Recommended Elements of Treatment Planning Documentation?

Items frequently included in a clinical treatment planning note to facilitate radiation oncology billing are:

1. Intent of the treatment (curative or palliative).
2. Extent of the disease (early or advanced).
3. Treatment modality (e.g., radiation, radiation with chemotherapy, radiation with brachytherapy and chemotherapy, preoperative, post· operative, etc.).
4. Planning considerations and justification for 3-D, IMRT, radiosurgery or SBRT.
5. Total dose/fractionation/beam energy.
6. Indication of customized blocking or customized immobilization.
7. Indication of special or unique circumstances or critical structures that could be dose limiting
8. Need for additional testing or review of specialized testing in order to accurately determine the target volume.
9. Use of anesthesia or specific patient related immobilization challenges.

It is not necessary for radiation oncology providers to include every item on the list for every patient. However, more complete documentation will allow coding and billing staff to independently assign the correct code level.

What are the Consequences of Missing or Incomplete Documentation?

Radiation oncology coders cannot make any assumptions about the clinical services so missing documentation may affect planning codes, which in turn determines billing and reimbursement. For example, if a provider intends to treat with 3D, IMRT, or Radio Surgery which are normally complex, but does not clearly document the treatment technique, a lower level planning code may be necessary.