Checklist: Therapeutic radiation-radiology services documentation
This checklist is intended to provide Healthcare providers with a reference for use when responding to medical documentation requests for therapeutic radiation services. It is not intended to replace the published guidelines. Healthcare providers retain responsibility to submit complete and accurate documentation.
| Check |
Documentation description |
|---|---|
| Documentation is for the correct beneficiary. |
|
| Documentation is for the correct date(s) of service. |
|
| Documentation contains a valid and legible signature, which follows CMS Signature Guidelines for Medical Review Purposes. |
|
| Documentation to support a signed order or medical records to support the intent to order by the treating physician, (e.g., signed progress note, or signed physician order/requisition). |
|
| Documentation supports a medically reasonable and necessary therapeutic radiation service was rendered (e.g., history and physical examination, progress/office notes, treatment plan/prescription, treatment notes, laboratory/diagnostic testing results, assessments, radiation/medication administration record, etc.). |
|
| Documentation includes evidence of the appropriate training and qualifications of the personnel involved in treatment. |
|
| Documentation that supports all supervision requirements were met for service(s) performed. |
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| Any additional documentation to support medical necessity or any applicable policy guidelines for the services billed. |
Disclaimer
This checklist was created as an aid to assist providers. This aid is not intended as a replacement for the documentation requirements published in national or local coverage determinations, or the CMS documentation guidelines. It is the responsibility of the provider of services to ensure the correct, complete, and thorough submission of documentation.