Bone Metastases Radiation Therapy Physician … Metastases Radiation Therapy Physician Worksheet...

eviCore Healthcare needs to collect sufficient clinical history and treatment plan information relevant to a request for radiation therapy treatment to establish the medical necessity of the service. eviCore Healthcare has provided a packet of cancer specific worksheets that will help you organize the information necessary to complete a medical necessity review of a radiation therapy treatment plan. The worksheets will guide you in preparing the specific information that will be collected on the phone or through the website submission portal. These worksheets can be faxed to 615.468.4457 to ensure proper medical necessity determination.

The most efficient way for a physician to obtain a medical necessity determination is to initiate a web request for a Radiation Therapy Treatment Plan by visiting the Medsolutions website: https://myportal.medsolutions.com To initiate a telephonic request for a Radiation Therapy Treatment Plan, please dial: 888.693.3211 and follow the prompts to initiate a new radiation therapy treatment medical necessity determination request.

Bone Metastases Radiation Therapy Physician Worksheet Pages 2 - 5

Brain Metastases Radiation Therapy Physician Worksheet Pages 6 - 9

Breast Cancer Radiation Therapy Physician Worksheet Pages 10 - 12

Cervical Cancer Radiation Therapy Physician Worksheet Pages 13 - 15

Primary Central Nervous System (CNS) Lymphoma Physician Worksheet Pages 16 - 17

Primary Central Nervous System (CNS) Neoplasm Physician Worksheet Pages 18 - 20

Colorectal Cancer Radiation Therapy Physician Worksheet Pages 21 - 23

Endometrial Cancer Radiation Therapy Physician Worksheet Pages 24 - 26

Gastric (Stomach) Cancer Radiation Therapy Physician Worksheet Pages 27 - 29

Head or Neck Radiation Therapy Physician Worksheet Pages 30 - 32

Non-Cancerous Radiation Therapy Physician Worksheet Pages 33 - 34

Non-Small Cell Lung Cancer Radiation Therapy Physician Worksheet Pages 35 - 37

Other Cancer Type Radiation Therapy Physician Worksheet Pages 38 - 41

Pancreatic Cancer Radiation Therapy Physician Worksheet Pages 42 - 43

Prostate Cancer Radiation Therapy Physician Worksheet Pages 44 - 47

Skin Cancer Radiation Therapy Physician Worksheet Pages 48 - 50

Small Cell Lung Cancer Radiation Therapy Physician Worksheet Pages 51 – 53

Radiation Oncology Procedure Code list Page 54

https://myportal.medsolutions.com/

Bone Metastases Radiation Therapy Physician Worksheet (As of 1 April 2015)

730 COOL SPRINGS BLVD. SUITE 800 • FRANKLIN, TN 37067 • PH: 888.693.3211 • FX: 877.791.4110 • www.CareCoreNational.com • www.MedSolutions.com

Completing this survey can provide quicker turnaround. Additional comments can be made in the comments section. We encourage you to electronically forward relevant data/notes, especially results of any previous imaging or testing. This form and all data submitted are considered medical records with

regard to privacy and accuracy. Any inconsistencies on this survey compared with the office medical record should be explained in the comments section.

URGENT (Same Day) REQUESTS ARE ONLY ACCEPTED BY PHONE AT 888.693.3211. Fax form (non-urgent requests only) to 877.791.4110

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Patient First Name: Patient Last Name:

DOB: Member ID: Group #: Health Plan:

Address: City: ST: Zip:

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Physician First Name: Physician Last Name:

Primary Specialty: NPI: Tax ID:


Phone #: Fax #: Contact Email:

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Facility Name: Facility Tax ID:


Phone #: Fax #: NPI: RETRO Date of Service:

Who will be the responsible contact for additional information, if requested, or question concerning this request? Print Name:_______________________________________________ Additional Information/Comments:

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Check the appropriate box describing you: Ordering Physician Facility Other: ____________________________ Sign and Date Below: Print Name:______________________________________________ Sign Name: ______________________________________________ MD RN LPN PA NP Other



Patient name:

What is the radiation therapy treatment start date (mm/dd/yyyy)? _____ /_____ / ______ 1. What is the site of the primary cancer?

Bladder Breast Cervical Colorectal Head/neck Kidney

Lung Melanoma Pancreas Prostate Sarcoma Other: ________________

2. Is this a solitary bone metastasis? Yes No 3. What is the location of the metastasis?

Femur Humerus Pelvis Rib

Shoulder Skull Spine - levels to be treated : _______ Other: _________________________

4. a. Are you treating a second and/or third bone site for this patient? Yes No

b. If a second and/or third site is being treated, what is the location of the metastasis? Select the location of the metastasis for each additional site being treated.

Site 2 Site 3

Femur Humerus Pelvis Rib Shoulder Skull Spine - levels to be treated : _______ Other: _________________________

Femur Humerus Pelvis Rib Shoulder Skull Spine - levels to be treated : _______ Other: _________________________

c. Will the sites be treated concurrently? Yes No

Continued on next page



5.

What is the external beam radiation therapy (EBRT) treatment technique? Select the treatment technique for each site, and fill in the number of gantry angles and fractions.

Site 1 Site 2 Site 3

Complex (77307) Complex (77307) Complex (77307)

3D (includes contouring + 3D reconstruction of GTV/CTV/PTV/OAR, conformal beams, DVHs, DRRs)



Intensity modulated radiation therapy (IMRT)



Proton beam therapy Proton beam therapy Proton beam therapy

Rotational arc therapy Rotational arc therapy Rotational arc therapy

Stereotactic body radiation therapy (SBRT)



Tomotherapy Tomotherapy Tomotherapy

Fractions: ______________ Fractions: ______________ Fractions: ______________

Gantry angles: __________ Gantry angles: __________ Gantry angles: __________

Please note that 3D technique is not considered medically necessary for standard two field treatment, and 77295 will not be reimbursed.

6. What is the reason for treatment? Select all that apply.

Extension into viscera Palliation of pain

Spinal cord compression Other:___________________

7. Does the patient have visceral metastases (e.g. lung, liver, brain, adrenal,

etc.)? Yes No




8. a. What is the patient’s ECOG performance status?

0 Fully active, able to carry on all pre-disease performance without restriction.

1 Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work.

2 Ambulatory and capable of all self-care but unable to carry out any work activities. Up and about more than 50% of waking hours.

3 Capable of only limited self-care, confined to bed or chair more than 50% of waking hours.

4 Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair.

b. If ECOG performance status is 3 or 4, is it expected that the ECOG status will improve as a result of this treatment? Yes No

9. Is the area to be treated abutting, overlapping, or within a previously

irradiated area? Yes No

10. Will IGRT be used? Yes No 11. Note any additional information in the space below.

Brain Metastases Radiation Therapy Physician Worksheet (As of 1 April 2015)





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Patient name:

What is the radiation therapy treatment start date (mm/dd/yyyy)? ______ /______ /______ 1. Is whole brain radiation therapy (WBRT) with complex (77307) technique

and a maximum of 10 fractions being requested*? Yes No

*If yes, no further information is required. If no, please continue. 2. What is the primary site?

Bladder Breast Gynecological

Colorectal Head/Neck Kidney

Lung Melanoma Pancreas

Sarcoma Other: __________

3. Is the primary tumor controlled? Yes No

4. Are non-brain visceral metastases (e.g. lung, liver, etc.) present on the most recent radiologic studies?

Yes No

5. a. Is the patient receiving chemotherapy or other systemic treatment? Yes No

b. If no, why is the patient not receiving chemotherapy or other systemic treatment?

The non-brain metastatic disease is stable; and therefore, not requiring systemic therapy There are no good systemic treatment options The patient is refusing systemic therapy The patient’s performance status does not allow for the delivery of systemic therapy

6. What is the patient’s

ECOG performance status?









7. a. Has the brain previously been treated with radiation therapy?

Yes No

b. If yes, what type of radiation therapy was previously used to treat the patient?

Previous whole brain radiation therapy (WBRT) Previous stereotactic radiosurgery (SRS)

8. If previous WBRT was used to treat the patient, then answer the following questions:

a. Was the last WBRT fraction delivered in the past 3 months? Yes No

b. What is the date of the last WBRT treatment? ______ /______ /______

9. If SRS was previously used to treat the patient, then answer the following questions:

a. Was the last SRS session delivered in the past 6 months? Yes No

b. What is the date of the last SRS treatment? ______ /______ /______

10. How many active brain lesions are visible on the most recent MRI? 1-3 4 or more

11. What is the treatment plan?

Whole brain

Partial brain

12. If whole brain is the selected treatment plan, then answer the following set of questions:

a. What treatment technique will be used for WBRT?

Complex (77307)



Tomotherapy

b. How many whole brain fractions will be delivered? Fractions: __________

c. Is a concurrent boost being delivered? If yes, answer questions corresponding to partial brain below.

Yes No




13. If partial brain is the selected treatment plan, then answer the following set of questions:

a. Is only partial brain being treated (no WBRT)? Yes No

b. Is this a boost in conjunction with WBRT? Yes No

c. What is the treatment technique for the partial brain treatment?

Complex (77307) 3D (includes contouring + 3D reconstruction of GTV/CTV/PTV/OAR, conformal beams, DVHs,

DRRs) Proton beam therapy Intensity modulated radiation therapy (IMRT) Tomotherapy Stereotactic radiosurgery (SRS)

d. How many partial brain fractions will be delivered? Fractions: __________

Please note that 3D technique is not considered medically necessary for standard 2 field whole brain treatment, and 77295 will not be reimbursed.

14. Note any additional information in the space below.

Breast Cancer Radiation Therapy Physician Worksheet (As of 10 April 2015)





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Patient name:

What is the radiation therapy treatment start date (mm/dd/yyyy)? _____ /______ /______ 1. Is the treatment being directed to the primary site (breast)? Yes No

If treatment is not being directed to the primary site, submit a request for the metastatic site

2. Does the patient have distant metastatic disease (M1 stage)? Yes No 3. Are you delivering adjuvant therapy to the whole breast or chest wall using

two gantry angles and 3D conformal treatment planning? If no, continue to question #4. If yes, skip forward to question #8.

Yes No

Please note that AMA and ASTRO position is that forward planned IMRT is billed as 3D conformal

4. What is the T-stage (pathologic T-stage if patient has had surgery)?

T0 T1

T2 T3

T4 Recurrent

Ductal carcinoma In Situ (DCIS)

5. What treatment plan to be executed for the initial phase?

Whole breast or chest wall radiotherapy (mastectomy performed) Partial breast radiotherapy once a day Partial breast radiotherapy twice a day

6. Will treatment include the internal mammary nodes? Yes No 7. What technique will be used for the initial phase of treatment?

Single catheter brachytherapy Multiple catheter brachytherapy Electronic brachytherapy Complex (77307) 3D (includes contouring + 3D reconstruction of GTV/CTV/PTV/OAR, conformal beams, DVHs, DRRs)

Single fraction intra-operative radiotherapy (IORT) Intensity modulated radiation therapy (IMRT) Proton beam therapy Rotational arc therapy Stereotactic body radiation therapy (SBRT) Tomotherapy




8. What technique will be used for the boost phase of treatment?

Electrons Photons Single catheter brachytherapy Electronic brachytherapy

Multiple catheter brachytherapy Single fraction intra-operative radiotherapy (IORT) Accuboost No boost phase will be delivered

9. Will IGRT be used? Yes No

10.

Will respiratory gating/deep inspiration breath hold (DIBH) be used for EBRT? Yes No

11. Note any additional information in the space below:

Cervical Cancer Radiation Therapy Physician Worksheet (As of 10 April 2015)





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Patient name:

What is the radiation therapy start date (mm/dd/yyyy)? _____ /______ /______

1. Is this treatment being directed to the primary site?

Yes No


2. Does the patient have distant metastatic disease? Yes No

3.

a. What is the treatment intent?

Post-operative Definitive Locoregional recurrence Palliative

b. If post-operative is the treatment intent, are any of the following risk factors present?

Yes No 1. Tumor > 4cm 2. Deep Stromal invasion 3. Lymphovascular invasion

4. Positive Pelvic Nodes 5. Positive Surgical Margin 6. Positive Parametrium

c. If definitive is the treatment intent, what is the patient’s initial FIGO (International Federation of

Gynecology and Obstetrics) stage?

Stage IA1

Stage IIA1

Stage IIIA

Stage IA2

Stage IIA2

Stage IIIB

Stage IB1

Stage IIB

Stage IVA

Stage IB2

Stage IVB

4. Will the para-aortic nodes be treated? Yes No

5. Is gross adenopathy present? Yes No

6.

What is the treatment plan?

External beam radiation therapy (EBRT) Brachytherapy Brachytherapy and EBRT




7. If brachytherapy is included in the treatment plan, then answer the following set of questions:

a. What is the dose rate?

Low dose rate (LDR) High dose rate (HDR)

b. How many fractions will be rendered? Fractions: _____

c. What is the implant type?

Tandem only Vaginal cylinder only Tandem and ovoids

Ovoids only Interstitial

8. If EBRT is included in the treatment plan, then answer the following set of questions:

a. What EBRT technique will be used?

Proton beam therapy Rotational arc therapy Tomotherapy Complex (77307)

Stereotactic body radiation therapy (SBRT) Intensity modulated radiation therapy (IMRT) 3D (includes contouring + 3D reconstruction of GTV/CTV/PTV/OAR,

conformal beams, DVHs, DRRs)

b. How many fractions will be rendered in phase 1? Fractions: _____

c. If applicable, how many fractions will be rendered in phase 2? Fractions: _____ N/A

9. Will the patient be receiving concurrent chemotherapy? Yes No



Primary Central Nervous System (CNS) Lymphoma Radiation Therapy Physician Worksheet

(As of 10 April 2015)





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Primary Central Nervous System (CNS) Lymphoma Radiation Therapy Physician Worksheet



Patient name:

What is the radiation therapy treatment start date (mm/dd/yyyy)? _____ /_____ / _______ 1. a. Has the patient received chemotherapy? Yes No

b. If the patient has received chemotherapy, what was the response?

Complete response (CR) Partial response (PR) No response (NR) Progressive disease (POD)

2. Will the patient be receiving concurrent chemotherapy? Yes No 3. What external beam radiation therapy (EBRT) technique will be used to deliver the radiation therapy?

Select a technique for each applicable phase, and fill in the number of fractions.

Phase 1 Phase 2

Complex (77307) Complex (77307)



Intensity modulated radiation therapy (IMRT) Intensity modulated radiation therapy (IMRT)

Proton beam therapy Proton beam therapy

Rotational arc therapy Rotational arc therapy

Stereotactic body radiation therapy (SBRT) Stereotactic body radiation therapy (SBRT)

Tomotherapy Tomotherapy

Number of fractions: _________________ Number of fractions: _________________ 4. Will IGRT be used? Yes No


Primary Central Nervous System (CNS) Neoplasm Radiation Therapy Physician Worksheet



Completing this survey can provide quicker turnaround. Additional comments can be made in the comments section. We encourage you to electronically forward relevant data/notes, especially results of any previous imaging or testing. This form and all data submitted are considered medical records with regard to privacy and accuracy. Any inconsistencies on this survey compared with the office medical record should be explained in the comments section. URGENT (Same Day) REQUESTS ARE ONLY ACCEPTED BY PHONE AT 888.693.3211. Fax form (non-urgent requests only) to 877.791.4110

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Patient name:

What is the radiation therapy treatment start date (mm/dd/yyyy)? ______ /______ /______ 1. What is the patient’s WHO grade or diagnosis?

WHO grade I: Pilocytic astrocytoma II: Low grade oligo/ astrocytoma/ependymoma III: Anaplastic astrocytoma IV: Glioblastoma multiform (GBM)

Diagnosis Primary spinal tumor Ependymoma Recurrent primary CNS malignant tumor previously irradiated Adult medulloblastoma Supratentorial PNET (primitive neuroectodermal tumor) Benign: Meningioma, Schwannoma, Pituitary Adenoma Other: ______________________________________

2. What is the

patient’s

ECOG performance status?

0 Fully active, able to carry on all pre-disease performance without restriction

1 Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work




3. What resection has been performed?

Biopsy only Subtotal resection Gross total resection





4. What external beam radiation therapy technique will be used to deliver the radiation therapy? Select a technique for each applicable phase, and fill in the number of fractions.

Phase I Phase II

Complex (77307) Complex (77307)



Intensity modulated radiation therapy (IMRT) Intensity modulated radiation therapy (IMRT)



Proton therapy Proton therapy

Stereotactic radiosurgery (SRS)/ Stereotactic body radiation therapy (SBRT)

Stereotactic radiosurgery (SRS)/ Stereotactic body radiation therapy (SBRT)

Number of fractions: _________________ Number of fractions: _________________




Colorectal Cancer Radiation Therapy Physician Worksheet (As of 31 December 2014)





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Who will be the responsible contact for additional information, if requested, or question concerning this request?

Print Name:_______________________________________________

Additional Information/Comments:

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Check the appropriate box describing you: Ordering Physician Facility Other: ____________________________

Sign and Date Below:

Print Name:______________________________________________

Sign Name: ______________________________________________ MD RN LPN PA NP

Other



Patient name:

What is the radiation therapy treatment start date (mm/dd/yyyy)? _____ /_____ /______

1. Is the treatment being directed to the primary site (rectum)? Yes No

If treatment is not being directed to the primary site, submit a request for the metastatic site.

2. What is the timing of radiation?

Neo-adjuvant (pre-operative)

Adjuvant radiation (post-operative) following local excision (e.g. transanal, Kraske)

Adjuvant radiation (post-operative) following transabdominal resection (LAR or APR)

Initial primary treatment/ definitive (no surgery planned)

Local recurrence/ persistence

3.

What is the clinical T stage?

T0

T1

T2

T3

T4

4. What is the nodal status?

Negative

Positive

N/A

5. a. Does the patient have metastatic disease? Yes No

b. If the patient has metastatic disease, is he/she planned to undergo

surgical resection of the metastases? Yes No

6. Were any of the following high risk features evident on the pathologic specimen?

Lymphovascular space invasion

Positive margins

Poorly differentiated tumors

No high risk features

N/A


7. What is the treatment intent?



Definitive

Palliation

8.

What external beam radiation therapy technique will be used to deliver the radiation therapy?


Phase I Phase II

3D (includes contouring + 3D

reconstruction of GTV/CTV/PTV/OAR,



reconstruction of GTV/CTV/PTV/OAR,


Intensity modulated radiation therapy

(IMRT)

Intensity modulated radiation therapy

(IMRT)



Proton beam therapy Proton beam therapy

Number of fractions: ______ Number of fractions: ______

9. Will the patient receive concurrent chemotherapy? Yes No



Endometrial Cancer Radiation Therapy Physician Worksheet (As of 10 April 2015)





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Patient name:

What is the radiation therapy treatment start date (mm/dd/yyyy)? _____ /_____ / _______

1. Is this treatment being directed to the primary site?

Yes No


2. What is the pathology?

Endometrioid

Papillary serous

Clear cell

Carcinosarcoma


4. What is the intent of treatment?

Palliative

Post-operative

Definitive or medically inoperable

Isolated locoregional recurrence after surgery

5. What is the FIGO (International Federation of Gynecology and Obstetrics) stage?

Stage IA

Stage IB

Stage IIA

Stage IIB

Stage IIIA

Stage IIIB

Stage IVA

Stage IVB

Stage IIIC

6. What is the grade of the endometrial cancer?

Grade 1

Grade 2

Grade 3

7. Are any of the following risk factors present?

1. Age is ≥ 60 years

2. Lymphovascular invasion

3. Lower uterine (cervical/glandular) involvement

Yes No






Brachytherapy

External beam radiation therapy (EBRT)

Brachytherapy and EBRT

10. If Brachytherapy is included in the treatment plan, then answer the following set of questions:


Low dose rate (LDR) High dose rate (HDR)

b. How many fractions will be rendered? Fractions: _____

c. What is the implant type?

Tandem only

Vaginal cylinder only

Ovoids only

Tandem and ovoids

Heyman capsules only

Interstitial


a. What EBRT technique will be used?

Proton beam therapy

Rotational arc therapy

Tomotherapy

Complex (77307)



3D (includes contouring + 3D reconstruction of

GTV/CTV/PTV/OAR, conformal beams, DVHs, DRRs)





Gastric (Stomach) Cancer Radiation Therapy Physician Worksheet (As of 31 December 2014)





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Patient name:

What is the radiation therapy treatment start date (mm/dd/yyyy)? _____ /_____ / ______

1. Will the treatment be directed to the primary site (stomach)? Yes No


2. Does the patient have distant metastatic disease (M1 stage)? Yes No

3. a. What is the treatment intent?

Pre-operative (neo-adjuvant)

Post-operative (adjuvant)

Definitive treatment

Palliation

b. If post-operative is the treatment intent, what is the pathological T stage?

T1

T2

T3

T4

c. If post-operative is the treatment intent, what is the pathological N stage?

N0

N1

d. If post-operative is the treatment intent, does the patient have any of the

following risk factors?

1. Poor differentiation

2. Lymphovascular invasion

3. Perineural invastion

4. Age < 50

Yes No




4. a. What external beam radiation therapy (EBRT) technique will be used?

3D (includes contouring + 3D reconstruction of GTV/CTV/PTV/OAR, conformal beams, DVHs,

DRRs)


Proton beam therapy



Tomotherapy






Head or Neck Radiation Therapy Physician Worksheet (As of 21 April 2015)





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Patient name:




2. What is the primary site?

Lip and oral cavity

Pharynx

Larynx

Nasal cavity and para-nasal sinuses

Thyroid

Mucosal melanoma of head and neck

Occult/unknown primary

Major salivary gland

Other: _________________________

3. Please annotate the patient staging (use pathological staging if post-op):

a. What is the clinical T stage?

T0

T1

T2

T3

T4

b. What is the clinical N stage?

N0

N1

N2a

N2b

N2c

N3

4.

What is the intent/timing of the treatment?

Definitive

Palliative

Post-operative

Isolated locoregional recurrence

Pre-operative

Salvage therapy


5. What technique will be used to deliver the radiation therapy?

Brachytherapy





6. If brachytherapy is the selected technique, then answer the following set of questions:

a. What type of brachytherapy will be used?

High dose rate

Low dose rate

b. What is the implant type?

Interstitial

Intracavitary

7. If EBRT is the selected technique, then what is the EBRT technique?

Complex (77307)

3D (includes contouring + 3D reconstruction of GTV/CTV/PTV/OAR, conformal beams, DVHs,

DRRs)


Intensity modulated radiation therapy (IMRT): fixed gantry

Tomotherapy


Proton beam therapy


9. Will the patient receive treatment twice daily during the course of treatment? Yes No


Non Cancerous Radiation Therapy Physician Worksheet (As of 10 April 2015)





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Non Cancerous Radiation Therapy Physician Worksheet (As of 10 April 2015)


Patient name:


1. Is the patient receiving radiation therapy for a benign tumor or other

non-cancerous diagnosis? Yes No

If treatment is not being received for a benign tumor or other non-cancerous diagnosis, then complete the “Cancer Other” worksheet or the worksheet that corresponds to the patient’s diagnosis

2. a. Why is the patient receiving radiation therapy?

Acoustic neuroma

Arteriovenous malformation (AVM)

Benign tumor

Cavernous Malformations

Epilepsy

Graves ophthalmopathy

Keloid scar

Parkinson’s disease

Pre/post orthopedic surgery

Prevention of calcifications

Trigeminal neuralgia

Other: _________________

b. If “other” was the selected reason, please explain the “other” reason for treatment below:

3. a. What external beam radiation therapy (EBRT) technique will be used?

Tomotherapy


Proton beam therapy

Electrons

Complex (77307)

3D (includes contouring + 3D reconstruction of GTV/CTV/PTV/OAR,


Stereotactic radiosurgery (SRS)/


Intensity modulated radiation therapy (IMRT





Non-Small Cell Lung Cancer Radiation Therapy Physician Worksheet (As of 21 April 2015)





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Patient name:

What is the radiation therapy treatment start date (mm/dd/yyyy)? _____ / _____ / ______

1. Is the treatment being directed to the primary site (lung)? Yes No

If treatment is not being directed to the primary site, complete the worksheet that corresponds

to the patient’s diagnosis.

2. a. What is the clinical T-stage?

TX T1 T2 T3 T4 Tis

b. What is the clinical N-stage?

NX N0 N1 N2 N3

c. What is the clinical M-stage?

M0 M1


Definitive

Pre-operative (neo-adjuvant)

Post- operative (adjuvant)

Palliation

b. If post-operative (adjuvant) is the treatment intent, then answer the following questions:

i. What is the margin status? Negative Positive

ii. Is there gross residual tumor? Yes No

iii. Is there evidence of extracapsular extension? Yes No

c. If palliation is the treatment intent, what technique will be used for palliation?


Brachytherapy

If Brachytherapy will be used for palliation, skip forward to question #8.


4. What EBRT technique will be used to deliver the radiation therapy?




Phase 1 Phase 2 Phase 3


3D (includes contouring

+ 3D reconstruction of

GTV/CTV/PTV/OAR,

conformal beams,

DVHs, DRRs)

3D (includes contouring

+ 3D reconstruction of

GTV/CTV/PTV/OAR,

conformal beams, DVHs,

DRRs)

3D (includes contouring +

3D reconstruction of

GTV/CTV/PTV/OAR,


DRRs)

Intensity modulated

radiation therapy

(IMRT)

Intensity modulated

radiation therapy (IMRT)

Intensity modulated




Stereotactic body

radiation therapy

(SBRT)

Stereotactic body

radiation therapy (SBRT)

Stereotactic body

radiation therapy (SBRT)


Number of fractions:

________

Number of fractions:

________ Number of fractions: ________

5. Will respiratory motion management be utilized? Yes No

6. Will concurrent chemotherapy be performed? Yes No

7.

Will IGRT be used? Yes No

8. If brachytherapy will be utilized for palliation, then answer the following questions:

a. Has the patient received EBRT? Yes No

b. How many brachytherapy treatments (fractions) will be

utilized?

Fractions: ___________

c. How many brachytherapy applications will be utilized? Applications: _________


Other Cancer Type Radiation Therapy Physician Worksheet (As of 21 April 2015)





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Patient name:

What is the radiation therapy start date (mm/dd/yyyy)? _____ /______ /_______

1. What is the primary site (fill in blank)? ______________________________

2. a. What is the

patient’s

ECOG

performance

status?






b. If the ECOG status is due to the cancer, is the status expected to

improve with radiation therapy treatment? Yes No


If the diagnosis is brain or bone metastases, stop and use the brain or bone metastases worksheet

4. a. What is the intent of treatment?

Initial primary treatment

Pre-operative radiation

Post-operative radiation

Palliation at primary site

Isolated local recurrence at primary or adjacent site

Palliation of metastatic site - explain below in question #4b

Other - explain below in question #4b

b. If intent of treatment is “palliation of metastatic site” or “other”, then use the space below to list the

metastatic sites to be treated and to explain the treatment intent in further detail.

If treatment intent is “palliation at metastatic site”, “palliation at primary site” or “other” (see question

#4a), skip forward to question #8. Otherwise, continue forward to question #5

5. a. What is the clinical stage?

T1 T2 T3 T4 Tx Tis

b. Nodes:

N0 N1 N2 N3 NX

6. Has this area received previous radiation? Yes No





8. a. What is the treatment plan?


Brachytherapy

Brachytherapy and EBRT

Selective internal radiation therapy (SIRT)

Iodine-131 (I-131)

b. If SIRT is the selected treatment plan, how many treatments will be

used? Treatments: _________

If “Selective internal radiation therapy (SIRT)” or “Iodine-131 (I-131)” is the selected treatment plan,

skip forward to question #11. Otherwise, continue forward to question #9


a. Will IGRT be used? Yes No

b. What is the EBRT technique?

Select a technique for each applicable phase, and fill in the number of fractions

Phase 1 Phase II Phase III



reconstruction of

GTV/CTV/PTV/OAR,


DRRs)



GTV/CTV/PTV/OAR,


DRRs)


reconstruction of

GTV/CTV/PTV/OAR,


DRRs)

Electrons Electrons Electrons

Intensity modulated radiation

therapy (IMRT)

Intensity modulated


Intensity modulated radiation

therapy (IMRT)



Stereotactic body radiation

therapy (SBRT)/Stereotactic

radiosurgery (SRS)



radiosurgery (SRS)



radiosurgery (SRS)


Number of fractions: ____ Number of fractions: ____ Number of fractions: ____






Low dose rate (LDR)

High dose rate (HDR)

b. How many applications will be used? Applications: _______


Pancreatic Cancer Radiation Therapy Physician Worksheet (As of 31 December 2014)





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Pancreatic Cancer Radiation Therapy Physician Worksheet (As of 31 December 2014)


Patient name:

What is the radiation therapy treatment start date (mm/dd/yyyy)? _____ /_____ / ______

1. Will the treatment be directed to the primary site (pancreas)? Yes No


2. a. Does the patient have distant metastatic disease (M1 stage)? Yes No

b. If no, what is the timing of radiation?

Adjuvant (post-op)

Neo-adjuvant (precedes surgery)

Local recurrence/persistence

Definitive

Palliative

3. a. What external beam radiation therapy (EBRT) technique will be used to deliver radiation therapy?

3D (includes contouring + 3D reconstruction

of GTV/CTV/PTV/OAR, conformal beams,

DVHs, DRRs)




Tomotherapy

Proton beam therapy




5.

Do you plan to use IGRT? Yes No


Prostate Cancer Radiation Therapy Physician Worksheet (As of 31 December 2014)





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Patient name:

What is the radiation therapy treatment start date (mm/dd/yyyy)? _____ /______ /______

1. Is the treatment being directed to the primary site? Yes No



3. What is the timing of the treatment?

Initial primary treatment

Post prostatectomy

4. What is the patient’s Gleason score (range: 2 to 10)? Gleason score:

______ If treatment’s timing is “initial primary treatment”, answer questions #5-6 and then skip forward to

question #9. If treatment’s timing is “post prostatectomy”, skip forward to questions #7-8.

5. Select the T stage at initial diagnosis.

T0

T1a

T1b

T1c

T2a

T2b

T2c

T3a

T3b

T4

6. What was the patient’s PSA level at the time of diagnosis (ng/mL)? PSA level: _____ ng/mL

7. Which of the following were noted in the pathology specimen? Select all that apply

Positive margins

ECE or SV involvement

LN involvement

Prostate cut-through

None

Other: ___________

8.

a. Is the most recent post-prostatectomy PSA score detectable?

If yes, answer question #8b. If no, skip to question #9. Yes No

b. If the score is detectable, what is the most recent post-prostatectomy PSA

score (ng/mL)? ________ ng/mL






Brachytherapy

EBRT and Brachytherapy


a. What is the EBRT technique?

Proton beam therapy


Linear accelerator external beam radiotherapy

b. If proton beam therapy is the selected EBRT technique, how many fractions

will be rendered? Fractions: ________

c. If SBRT is the selected EBRT technique, how many fractions will be

rendered? Fractions: ________

d. If linear accelerator external beam radiotherapy is the selected EBRT technique, what type will be

used? Select the technique per phase, and fill in the number of fractions.

Phase 1 Phase 2 Phase 3 (optional) Phase 4 (optional)

3D (includes

contouring + 3D

reconstruction of

GTV/CTV/PTV/

OAR, conformal

beams, DVHs,

DRRs)

3D (includes

contouring + 3D

reconstruction of

GTV/CTV/PTV/

OAR, conformal

beams, DVHs,

DRRs)

3D (includes

contouring + 3D

reconstruction of

GTV/CTV/PTV/

OAR, conformal

beams, DVHs,

DRRs)

3D (includes

contouring + 3D

reconstruction of

GTV/CTV/PTV/

OAR, conformal

beams, DVHs,

DRRs)

Intensity modulated

radiation therapy

(IMRT)

Intensity modulated

radiation therapy

(IMRT)

Intensity modulated

radiation therapy

(IMRT)

Intensity modulated

radiation therapy

(IMRT)

Rotational arc

therapy

Rotational arc

therapy

Rotational arc

therapy

Rotational arc

therapy

Tomotherapy Tomotherapy Tomotherapy Tomotherapy

Fractions: _________ Fractions: _________ Fractions: _________ Fractions: _________





a. What type of brachytherapy will be utilized?

Low dose brachytherapy (seed implant)

High dose brachytherapy

b. If HDR brachytherapy is selected, what is the number of applications? Applications:______

c. If HDR brachytherapy is selected, what is the number of fractions? Fractions: ________

12. Note additional information in the space below.

Skin Cancer Radiation Therapy Physician Worksheet (As of 10 April 2015)





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Patient name:

What is the radiation therapy treatment start date (mm/dd/yyyy)? _____ / _____ / _______

1. What is the histology?

Basal cell carcinoma

Squamous cell carcinoma

Melanoma

Merkel cell carcinoma

Cutaneous lymphoma

Kaposi’s sarcoma

Other: ________________________

2. Does the patient have distant metastasis (M1)? Yes No

If you are treating the metastatic site, please stop and use the appropriate worksheet for the metastatic site being treated

3. Will regional lymph nodes be irradiated? Yes No

4.

What is the treatment plan?


Brachytherapy

5. If EBRT is the selected treatment plan, then answer the following set of questions:

a. What type of EBRT will be used?

Superficial x-ray SRT-100

Xstrahl (100, 150, 200, or 300)

Electron beam Total skin irradiation

Focal skin irradiation

Photon beam

Complex (77307)

3D (includes contouring + 3D reconstruction of GTV/CTV/PTV/OAR,





Proton beam therapy

Tomotherapy

b. How many phases of the selected EBRT technique will be rendered? Phases: ____________

c. How many total fractions of the selected EBRT technique will be rendered? Fractions: ___________




6. If brachytherapy is the selected treatment plan, then answer the following set of questions:

a. What type of brachytherapy will be used?

Low dose rate

High dose rate

Electronic brachytherapy (e.g. Xoft [eBx], Esteya)

b. How many applications? Applications: ________

c. If low dose rate is the selected brachytherapy type, what type of low dose rate will be used?

Interstitial

Other: ________________



Please be advised treatment of multiple sites is considered concurrent treatment

Small Cell Lung Cancer Radiation Therapy Physician Worksheet (As of 10 April 2015)





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Patient name:

What is the radiation therapy treatment start date (mm/dd/yyyy)? _____ / _____ / ______

1. Is the treatment being directed to the primary site (lung or brain (PCI))? Yes No


2. What is the stage of the cancer? Limited Extensive

3. a. Is this request for a prophylactic cranial irradiation (PCI)? Yes No

b. If request is for a PCI, how many treatments (fractions) will be rendered? Fractions: _________

4. What is the response status after initial therapy?

Complete response (CR)

No response (NR)

Partial response (PR)

Progressive disease (POD)

If request is for PCI, skip forward to question #11 (see question #3a). If PCI is not requested, continue forward to question #5


Definitive

Palliation

b. If palliation is the treatment intent, what technique will be utilized for palliation?


Brachytherapy

6. Answer the following set of questions if brachytherapy will be used for palliation (see question #5b). Then

skip forward to question #8.

a. Has the patient failed prior EBRT? Yes No

b. How many applications of brachytherapy will be used? Applications: _______

c. How many brachytherapy treatments (fractions) will be rendered? Fractions: _________




7. Answer the following question if an EBRT treatment plan will be utilized.

a. What EBRT technique will be used to deliver the radiation therapy?


Phase 1 Phase 2 Phase 3

Complex (77307)

Complex (77307)

Complex (77307)



GTV/CTV/PTV/OAR,


DRRs)



GTV/CTV/PTV/OAR,


DRRs)



GTV/CTV/PTV/OAR,


DRRs)

Intensity Modulated

Radiation Therapy (IMRT)

Intensity Modulated


Intensity Modulated





Number of fractions: ______ Number of fractions: ______ Number of fractions: ______

8. Will concurrent chemotherapy be used? Yes No

9. Will respiratory motion management be used? Yes No

10. Will hyper-fractionation (BID) be used? Yes No



Radiation Oncology Patient Name: ________________________________ DOB: ______________

RADIATION THERAPY PR OCEDURE CODES

Please select the appropriate CPT code and include the number of units that are being requested. If your code is not listed, please provide the CPT and number of units in the blank spaces at the bottom of the form.

Qty 2015 HCPCS

2015 CPT

Description(deleted 2014 code) Qty 2015 HCPCS

2015 CPT

Description(deleted 2014 code)

G6016 Compensator IMRT (0073T) G6009 11-19 MV TX Delivery Per Day, Intermediate (77409)

0182T High Dose Rate Electronic Brachytherapy, Per Fraction

G6010 20 MV or greater Tx Delivery, Intermediate (77411)

76873 Prostate Volume Study G6011 77412 Radiation treatment delivery, >1 MeV; complex

G6001 Ultrasound Guidance For Placement RT Fields (76950)

G6012 6-10 MV Tx Delivery Per Day, Compl ex (77413)

76965 US Guidance for Interstitial Radioelement Application

G6013 11-19 MV Tx Delivery Per Day, Complex (77414)

77014 CT Guidance For Placement RT Fields G6014 20 MV or greater Tx Delivery, Complex (77416)

77261 Clinical Treatment Plan , Simple 77417 Port Films

77262 Clinical Treatment Plan , Intermediate G6015 IMRT Treatment Delivery (77418)

77263 Clinical Treatment Plan , Complex 77385 Intensity modulated treatment delivery (IMRT); simple

77280 Simple Sims 77386 Intensity modulated treatment delivery (IMRT) ; complex

77285 Intermediate Sims 77387 Guidance for localization of target volume, includes intrafraction tracking, when performed

77290 Complex Sims G6017 Intrafraction Loc. & Tracking(0197T)

+77293 Respiratory Motion Management G6002 Xray Guidance for Target Volume Delivery(77421)

77295 3D Sim Planning 77424 Intra Operative Treatment, photons

77300 Calculations 77425 Intra Operative Treatment, electrons

77301 IMRT Treatmen t Planning 77427 Weekly Mgmt 5 tx

77306 Teletherapy isodose plan; simple, includes basic dosimetry calculation(s)

77431 Complete Mgmt 1 To 2 Courses

77307 Teletherapy isodose plan; complex, includes basic dosimetry calculation(s)

77432 SRS Tx Mgmt Cranial Lesions

77316 Brachytherapy isodose plan; simple, includes basic dosimetry calculation(s)

77435 SBRT Treatment Management

77317

Brachytherapy isodose plan; intermediate, includes basic dosimetry calculation(s)

77469 Intra Operative Management

77318 Brachytherapy isodose plan; complex, includes basic dosimetry calculation(s)

77470 Special Tx Procedure

77321 Special Teletherapy Port Plan 77520 Proton Treatment Delivery, Simple w/o compensation

77331 Microdosimetry 77522 Proton Treatment Delivery, Simple compensation

77332 Simple Treatment Device 77523 Proton Treatment Delivery; Intermediate

77333 Intermediate Treatment Device 77525 Proton Treatment Delivery; Complex

77334 Complex Treatment Device 77761 Intracavitary Radiation Source Application; Simple

77336 Physics Support 77762 Intracavitary Radiation Source Application; Intermediate

77338 MultiLeaf Collimator for IMRT 77763 Intracavitary Radiation Source Application; Complex

77370 Physics Consult 77776 Simple Interstitial Radioelement Application

77371 SRS Delivery 1 Session, Cobalt 77777 Intermediate Interstitial Radioelement Application

77372 SRS Linear Accelator Based, 5 Session 77778 Complex Interstitial Radioelement Application

77373 SBRT Linac >1, 5 Session 77785 Remote Afterloading HDR Brachytherapy; 1-12 Channels

77401 Kilovoltage Tx delivery (all inclusive) 77786 Remote Afterloading HDR Brachytherapy; 2-12 Channels

G6003 77402 Radiation treatment delivery, >1 MeV; simple 77787 Remote Afterloading HDR Brachytherapy; > 12 Channels

G6004 6-10 MV Tx Delivery, Simple (77403) 77790 Supervision, Handling & Loading Source

G6005 11-19 MV Tx Delivery per Day, Simple (77404) G0173 Linac Based SRS, Single Session

G6006 20 MV or greater Tx Delivery, Simple (77406) G0251 Linac Based SRS Up to 5 Sessions

G6007 77407 Radiation treatment delivery, >1 MeV; Intermediate G0339 SRS Robotic 1st Session

G6008 6-10 MV Tx Delivery Per Day, Intermediate (77408) G0340 SRS Robotic Sessions 2 through 5

77600 Hyperthermia, external super�cial

77605 Hyperthermia, deep greater than 4 cm

77610 Hyperthermia, interstitial probes (5 or less)

77615 Hyperthermia, interstitial probes (5 or more)

77620 Hyperthermia, intracavity probes

Bone Metastases Radiation Therapy Physician … Metastases Radiation Therapy Physician Worksheet...

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