Radiation Therapy Checklist - NantHealth · 77424 Photons External Beam RT Intraoperative Radiation...
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NantHealth, Inc., a member of the NantWorks ecosystem of companies, is a next-generation, evidence- based, personalized healthcare company enabling improved patient outcomes and more effective treatment decisions for critical illnesses. NantHealth’s focused portfolio exemplifies its unique systems-based approach to personalized healthcare and integrates novel analysis with large-scale, biometric and phenotypic data to track patient outcomes and deliver precision medicine. For more information, please visit www.nanthealth.com. Confidentiality Statement: The documents accompanying this transmission contain confidential health information that is legally privileged. This information is intended only for the use of the individual(s) or entities listed above. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or action taken in reliance on the contents of these documents is strictly prohibited. If you receive this information in error, please notify the sender immediately and arrange for the return or destruction of these documents. Radiation Therapy Checklist This information is needed for treatment plan entry into Eviti Connect ✓ Name: _____________________________________________ DOB: _________ Male/Female ✓ Insurance Plan: ______________________ID: _____________________________ ✓ Date of Diagnosis: __________________________ or Recurrence _____________ ✓ Cancer Type (site): _______________________________________________ ✓ Pathology: _____________________________________________________ ✓ ICD-10 Code: _______________________ Physician: ___________________________ NPI: __________ Tax ID: ________ Contact Name: _____________________________ Ph: ____________________ Fax: _____________________________ Email: __________________________ ✓ Stage of Disease: (e.g. Stage IIa, Recurrent) __________________ If applicable, Metastasis Site(s): _____________ Metastasis Dx. Date: ________________ ✓ Line of Therapy: (circle one) Neoadjuvant Adjuvant Definitive Palliative ✓ Goal of Therapy/Intent: (circle one) Curative Palliative Radiation Target site(s): ___________________________ Treatment Start Date: _________ Particle: (circle one) Photons / Electrons / Photon/Electron / Protons / Neutrons Energy: _________ MV or MeV Total XRT dose: (do not include boost) __________ Gy Number of fractions: ________ Radiation Delivery Technique (select one): Simple Intermediate Complex Intensity Modulated Radiation - IMRT Stereotactic Radiosurgery (CPT-77372) Stereotactic Body Radiotherapy (CPT-77373, GO339, GO340) Superficial/Orthovoltage Is image guided (IGRT) or intrafraction tracking being prescribed? Yes No (Please note: IGRT is generally not necessary for 3D conformal radiation and will require patient specific rationale for authorization, if unsure please check with MD before circling yes, as an incorrect answer may affect authorization)
Transcript of Radiation Therapy Checklist - NantHealth · 77424 Photons External Beam RT Intraoperative Radiation...
NantHealth, Inc., a member of the NantWorks ecosystem of companies, is a next-generation, evidence-based, personalized healthcare company enabling improved patient outcomes and more effective treatment decisions for critical illnesses. NantHealth’s focused portfolio exemplifies its unique systems-based approach to personalized healthcare and integrates novel analysis with large-scale, biometric and phenotypic data to track patient outcomes and deliver precision medicine. For more information, please visit www.nanthealth.com. Confidentiality Statement: The documents accompanying this transmission contain confidential health information that is legally privileged. This information is intended only for the use of the individual(s) or entities listed above. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or action taken in reliance on the contents of these documents is strictly prohibited. If you receive this information in error, please notify the sender immediately and arrange for the return or destruction of these documents.
Radiation Therapy Checklist This information is needed for treatment plan entry into Eviti Connect
✓Name: _____________________________________________ DOB: _________ Male/Female
✓Insurance Plan: ______________________ID: _____________________________
✓Date of Diagnosis: __________________________ or Recurrence _____________
✓Cancer Type (site): _______________________________________________
✓Pathology: _____________________________________________________
✓ICD-10 Code: _______________________
Physician: ___________________________ NPI: __________ Tax ID: ________
Contact Name: _____________________________ Ph: ____________________
Fax: _____________________________ Email: __________________________
✓Stage of Disease: (e.g. Stage IIa, Recurrent) __________________ If applicable, Metastasis Site(s): _____________ Metastasis Dx. Date: ________________
✓Line of Therapy: (circle one) Neoadjuvant Adjuvant Definitive Palliative
✓Goal of Therapy/Intent: (circle one) Curative Palliative
Radiation Target site(s): ___________________________ Treatment Start Date: _________ Particle: (circle one) Photons / Electrons / Photon/Electron / Protons / Neutrons
Energy: _________ MV or MeV Total XRT dose: (do not include boost) __________ Gy Number of fractions: ________
Radiation Delivery Technique (select one):
Simple Intermediate Complex Intensity Modulated Radiation - IMRT Stereotactic Radiosurgery (CPT-77372) Stereotactic Body Radiotherapy (CPT-77373, GO339, GO340) Superficial/Orthovoltage
Is image guided (IGRT) or intrafraction tracking being prescribed? Yes No
(Please note: IGRT is generally not necessary for 3D conformal radiation and will require
patient specific rationale for authorization, if unsure please check with MD before circling yes, as an incorrect answer may affect authorization)
NantHealth, Inc., a member of the NantWorks ecosystem of companies, is a next-generation, evidence-based, personalized healthcare company enabling improved patient outcomes and more effective treatment decisions for critical illnesses. NantHealth’s focused portfolio exemplifies its unique systems-based approach to personalized healthcare and integrates novel analysis with large-scale, biometric and phenotypic data to track patient outcomes and deliver precision medicine. For more information, please visit www.nanthealth.com. Confidentiality Statement: The documents accompanying this transmission contain confidential health information that is legally privileged. This information is intended only for the use of the individual(s) or entities listed above. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or action taken in reliance on the contents of these documents is strictly prohibited. If you receive this information in error, please notify the sender immediately and arrange for the return or destruction of these documents.
Is a Radiation Therapy boost planned: Yes No Boost Site(s): ______________________
Particle: (circle one) Photons Electrons Photon/Electron Protons Neutrons
Energy: _________ MV or MeV Boost dose: ____________ Gy Number of fractions: _______ Radiation Delivery Technique (circle one):
Simple Intermediate Complex IMRT Is image guided (IGRT) or intrafraction tracking being prescribed? Yes No
(Please note: IGRT is generally not necessary for 3D conformal radiation and will require
patient specific rationale for authorization, if unsure please check with MD before circling yes, as an incorrect answer may affect authorization)
Required information if Brachytherapy selected as Method of Delivery for Treatment or Boost FOR LDR selection - complete the following: Route: infusion/instillation of element Interstitial Intracavitary Surface Delivery Technique: Simple Intermediate Complex Number of Fractions: ___________ Total Dose: ___________ Gy Number of sources per fraction: ___________ Isotopes: (Select isotope from list below) Cesium-131, non-stranded, per source – C2643 Cesium-131, stranded, per source - C2642 Gold-198, non-stranded, per source- C1716 Iodine-125 high activity, greater than 1.01 mCI (NIST), non-stranded, per source- C2634 Iodine-125 non stranded, per source - C2639 Iodine-125 stranded, per source - C2638 Iodine-125 sodium iodide solution, therapeutic, per millicurie- A9527 Iridium-192, non-high dose rate, non-stranded, per source- C1719 Not otherwise specified, non-stranded, per source - C2699 Not otherwise specified, stranded, per source - C2698 Palladium -103, high activity, greater than 2.2.mCi (NIST), non-stranded per source - C2635 Palladium-103 non-stranded, per 1mm - C2636 Palladium-103 non-stranded, per source - C2641 Palladium-103 stranded, per source - C2640 Yttrium-90, non-stranded, per source - C2616
NantHealth, Inc., a member of the NantWorks ecosystem of companies, is a next-generation, evidence-based, personalized healthcare company enabling improved patient outcomes and more effective treatment decisions for critical illnesses. NantHealth’s focused portfolio exemplifies its unique systems-based approach to personalized healthcare and integrates novel analysis with large-scale, biometric and phenotypic data to track patient outcomes and deliver precision medicine. For more information, please visit www.nanthealth.com. Confidentiality Statement: The documents accompanying this transmission contain confidential health information that is legally privileged. This information is intended only for the use of the individual(s) or entities listed above. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or action taken in reliance on the contents of these documents is strictly prohibited. If you receive this information in error, please notify the sender immediately and arrange for the return or destruction of these documents.
FOR HDR selection – complete the following: Number of Channels: ________________ Number of Fractions: ____________________ Total Dose: ________________________ Gy Number of sources per fraction: _______ Iridium – 192, high dose rate, non-stranded, per source – C1717 FOR HDRE selection – complete the following: Number of fractions: _____________ Total Dose: ____________ Gy
Please circle requested codes:
0394T Brachytherapy
0395T Brachytherapy
77371 Photons External Beam RT Gamma Knife
77372 Photons External Beam RT Stereotactic RadioSurgery (SRS) (single fraction) Brain
77373 Photon External Beam RT Stereotactic Body Radiotherapy (SBRT or SABR) all fractions
77385 Photons External Beam RT IMRT Simple
77386 Photons External Beam RT IMRT Complex
77401 Photon/Electron External Beam RT superficial/ortho
77402 Photons External Beam RT simple
77407 Photons External Beam RT intermediate
77412 Photon/Electron External Beam RT complex
77422 Neutrons External Beam RT Single Port with No/Simple Blocking
77423 Neutrons External Beam RT Complex
77424 Photons External Beam RT Intraoperative Radiation Therapy (IORT): X-ray
77425 Electrons External Beam RT Intraoperative Radiation Therapy (IORT): Electron
77520 Protons External Beam RT Simple
77522 Protons External Beam RT Simple with compensation
77523 Protons External Beam RT Intermediate
77525 Protons External Beam RT Complex
77750 Brachytherapy Intermediate
77750 Brachytherapy Simple
77750 Brachytherapy Complex
77761 Brachytherapy Simple
77762 Brachytherapy Intermediate
NantHealth, Inc., a member of the NantWorks ecosystem of companies, is a next-generation, evidence-based, personalized healthcare company enabling improved patient outcomes and more effective treatment decisions for critical illnesses. NantHealth’s focused portfolio exemplifies its unique systems-based approach to personalized healthcare and integrates novel analysis with large-scale, biometric and phenotypic data to track patient outcomes and deliver precision medicine. For more information, please visit www.nanthealth.com. Confidentiality Statement: The documents accompanying this transmission contain confidential health information that is legally privileged. This information is intended only for the use of the individual(s) or entities listed above. If you are not the intended recipient, you are hereby notified that any disclosure, copying, distribution, or action taken in reliance on the contents of these documents is strictly prohibited. If you receive this information in error, please notify the sender immediately and arrange for the return or destruction of these documents.
77763 Brachytherapy Complex
77767 Brachytherapy Null
77768 Brachytherapy Null
77770 Brachytherapy Null
77771 Brachytherapy Null
77772 Brachytherapy Null
77789 Brachytherapy Simple
77789 Brachytherapy Intermediate
77789 Brachytherapy Complex
G6003 Photon/Electron External Beam RT simple
G6004 Photon/Electron External Beam RT simple
G6005 Photons External Beam RT simple
G6006 Photon/Electron External Beam RT simple
G6007 Photon/Electron External Beam RT intermediate
G6008 Photon/Electron External Beam RT intermediate
G6009 Photon/Electron External Beam RT intermediate
G6010 Photon/Electron External Beam RT intermediate
G6011 Photon/Electron External Beam RT complex
G6012 Photon/Electron External Beam RT complex
G6013 Photon/Electron External Beam RT complex
G6015 Photon/Electron External Beam RT Intensity Modulated (IMRT)
G6016 Photons External Beam RT Compensator-based IMRT
Other CPTs related to Treatments and Account for in eviti:
G6017/0197T Gating
77014/77387/G6001/G6002/76950/77421 IGRT
77600/77605/77610/77615 Hyperthermia 77417
Port Films
If you do not receive an automated code the request will be move to Eviti for review, please attach the following to the case, email [email protected] or fax to 888-468-1423:
- RT consult - Rx or completed RT checklist - PathologyScans if relative to treatment
For assistance, please contact the NantHealth Eviti support center @ 888-482-8057
