Bone Metastases Radiation Therapy Physician … Metastases Radiation Therapy Physician Worksheet...
Transcript of 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
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
Mem
ber
Patient First Name: Patient Last Name:
DOB: Member ID: Group #: Health Plan:
Address: City: ST: Zip:
Phys
icia
n
Physician First Name: Physician Last Name:
Primary Specialty: NPI: Tax ID:
Address: City: ST: Zip:
Phone #: Fax #: Contact Email:
Faci
lity
Facility Name: Facility Tax ID:
Address: City: ST: Zip:
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:
Sign
atur
e
Check the appropriate box describing you: Ordering Physician Facility Other: ____________________________ Sign and Date Below: Print Name:______________________________________________ Sign Name: ______________________________________________ MD RN LPN PA NP Other
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
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
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
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)
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)
Proton beam therapy Proton beam therapy Proton beam therapy
Rotational arc therapy Rotational arc therapy Rotational arc therapy
Stereotactic body radiation therapy (SBRT)
Stereotactic body radiation therapy (SBRT)
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
Continued on next page
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
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)
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
Mem
ber
Patient First Name: Patient Last Name:
DOB: Member ID: Group #: Health Plan:
Address: City: ST: Zip:
Phys
icia
n
Physician First Name: Physician Last Name:
Primary Specialty: NPI: Tax ID:
Address: City: ST: Zip:
Phone #: Fax #: Contact Email:
Faci
lity
Facility Name: Facility Tax ID:
Address: City: ST: Zip:
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:
Sign
atur
e
Check the appropriate box describing you: Ordering Physician Facility Other: ____________________________ Sign and Date Below: Print Name:______________________________________________ Sign Name: ______________________________________________ MD RN LPN PA NP Other
Brain 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
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?
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.
Continued on next page
Brain 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
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)
3D (includes contouring + 3D reconstruction of GTV/CTV/PTV/OAR, conformal beams, DVHs, DRRs)
Intensity modulated radiation therapy (IMRT)
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
Continued on next page
Brain 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
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)
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
Mem
ber
Patient First Name: Patient Last Name:
DOB: Member ID: Group #: Health Plan:
Address: City: ST: Zip:
Phys
icia
n
Physician First Name: Physician Last Name:
Primary Specialty: NPI: Tax ID:
Address: City: ST: Zip:
Phone #: Fax #: Contact Email:
Faci
lity
Facility Name: Facility Tax ID:
Address: City: ST: Zip:
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:
Sign
atur
e
Check the appropriate box describing you: Ordering Physician Facility Other: ____________________________ Sign and Date Below: Print Name:______________________________________________ Sign Name: ______________________________________________ MD RN LPN PA NP Other
Breast Cancer Radiation Therapy Physician Worksheet (As of 10 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
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
Continued on next page
Breast Cancer Radiation Therapy Physician Worksheet (As of 10 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
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)
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
Mem
ber
Patient First Name: Patient Last Name:
DOB: Member ID: Group #: Health Plan:
Address: City: ST: Zip:
Phys
icia
n
Physician First Name: Physician Last Name:
Primary Specialty: NPI: Tax ID:
Address: City: ST: Zip:
Phone #: Fax #: Contact Email:
Faci
lity
Facility Name: Facility Tax ID:
Address: City: ST: Zip:
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:
Sign
atur
e
Check the appropriate box describing you: Ordering Physician Facility Other: ____________________________ Sign and Date Below: Print Name:______________________________________________ Sign Name: ______________________________________________ MD RN LPN PA NP Other
Cervical Cancer Radiation Therapy Physician Worksheet (As of 10 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
Patient name:
What is the radiation therapy start date (mm/dd/yyyy)? _____ /______ /______
1. Is this treatment being directed to the primary site?
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? 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
Continued on next page
Cervical Cancer Radiation Therapy Physician Worksheet (As of 10 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
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
10. Will IGRT be used? Yes No
11. Note any additional information in the space below:
Primary Central Nervous System (CNS) Lymphoma Radiation Therapy Physician Worksheet
(As of 10 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
Mem
ber
Patient First Name: Patient Last Name:
DOB: Member ID: Group #: Health Plan:
Address: City: ST: Zip:
Phys
icia
n
Physician First Name: Physician Last Name:
Primary Specialty: NPI: Tax ID:
Address: City: ST: Zip:
Phone #: Fax #: Contact Email:
Faci
lity
Facility Name: Facility Tax ID:
Address: City: ST: Zip:
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:
Sign
atur
e
Check the appropriate box describing you: Ordering Physician Facility Other: ____________________________ Sign and Date Below: Print Name:______________________________________________ Sign Name: ______________________________________________ MD RN LPN PA NP Other
Primary Central Nervous System (CNS) Lymphoma Radiation Therapy Physician Worksheet
(As of 10 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
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)
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)
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
5. Note any additional information in the space below:
Primary Central Nervous System (CNS) Neoplasm Radiation Therapy Physician Worksheet
(As of 21 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
Mem
ber
Patient First Name: Patient Last Name:
DOB: Member ID: Group #: Health Plan:
Address: City: ST: Zip:
Phys
icia
n
Physician First Name: Physician Last Name:
Primary Specialty: NPI: Tax ID:
Address: City: ST: Zip:
Phone #: Fax #: Contact Email:
Faci
lity
Facility Name: Facility Tax ID:
Address: City: ST: Zip:
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:
Sign
atur
e
Check the appropriate box describing you: Ordering Physician Facility Other: ____________________________ Sign and Date Below: Print Name:______________________________________________ Sign Name: ______________________________________________ MD RN LPN PA NP Other
Primary Central Nervous System (CNS) Neoplasm Radiation Therapy Physician Worksheet
(As of 21 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
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
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.
3. What resection has been performed?
Biopsy only Subtotal resection Gross total resection
Continued on next page
Primary Central Nervous System (CNS) Neoplasm Radiation Therapy Physician Worksheet
(As of 21 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
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)
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)
Tomotherapy Tomotherapy
Rotational arc therapy Rotational arc therapy
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: _________________
5. Will the patient be receiving concurrent chemotherapy? Yes No
6. Will IGRT be used? Yes No
7. Note any additional information in the space below:
Colorectal Cancer Radiation Therapy Physician Worksheet (As of 31 December 2014)
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
Me
mb
er
Patient First Name: Patient Last Name:
DOB: Member ID: Group #: Health Plan:
Address: City: ST: Zip:
Ph
ys
icia
n
Physician First Name: Physician Last Name:
Primary Specialty: NPI: Tax ID:
Address: City: ST: Zip:
Phone #: Fax #: Contact Email:
Fa
cil
ity
Facility Name: Facility Tax ID:
Address: City: ST: Zip:
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:
Sig
na
ture
Check the appropriate box describing you: Ordering Physician Facility Other: ____________________________
Sign and Date Below:
Print Name:______________________________________________
Sign Name: ______________________________________________ MD RN LPN PA NP
Other
Colorectal Cancer Radiation Therapy Physician Worksheet (As of 31 December 2014)
730 COOL SPRINGS BLVD. SUITE 800 • FRANKLIN, TN 37067 • PH: 888.693.3211 • FX: 877.791.4110 • www.CareCoreNational.com • www.MedSolutions.com
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
Continued on next page
7. What is the treatment intent?
Colorectal Cancer Radiation Therapy Physician Worksheet (As of 31 December 2014)
730 COOL SPRINGS BLVD. SUITE 800 • FRANKLIN, TN 37067 • PH: 888.693.3211 • FX: 877.791.4110 • www.CareCoreNational.com • www.MedSolutions.com
Definitive
Palliation
8.
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
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)
Tomotherapy Tomotherapy
Rotational arc therapy Rotational arc therapy
Proton beam therapy Proton beam therapy
Number of fractions: ______ Number of fractions: ______
9. Will the patient receive concurrent chemotherapy? Yes No
10. Will IGRT be used? Yes No
11. Note any additional information in the space below.
Endometrial Cancer Radiation Therapy Physician Worksheet (As of 10 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
Me
mb
er
Patient First Name: Patient Last Name:
DOB: Member ID: Group #: Health Plan:
Address: City: ST: Zip:
Ph
ys
icia
n
Physician First Name: Physician Last Name:
Primary Specialty: NPI: Tax ID:
Address: City: ST: Zip:
Phone #: Fax #: Contact Email:
Fa
cil
ity
Facility Name: Facility Tax ID:
Address: City: ST: Zip:
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:
Sig
na
ture
Check the appropriate box describing you: Ordering Physician Facility Other: ____________________________
Sign and Date Below:
Print Name:______________________________________________
Sign Name: ______________________________________________ MD RN LPN PA NP
Other
Endometrial Cancer Radiation Therapy Physician Worksheet (As of 10 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
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
If treatment is not being directed to the primary site, submit a request for the metastatic site
2. What is the pathology?
Endometrioid
Papillary serous
Clear cell
Carcinosarcoma
3. Does the patient have distant metastatic disease? Yes No
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
8. Will the patient be receiving concurrent chemotherapy? Yes No
Continued on next page
Endometrial Cancer Radiation Therapy Physician Worksheet (As of 10 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
9. What is the treatment plan?
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:
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
Ovoids only
Tandem and ovoids
Heyman capsules only
Interstitial
11. 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)
Intensity modulated radiation therapy (IMRT)
Stereotactic body radiation therapy (SBRT)
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
12. Will IGRT be used? Yes No
13. Note any additional information in the space below:
Gastric (Stomach) Cancer Radiation Therapy Physician Worksheet (As of 31 December 2014)
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
Me
mb
er
Patient First Name: Patient Last Name:
DOB: Member ID: Group #: Health Plan:
Address: City: ST: Zip:
Ph
ys
icia
n
Physician First Name: Physician Last Name:
Primary Specialty: NPI: Tax ID:
Address: City: ST: Zip:
Phone #: Fax #: Contact Email:
Fa
cil
ity
Facility Name: Facility Tax ID:
Address: City: ST: Zip:
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:
Sig
na
ture
Check the appropriate box describing you: Ordering Physician Facility Other: ____________________________
Sign and Date Below:
Print Name:______________________________________________
Sign Name: ______________________________________________ MD RN LPN PA NP
Other
Gastric (Stomach) Cancer Radiation Therapy Physician Worksheet (As of 31 December 2014)
730 COOL SPRINGS BLVD. SUITE 800 • FRANKLIN, TN 37067 • PH: 888.693.3211 • FX: 877.791.4110 • www.CareCoreNational.com • www.MedSolutions.com
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
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. 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
Continued on next page
Gastric (Stomach) Cancer Radiation Therapy Physician Worksheet (As of 31 December 2014)
730 COOL SPRINGS BLVD. SUITE 800 • FRANKLIN, TN 37067 • PH: 888.693.3211 • FX: 877.791.4110 • www.CareCoreNational.com • www.MedSolutions.com
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)
Intensity modulated radiation therapy (IMRT)
Proton beam therapy
Rotational arc therapy
Stereotactic body radiation therapy (SBRT)
Tomotherapy
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
5. Will the patient receive concurrent chemotherapy? Yes No
6. Will IGRT be used? Yes No
7. Note any additional information in the space below.
Head or Neck Radiation Therapy Physician Worksheet (As of 21 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
Me
mb
er
Patient First Name: Patient Last Name:
DOB: Member ID: Group #: Health Plan:
Address: City: ST: Zip:
Ph
ys
icia
n
Physician First Name: Physician Last Name:
Primary Specialty: NPI: Tax ID:
Address: City: ST: Zip:
Phone #: Fax #: Contact Email:
Fa
cil
ity
Facility Name: Facility Tax ID:
Address: City: ST: Zip:
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:
Sig
na
ture
Check the appropriate box describing you: Ordering Physician Facility Other: ____________________________
Sign and Date Below:
Print Name:______________________________________________
Sign Name: ______________________________________________ MD RN LPN PA NP
Other
Head or Neck Radiation Therapy Physician Worksheet (As of 21 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
Patient name:
What is the radiation therapy start date (mm/dd/yyyy)? _____ /______ /______
1. Does the patient have distant metastatic disease (M1 stage)? Yes No
If treatment is not being directed to the primary site, submit a request for the metastatic site.
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
Continued on next page
5. What technique will be used to deliver the radiation therapy?
Brachytherapy
External beam radiation therapy (EBRT)
Continued on next page
Head or Neck Radiation Therapy Physician Worksheet (As of 21 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
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)
Stereotactic body radiation therapy (SBRT)
Intensity modulated radiation therapy (IMRT): fixed gantry
Tomotherapy
Rotational arc therapy
Proton beam therapy
8. Will the patient be receiving concurrent chemotherapy? Yes No
9. Will the patient receive treatment twice daily during the course of treatment? Yes No
10. Note any additional information in the space below:
Non Cancerous Radiation Therapy Physician Worksheet (As of 10 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
Me
mb
er
Patient First Name: Patient Last Name:
DOB: Member ID: Group #: Health Plan:
Address: City: ST: Zip:
Ph
ys
icia
n
Physician First Name: Physician Last Name:
Primary Specialty: NPI: Tax ID:
Address: City: ST: Zip:
Phone #: Fax #: Contact Email:
Fa
cil
ity
Facility Name: Facility Tax ID:
Address: City: ST: Zip:
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:
Sig
na
ture
Check the appropriate box describing you: Ordering Physician Facility Other: ____________________________
Sign and Date Below:
Print Name:______________________________________________
Sign Name: ______________________________________________ MD RN LPN PA NP
Other
Non Cancerous Radiation Therapy Physician Worksheet (As of 10 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
Patient name:
What is the radiation therapy start date (mm/dd/yyyy)? _____ /______ /______
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
Rotational arc therapy
Proton beam therapy
Electrons
Complex (77307)
3D (includes contouring + 3D reconstruction of GTV/CTV/PTV/OAR,
conformal beams, DVHs, DRRs)
Stereotactic radiosurgery (SRS)/
Stereotactic body radiation therapy (SBRT)
Intensity modulated radiation therapy (IMRT
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
4. Will IGRT be used? Yes No
5. Note any additional information in the space below.
Non-Small Cell Lung Cancer Radiation Therapy Physician Worksheet (As of 21 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
Me
mb
er
Patient First Name: Patient Last Name:
DOB: Member ID: Group #: Health Plan:
Address: City: ST: Zip:
Ph
ys
icia
n
Physician First Name: Physician Last Name:
Primary Specialty: NPI: Tax ID:
Address: City: ST: Zip:
Phone #: Fax #: Contact Email:
Fa
cil
ity
Facility Name: Facility Tax ID:
Address: City: ST: Zip:
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:
Sig
na
ture
Check the appropriate box describing you: Ordering Physician Facility Other: ____________________________
Sign and Date Below:
Print Name:______________________________________________
Sign Name: ______________________________________________ MD RN LPN PA NP
Other
Non-Small Cell Lung Cancer Radiation Therapy Physician Worksheet (As of 21 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
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
3. a. What is the treatment intent?
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?
External beam radiation therapy (EBRT)
Brachytherapy
If Brachytherapy will be used for palliation, skip forward to question #8.
Continued on next page
4. What EBRT technique will be used to deliver the radiation therapy?
Select a technique for each applicable phase, and fill in the number of fractions.
Non-Small Cell Lung Cancer Radiation Therapy Physician Worksheet (As of 21 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
Phase 1 Phase 2 Phase 3
Complex (77307) Complex (77307) Complex (77307)
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)
Proton beam therapy Proton beam therapy Proton beam therapy
Rotational arc therapy Rotational arc therapy Rotational arc therapy
Stereotactic body
radiation therapy
(SBRT)
Stereotactic body
radiation therapy (SBRT)
Stereotactic body
radiation therapy (SBRT)
Tomotherapy Tomotherapy Tomotherapy
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: _________
9. Note any additional information in the space below.
Other Cancer Type Radiation Therapy Physician Worksheet (As of 21 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
Me
mb
er
Patient First Name: Patient Last Name:
DOB: Member ID: Group #: Health Plan:
Address: City: ST: Zip:
Ph
ys
icia
n
Physician First Name: Physician Last Name:
Primary Specialty: NPI: Tax ID:
Address: City: ST: Zip:
Phone #: Fax #: Contact Email:
Fa
cil
ity
Facility Name: Facility Tax ID:
Address: City: ST: Zip:
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:
Sig
na
ture
Check the appropriate box describing you: Ordering Physician Facility Other: ____________________________
Sign and Date Below:
Print Name:______________________________________________
Sign Name: ______________________________________________ MD RN LPN PA NP
Other
Other Cancer Type Radiation Therapy Physician Worksheet (As of 21 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
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?
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 the ECOG status is due to the cancer, is the status expected to
improve with radiation therapy treatment? Yes No
3. Does the patient have distant metastatic disease? 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
7. Will the patient receive concurrent chemotherapy? Yes No
Continued on next page
Other Cancer Type Radiation Therapy Physician Worksheet (As of 21 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
8. a. What is the treatment plan?
External beam radiation therapy (EBRT)
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
9. If EBRT is included in the treatment plan, then answer the following set of questions:
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
Complex (77307) Complex (77307) Complex (77307)
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)
Electrons Electrons Electrons
Intensity modulated radiation
therapy (IMRT)
Intensity modulated
radiation therapy (IMRT)
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)/Stereotactic
radiosurgery (SRS)
Stereotactic body radiation
therapy (SBRT)/Stereotactic
radiosurgery (SRS)
Stereotactic body radiation
therapy (SBRT)/Stereotactic
radiosurgery (SRS)
Tomotherapy Tomotherapy Tomotherapy
Number of fractions: ____ Number of fractions: ____ Number of fractions: ____
Continued on next page
Other Cancer Type Radiation Therapy Physician Worksheet (As of 21 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
10. 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 applications will be used? Applications: _______
11. Note any additional information in the space below:
Pancreatic Cancer Radiation Therapy Physician Worksheet (As of 31 December 2014)
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:
Ph
ys
icia
n
Physician First Name: Physician Last Name:
Primary Specialty: NPI: Tax ID:
Address: City: ST: Zip:
Phone #: Fax #: Contact Email:
Fa
cil
ity
Facility Name: Facility Tax ID:
Address: City: ST: Zip:
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:
Sig
na
ture
Check the appropriate box describing you: Ordering Physician Facility Other: ____________________________
Sign and Date Below:
Print Name:______________________________________________
Sign Name: ______________________________________________ MD RN LPN PA NP
Other
Pancreatic Cancer Radiation Therapy Physician Worksheet (As of 31 December 2014)
730 COOL SPRINGS BLVD. SUITE 800 • FRANKLIN, TN 37067 • PH: 888.693.3211 • FX: 877.791.4110 • www.CareCoreNational.com • www.MedSolutions.com
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
If treatment is not being directed to the primary site, submit a request for the metastatic site.
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)
Intensity modulated radiation therapy (IMRT)
Rotational arc therapy
Stereotactic body radiation therapy (SBRT)
Tomotherapy
Proton beam therapy
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
4. Will the patient receive concurrent chemotherapy? Yes No
5.
Do you plan to use IGRT? Yes No
6. Note any additional information in the space below.
Prostate Cancer Radiation Therapy Physician Worksheet (As of 31 December 2014)
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
Me
mb
er
Patient First Name: Patient Last Name:
DOB: Member ID: Group #: Health Plan:
Address: City: ST: Zip:
Ph
ys
icia
n
Physician First Name: Physician Last Name:
Primary Specialty: NPI: Tax ID:
Address: City: ST: Zip:
Phone #: Fax #: Contact Email:
Fa
cil
ity
Facility Name: Facility Tax ID:
Address: City: ST: Zip:
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:
Sig
na
ture
Check the appropriate box describing you: Ordering Physician Facility Other: ____________________________
Sign and Date Below:
Print Name:______________________________________________
Sign Name: ______________________________________________ MD RN LPN PA NP
Other
Prostate Cancer Radiation Therapy Physician Worksheet (As of 31 December 2014)
730 COOL SPRINGS BLVD. SUITE 800 • FRANKLIN, TN 37067 • PH: 888.693.3211 • FX: 877.791.4110 • www.CareCoreNational.com • www.MedSolutions.com
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
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. 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
Continued on next page
Prostate Cancer Radiation Therapy Physician Worksheet (As of 31 December 2014)
730 COOL SPRINGS BLVD. SUITE 800 • FRANKLIN, TN 37067 • PH: 888.693.3211 • FX: 877.791.4110 • www.CareCoreNational.com • www.MedSolutions.com
9. What is the treatment plan?
External beam radiation therapy (EBRT)
Brachytherapy
EBRT and Brachytherapy
10. If EBRT is included in the treatment plan, then answer the following set of questions:
a. What is the EBRT technique?
Proton beam therapy
Stereotactic body radiation therapy (SBRT)
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: _________
Continued on next page
Prostate Cancer Radiation Therapy Physician Worksheet (As of 31 December 2014)
730 COOL SPRINGS BLVD. SUITE 800 • FRANKLIN, TN 37067 • PH: 888.693.3211 • FX: 877.791.4110 • www.CareCoreNational.com • www.MedSolutions.com
11. If brachytherapy is included in the treatment plan, then answer the following set of questions:
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)
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
Me
mb
er
Patient First Name: Patient Last Name:
DOB: Member ID: Group #: Health Plan:
Address: City: ST: Zip:
Ph
ys
icia
n
Physician First Name: Physician Last Name:
Primary Specialty: NPI: Tax ID:
Address: City: ST: Zip:
Phone #: Fax #: Contact Email:
Fa
cil
ity
Facility Name: Facility Tax ID:
Address: City: ST: Zip:
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:
Sig
na
ture
Check the appropriate box describing you: Ordering Physician Facility Other: ____________________________
Sign and Date Below:
Print Name:______________________________________________
Sign Name: ______________________________________________ MD RN LPN PA NP
Other
Skin Cancer Radiation Therapy Physician Worksheet (As of 10 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
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?
External beam radiation therapy (EBRT)
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,
conformal beams, DVHs, DRRs)
Intensity modulated radiation therapy (IMRT)
Rotational arc therapy
Stereotactic body radiation therapy (SBRT)
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: ___________
Continued on next page
Skin Cancer Radiation Therapy Physician Worksheet (As of 10 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
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: ________________
7. Will IGRT be used? Yes No
8. Note any additional information in the space below:
Please be advised treatment of multiple sites is considered concurrent treatment
Small Cell Lung Cancer Radiation Therapy Physician Worksheet (As of 10 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
Me
mb
er
Patient First Name: Patient Last Name:
DOB: Member ID: Group #: Health Plan:
Address: City: ST: Zip:
Ph
ys
icia
n
Physician First Name: Physician Last Name:
Primary Specialty: NPI: Tax ID:
Address: City: ST: Zip:
Phone #: Fax #: Contact Email:
Fa
cil
ity
Facility Name: Facility Tax ID:
Address: City: ST: Zip:
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:
Sig
na
ture
Check the appropriate box describing you: Ordering Physician Facility Other: ____________________________
Sign and Date Below:
Print Name:______________________________________________
Sign Name: ______________________________________________ MD RN LPN PA NP
Other
Small Cell Lung Cancer Radiation Therapy Physician Worksheet (As of 10 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
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
If treatment is not being directed to the primary site, submit a request for the metastatic site
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
5. a. What is the treatment intent?
Definitive
Palliation
b. If palliation is the treatment intent, what technique will be utilized for palliation?
External beam radiation therapy (EBRT)
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: _________
Continued on next page
Small Cell Lung Cancer Radiation Therapy Physician Worksheet (As of 10 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
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?
Select a technique for each applicable phase, and fill in the number of fractions.
Phase 1 Phase 2 Phase 3
Complex (77307)
Complex (77307)
Complex (77307)
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)
Tomotherapy Tomotherapy Tomotherapy
Rotational arc therapy Rotational arc therapy Rotational arc therapy
Proton beam therapy Proton beam therapy Proton beam therapy
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
11. Will IGRT be used? Yes No
12. Note any additional information in the space below:
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