Stereotactic Body Radiation Therapy

Insufficient documentation means that something was missing from the medical records. Below are the most common reasons CERT determined there was insufficient documentation that caused improper payments for stereotactic body radiation therapy (SBRT): 

• Authenticated stereotactic body radiation therapy treatment plan including the dosimetry and prescription.
• Authenticated stereotactic body radiation therapy delivery flowsheet/note.

Documentation Requirements

• The patient’s medical records must support the medical necessity and frequency of treatment. The medical record must clearly indicate the critical nature of the anatomy or other circumstances necessitating the services, the patient's functional status and a description of current performance status (Karnofsky Performance Status).
• Treatment date and the current treatment dose.
• The signed SBRT treatment plan.
• The signed SBRT delivery flowsheet/note.

Related Content

• Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-02, Medicare Benefit Policy Manual, Chapter 6,Section 20.5 – Outpatient Therapeutic Services
• Local Coverage Determination (L35076) Stereotactic Radiation Therapy: StereotacticServices (SRS) and Stereotactic Body Radiation Therapy (SBRT)