This page addresses follow-up questions and additional information pertinent to our webinar
ICD-10-CM Stroke Coding: The Why Behind the Codes.
** The coding information and guidance are valid at the time of publishing. Learners are encouraged to research
subsequent official guidance in the areas associated with the topic as they can change rapidly.

Q: What documentation must be captured within the medical record?
A: The main purpose of the medical record is to ensure the patient receives medically necessary care; this includes from a clinical perspective documentation of the diagnosis, staging, imaging studies/tests required, the treatment regimen, and needed procedures. Additionally, the documentation must support payer documentation requirements as authoritative entities and payers have established documentation guidelines and requirements to support billing and potential reimbursement.

Q: If a nurse practitioner performs and documents the weekly exam during a radiation treatment management encounter, and the radiation oncologist’s attestation notes review of the APP note and agreement with the AAP documentation, can the radiation oncologist bill for the service if they are present during the encounter?
A: The split/shared visit concept does not apply to the weekly treatment management encounters. An APP cannot bill for radiation treatment management, and the radiation oncologist can only bill for services performed by the radiation oncologist. Radiation treatment management requires a minimum of one examination of the patient by the physician in addition to medical evaluation and management per each reported unit of CPT 77427. The physician also performs other cognitive and technical activities. Overall, these functions support the physician’s continual assessment of the patient.
https://www.astro.org/Daily-Practice/Coding/Coding-Guidance/Coding-FAQ-39;s-and-Tips/FAQ-Treatment-Management

Q: Will a time-out verification check-box form signed by both the radiation therapist and radiation oncologist indicating correct treatment site/body area, correct laterality/side, correct position/special equipment, and image approval along with the simulation parameters meet the physician documentation requirements for simulation services?
A: The dated and time stamped signature by the radiation oncologist on the form establishes physician presence during the procedure. Best practice is for the physician to include an attestation statement describing activities directly performed by the radiation oncologist during the procedure.

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