If you are new to radiation oncology, the process of care, CPT code reporting, and documentation requirements can be overwhelming. Patients who receive radiation therapy typically follow a general process of care beginning with an initial visit with the radiation oncologist. If it is determined that radiation therapy is appropriate for the patient, the process concludes with the patient receiving treatment with follow-up care.

But what takes place between the initial visit and treatment of the patient?

The process of care includes several steps that are required to ensure safe and effective treatment is furnished to the patient.

The process of care can be generalized into seven separate steps:

  1. E/M: Evaluation service before a treatment decision is made
  2. Clinical Treatment Planning: Outlines the clinical and technical details of the patient’s radiation therapy
  3. Simulation: Process of determining patient positioning and acquiring appropriate imaging and data necessary to develop the radiation treatment
  4. Dosimetry planning: Planning to determine the prescribed dose of treatment with care to the surrounding normal tissue
  5. Verification or IGRT: Verification is a “dry-run” process prior to treatment delivery
  6. Treatment Delivery: Delivery of radiation therapy
  7. Physics & Treatment Management: Physics-Ongoing review of patient chart, documented assessment of the patient’s treatment chart; treatment management- the radiation oncologist’s management of the patient’s progress, side effects and response to treatment

There may be several reportable codes at each step of the process with professional and/or technical reporting for each CPT code.

If your curiosity concerning the radiation oncology process of care is piqued, be sure to check out the Introducing Radiology Oncology, CPT Coding for Radiation Therapy Part 1 webinar.

Looking for additional information on this topic?

Tamara Jones, RHIT, CPC, CPMA, CRC

Tamara Jones, RHIT, CPC, CPMA, CRC

Senior Coding Quality Auditor

Tamara brings over 15 years to Haugen’s team of Coding Quality Auditors & educators. She began her career as a denials specialist, instilling the importance of accuracy from the start! Tamara has a very investigative, analytical mindset which guided her through the roles as claims and coding managers, finding her fit as an auditor. Tamara enjoys reviewing coding assignments, digging into the clinical documentation, and working with clients to share opportunities for improvement. She has identified opportunities for clients to improve clinical documentation, identify deficiencies in processes or guidelines, and provide education to help their staff excel!


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