Radiation Oncology Electronic Medical Records and Documentation

Electronic Medical Record of prostate cancer using MOSAIQ as an example.
The above EMR illustrates numerous opportunities of documentation for use in medical necessity and the appeals process to payers. The image represents a prostate with multiple treatment fields that create opportunities in billing for calculations and treatment devices. Each of the referenced areas requires a radiation oncologist’s signature and approval.


Electronic Medical Records may help to reduce errors by utilizing the available tools and system functionality. However, if the beginning process is incorrect, errors can and will occur. The initial creation of an electronic template is a crucial time. Take time to ensure that everything is correct before implementation. We highly recommend that you visit cms.gov to search for local coverage determinations (LCD). As you may know, LCDs are rules from Medicare for your particular specialty and type of treatment delivery. For example, the local coverage determination provides a list of covered and non-covered diagnoses per treatment modality.

When documenting, we all strive to provide supporting documentation for each process. In doing so, sometimes we fail at the basic requirements. We understand the importance of detailing each step. We list imaging via stereoscopic guidance or cone-beam CT, for use in IMRT. In brachytherapy, we mention number of catheters, needles, and type of radioactive source. We document special requests such as special treatment procedures or special physics consultations. We document data service, number of units, and patient names as basics. Especially in the age of Electronic Medical Records, it’s best to go back to basics and review our documentation comprehensively.

Questions to Consider when Creating Accurate Documentation
  1. Has the physician clearly documented medical necessity?
  2. Does the Electronic Medical Record clearly state the date of service?
  3. Have we accurately identified the number of units, applicable CPT® codes, and the corresponding diagnosis ICD-10 codes?
  4. Does the document allow for required elements for the corresponding procedure?
  5. Does the document include the required components for an electronic approval or signature?

Best practices recommend utilizing a standard format when developing electronic forms and templates to ensure required elements such as dates, patient identifiers, and electronic approvals are consistent for all users and procedures. It is further recommended to gauge accurate use and completion of the documentation once the document has been implemented. Timely identification and correction of documentation issues may prove to be beneficial in the event of a payer review. They could provide improvements in the quality of documentation available for other providers and clinicians.  Keep in mind that any and all documentation may be utilized in the appeals process to payers to overturn denials for payment.

How Revenue Cycle Coding Strategies Can Help

RCCS recommends a Medical Record Review to ensure the required documentation and the electronic medical record supports every billed service. Our consultants are experts at specialty coding in the areas of radiation oncology, medical oncology, radiology, interventional radiology, surgery, cardiology, and more. Additionally, our team is able to easily maneuver radiation EMRs in ARIA® or MOSAIQ® and interfaced to EHRs housed in EPIC, CERNER, and more.

Want more specialized guidance from the experts? Browse RCCS’s services and outsourcing options for charge capture in radiation oncology as well as outsourced coding with Coding+. to see how consulting, training and coding by industry insiders can impact your organization. In addition, CEU-certified webinars and online training, and specialty-specific Navigators® are available at the RCCS store.

A collection of educational resources covering radiology, medical oncology, radiation oncology, online tutorials, and other educational materials to gain CEUs. 

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