Transcription
Radiation Therapy ChecklistThe Eviti online treatment plan requires the following information.Patient Name:DOB:Insurance Plan:Insurance ID:Patient ZIP Code:Date of Diagnosis:Physician Name:Male / FemalePractice Tax ID:Physician NPI:Submitter Contact Name:Phone: Fax: Email:Patient Treatment DetailsCancer Type (site): ICD-10 Code:Pathology:Current Stage of Disease: (e.g. Stage IIa, Recurrent)If applicable:Metastasis Site(s):Metastasis Dx. Date:Line of Therapy: (circle one)NeoadjuvantAdjuvantGoal of Treatment/Intent: (circle one)CurativeNon-Curative/PalliativeIs this a clinical trial?Clinical trial ID or name:Site of service: (circle one)Yes / NoDefinitive PalliativeInpatient / OutpatientSite name:Site city or ZIP Code:Confidentiality Statement: The documents accompanying this transmission contain confidential health information that is legallyprivileged. This information is intended only for the use of the individual(s) or entities listed above. If you are not the intended recipient,you are hereby notified that any disclosure, copying, distribution, or action taken in reliance on the contents of these documents is strictlyprohibited. If you receive this information in error, please notify the sender immediately and arrange for the return or destruction ofthese documents.
Radiation Target site(s):Treatment Start Date:Particle: (circle one)Photons / Electrons / Photon/Electron / Protons / NeutronsEnergy:MV or MeVTotal XRT dose: (do not include boost) GyNumber of fractions:Radiation Delivery Technique (select one):Simple Intermediate ComplexIntensity Modulated Radiation - IMRTStereotactic Radiosurgery (CPT-77372)Stereotactic Body Radiotherapy (CPT-77373, GO339, GO340)Superficial/OrthovoltageIs image guided (IGRT) or intrafraction tracking being prescribed?Yes No(Please note: IGRT is generally not necessary for 3D conformal radiation and will require patient specificrationale for authorization. If unsure please check with MD before circling yes, as an incorrect answermay affect authorization)Is Radiation Therapy Boost Planned: YesNoBoost Site(s):Particle: (circle one)Photons ElectronsEnergy: MV or MeVPhoton/Electron ProtonsBoost Dose: GyNeutronsNumber of Fractions:Radiation Delivery Technique (circle one):SimpleIntermediateComplexIs image guided (IGRT) or intrafraction tracking being prescribed?IMRTYesNo(Please note: IGRT is generally not necessary for 3D conformal radiation and will require patient specificrationale for authorization. If unsure, please check with MD before circling yes as an incorrect answermay affect authorization)Required information if Brachytherapy selected as Method of Delivery for Treatment or BoostFOR LDR selection - complete the following:Route: infusion /instillation of element Interstitial Intracavitary SurfaceDelivery Technique:SimpleIntermediateComplexConfidentiality Statement: The documents accompanying this transmission contain confidential health information that is legallyprivileged. This information is intended only for the use of the individual(s) or entities listed above. If you are not the intended recipient,you are hereby notified that any disclosure, copying, distribution, or action taken in reliance on the contents of these documents is strictlyprohibited. If you receive this information in error, please notify the sender immediately and arrange for the return or destruction ofthese documents.
Number of Fractions:Total Dose: GyNumber of sources per fraction:Isotopes: (Select isotope from list below)Cesium-131, non-stranded, per source – C2643Cesium-131, stranded, per source - C2642Gold-198, non-stranded, per source- C1716Iodine-125 high activity, greater than 1.01 mCI (NIST), non-stranded, per source- C2634Iodine-125 non stranded, per source - C2639Iodine-125 stranded, per source - C2638Iodine-125 sodium iodide solution, therapeutic, per millicurie- A9527Iridium-192, non-high dose rate, non-stranded, per source-C1719Not otherwise specified, non-stranded, per source - C2699Not otherwise specified, stranded, per source - C2698Palladium -103, high activity, greater than 2.2.mCi (NIST), non-stranded per source - C2635Palladium-103 non-stranded, per 1mm - C2636Palladium-103 non-stranded, per source - C2641Palladium-103 stranded, per source - C2640Yttrium-90, non-stranded, per source - C2616FOR HDR selection – complete the following:Number of Channels: Number of Fractions:Total Dose: Gy Number of sources per fraction:Iridium – 192, high dose rate, non-stranded, per source – C1717FOR HDRE selection – complete the following:Number of fractions: Total Dose: GyConfidentiality Statement: The documents accompanying this transmission contain confidential health information that is legallyprivileged. This information is intended only for the use of the individual(s) or entities listed above. If you are not the intended recipient,you are hereby notified that any disclosure, copying, distribution, or action taken in reliance on the contents of these documents is strictlyprohibited. If you receive this information in error, please notify the sender immediately and arrange for the return or destruction ofthese documents.
Please circle requested onsBrachytherapyBrachytherapyExternal Beam RTExternal Beam RTExternal Beam RTExternal Beam RTExternal Beam RTExternal Beam RTExternal Beam RTExternal Beam RTExternal Beam RTExternal Beam RTExternal Beam RTExternal Beam RTExternal Beam RTExternal Beam RTExternal Beam RTExternal Beam RTExternal Beam ytherapyBrachytherapyBrachytherapyExternal Beam RTExternal Beam RTExternal Beam RTExternal Beam RTExternal Beam RTExternal Beam RTExternal Beam RTExternal Beam RTExternal Beam RTExternal Beam RTExternal Beam RTExternal Beam RTExternal Beam RTGamma KnifeStereotactic RadioSurgery (SRS) (single fraction) BrainStereotactic Body Radiotherapy (SBRT or SABR) all fractionsIMRT SimpleIMRT ingle Port with No/Simple BlockingComplexIntraoperative Radiation Therapy (IORT): X-rayIntraoperative Radiation Therapy (IORT): ElectronSimpleSimple with mplexcomplexcomplexIntensity Modulated (IMRT)Compensator-based IMRTConfidentiality Statement: The documents accompanying this transmission contain confidential health information that is legallyprivileged. This information is intended only for the use of the individual(s) or entities listed above. If you are not the intended recipient,you are hereby notified that any disclosure, copying, distribution, or action taken in reliance on the contents of these documents is strictlyprohibited. If you receive this information in error, please notify the sender immediately and arrange for the return or destruction ofthese documents.
Other CPTs related to Treatments and Account for in 17Port FilmsIf you do not receive an automated Eviti code, the request goes to Eviti for review. Please attach the followingdocuments to the online treatment plan: RT consult Rx or completed RT checklist Pathology Scans if relative to treatmentIf you don’t attach the documents online, you can email them to mr@eviti.com or fax them to 888-468-1423.If faxing, please use the Eviti-generated QR coded cover sheet.Confidentiality Statement: The documents accompanying this transmission contain confidential health information that is legallyprivileged. This information is intended only for the use of the individual(s) or entities listed above. If you are not the intended recipient,you are hereby notified that any disclosure, copying, distribution, or action taken in reliance on the contents of these documents is strictlyprohibited. If you receive this information in error, please notify the sender immediately and arrange for the return or destruction ofthese documents.
77424 Photons External Beam RT Intraoperative Radiation Therapy (IORT): X-ray 77425 Electrons External Beam RT Intraoperative Radiation Therapy (IORT): Electron 77520 Protons External Beam RT Simple 77522 Protons External Beam RT Simple with compensation 77523 Protons External Beam RT Intermediate .
