Preventive Services Documentation Requirements - JE Part B
Preventive Services Documentation Requirements
It is expected that patient's medical records reflect the need for care/services provided. The listing of records is not all inclusive. Providers must ensure all necessary records are submitted to support services rendered. They may include:
Initial Preventive Physical Examination (IPPE)
| Check box if submitted | Brief Description |
|---|---|
| Correct Beneficiary and Date of Service | |
| Office and/or progress notes detailing elements listed below | |
| Beneficiary's medical, family and social history | |
| Beneficiary's potential risk factors for depression, including current or past experiences with depression or other mood disorders | |
| Beneficiary's functional ability and level of safety | |
| Physical Assessment – Height, weight, body mass index and blood pressure; visual acuity screen; other factors as deemed appropriate based on medical, family and social history and current clinical standards | |
| End-of-life planning, on agreement of the beneficiary | |
| Educate, counsel and refer based on previous 5 components of medical, family and social history; potential risk factors for depression and other mood disorders; functional ability and level of safety; exam; and end-of-life planning | |
| Educate, counsel and refer for other preventive services – Brief written plan for other appropriate screenings | |
| Advance Beneficiary Notice of Noncoverage (ABN), if applicable | |
| Completed Noridian Part B Signature Attestation Statement or Signature Log for illegible signature, if applicable |
Annual Wellness Visit (AWV)
| Check | Brief Description |
|---|---|
| Correct Beneficiary and Date of Service | |
| Exam Details | |
| Office and/or progress notes detailing elements listed below | |
| Health Risk Assessment (HRA) – Demographic data; Self-assessment of health status; Psychosocial risks; Behavioral risks; Activities of Daily Living (ADLs), including, but not limited to: dressing, bathing, and walking; and Instrumental ADLs, including, but not limited to: shopping, housekeeping, managing own medications, and handling finances | |
| List of beneficiary current providers and suppliers | |
| Beneficiary medical, family and social history | |
| Beneficiary potential risk factors for depression, including current or past experiences with depression or other mood disorders | |
| Beneficiary functional ability and level of safety | |
| Beneficiary Physical Assessment - Height, weight, body mass index (or waist circumference, if appropriate), blood pressure and other routine measurements as deemed appropriate based on medical and family history | |
| Beneficiary cognitive impairments, if applicable | |
| Beneficiary's written screening schedule, such as a checklist for next 5 to 10 years, as appropriate | |
| List of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or underway for beneficiary | |
| Personalized health advice to beneficiary and a referral, as appropriate, to health education or preventive counseling services or programs | |
| Advance Beneficiary Notice of Noncoverage (ABN), if applicable | |
| Completed Noridian Part B Signature Attestation Statement or Signature Log for illegible signature, if applicable |
Multiple CMS contractors are charged with completing reviews of medical records. See Identifying Which Entity Completed a Part B Claim Review for detailed information about each of these contractors.
Documentation Submission
Once a provider compiles all the necessary documentation, it is important to submit them to the appropriate contractor according to the request received. Select the request below to view the appropriate submission instructions.
- Noridian Medical Review - Automated Development System (ADS) Letter
- Comprehensive Error Rate Testing (CERT) - CID Request
- Level One Appeal - Redetermination Request
View the Preventive Services webpage for more information and resources.
Documentation Requirements Disclaimer
The documentation requirements contents/references provided within this section were prepared as educational tools and are not intended to grant rights or impose obligations. Use of these documents are not intended to take the place of either written law or regulations.
The listing of records is not all inclusive. Providers must ensure all necessary records are submitted to support services rendered.
Important that physician intent, physician decision and physician recommendation to provide services derived clearly from the medical record and properly authenticated.
The submission of these records shall not guarantee payment as all applicable coverage requirements must be met.
