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Documentation Requirements

The following list may be used as reference guides, when submitting documentation to Medicare. Each charge on a claim should be supported with the following:
  • Documentation and Coding that Demonstrates Medical Necessity
  • Documentation proving the service/procedure was performed

NEW! Watch the below list continue to expand as updates are made. 

Documentation Requirements webpages will not be created for every possible situation or provider type.

Provider Type/Topic Specific Requirements

Additional General Requirements

Last Updated Apr 21, 2017

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. 

Last Updated Apr 06, 2016