Drugs, Biologicals and Injections Documentation Requirements

Chemotherapy Administration

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:

Check Brief Description
  Legible handwritten physician and/or clinician signatures
  Valid electronic physician and/or clinician signatures
  Physician or Non-Physician Practitioner (NPP) order for date(s) of service the medication(s) was administered, including name of the medication, dose, route of administration and frequency
  Medication Administration Record (MAR) from date(s) of service that include name of the medication(s), dose, route of administration and infusion start and stop times, if applicable
  Records of patient's condition before, during and after this billing period to support medical necessity and reason for medication administration
  • Most recent physician clinic/ER/progress notes pertaining to diagnosis/reason for medication administration
  • Nurse notes related to administration of medication(s)
  • Listing of most current patient medications if applicable
  Diagnostic test results/reports, including imaging and/or laboratory reports, including those prior to claim date(s) of service if related, to support medical necessity and reason for medication administration, if applicable
  • When no official imaging report is available, the following components must be present within medical records: date(s) imaging was completed, type(s) of imaging/exam and detailed findings
  Documentation to support a covered diagnosis as indicated in Chemotherapy Administration Medicare Coverage Article
  Procedure/operative/anesthesia report, if applicable
  Office visit and/or evaluation and management (E&M) documentation if billed on same date(s) of service under medical review
  Documentation to support indications and/or criteria as specified in Local Coverage Determinations (LCDs), National Coverage Determinations (NCDs) or coverage article for service(s) billed, if applicable
  Advance Beneficiary Notice of Noncoverage (ABN), if applicable

Multiple CMS contractors are charged with completing reviews of medical records. See Identifying Which Entity Completed a Part A 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.

View the Drugs, Biologicals, and Injections webpage for additional information and resources.

Drug Administration

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:

Check Brief Description
 

Legible handwritten physician and/or clinician signatures

 

Valid electronic physician and/or clinician signatures

  • If an Electronic Health Record (EHR) is used, the Electronic Order Signature Process [PDF] should be submitted to verify provider's Electronic Ordering System is secure
 

Physician or Non-Physician Practitioner (NPP) order for date of service medication(s) was administered including dose, route of administration and frequency

 

Medication administration records from date of service that include a dose and route given

  • Documentation support amount of medication wasted if billing with a JW modifier
 

Records of patient's condition before, during and after this billing period to support medical necessity and reason the service was provided

  • Most recent physician clinic/progress notes pertaining to diagnosis/reason medication is being given
  • Nurse notes related to the administration of the medication
  • Listing of most current patient medications if applicable
 

Diagnostic test results/reports, including imaging and/or laboratory reports, including those prior to claim date(s) of service if related, to support medical necessity and reason drug was administered

  • When no official imaging report is available, the following components must be present within medical records: date(s) imaging was completed, type(s) of imaging/exam, and detailed findings
 

If dosage for drug under review is outside allowed amount per drug compendium, submit documentation to support medical necessity of this dose variance (e.g.clinical trial, article, studies, etc.)

 

Office visit and/or evaluation and management (E&M) documentation, if billed on same date(s) of service under medical review

 

Documentation to support indications and/or criteria as specified in Local Coverage Determinations (LCDs), National Coverage Determinations (NCDs), or coverage article for service(s) billed, if applicable

 

Advance Beneficiary Notice of Noncoverage (ABN), if applicable

 

Multiple CMS contractors are charged with completing reviews of medical records. See Identifying Which Entity Completed a Part A 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.

Facet Injection

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:

Check Brief Description
  Legible handwritten physician and/or clinician signatures
  Valid electronic physician and/or clinician signatures
  • If an Electronic Health Record (EHR) is used, the Electronic Order Signature Process [PDF] should be submitted to verify provider's Electronic Ordering System is secure
  Physician or Non-Physician Practitioner (NPP) order for date of service, if applicable
  Legible procedure note that includes sufficient detail to allow reconstruction of procedure
  Medication Administration Record (MAR) to support total contrast, anesthetic and/or steroid volumes injected into facet joint or medial branch (MB) nerve area
  Documentation supporting pre and/or post procedural pain assessments
  Records of patient's condition before, during and after this billing period to support medical necessity and reason service was provided
  • Initial pre-procedural evaluation and/or history and appropriately focused musculoskeletal physical examination
  • History of at least three months of moderate to severe pain with functional impairment
  • Conservative measures trialed and effectiveness of those measures
  Clinical assessment and/or diagnostic imaging reports implicating facet joint as putative source of pain
  • Documentation to support pain is primarily axial and/or not associated with radiculopathy and/or neurogenic claudication
  • Documentation to support no non-facet pathology is present that could explain source of pain
  Documentation to support a covered diagnosis as indicated in Facet Joint Injections, Medial Branch Blocks, and Facet Joint Radiofrequency Neurotomy Local Coverage Determination (LCD)
  Office visit and/or evaluation and management (E&M) documentation, if billed on same date(s) of service under medical review
  Documentation to support indications and/or criteria as specified in LCDs, National Coverage Determinations (NCDs) or coverage article for service(s) billed, if applicable
  Advance Beneficiary Notice of Noncoverage (ABN), if applicable

 

Multiple CMS contractors are charged with completing reviews of medical records. See Identifying Which Entity Completed a Part A 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.

View the Drugs, Biologicals and Injections webpage for additional information and resources.

Last Updated Feb 08, 2019

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.