Inpatient Prospective Payment System (PPS) Hospital 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:

Check Brief Description
  Legible handwritten physician and/or clinician signatures
  Valid electronic physician and/or clinician signatures
  Physician or Non-Physician Practitioner (NPP) order(s) for date of service including admission order
  Physician certification of medical necessity of admission
  Records of patient's condition before, during and after this billing period to support medical necessity and reason service was provided
  • Emergency room records
  • Hospital history and physical
  • Nurses notes
  • Physician progress notes
  • Operative reports
  • Treatment records
  • Consultation reports
  Observation orders and daily progress notes, if applicable
  Disposition/discharge notes/hospital discharge summary
  Radiological reports and other pertinent diagnostic test results to support need/medical necessity for procedure, if applicable
  Medication Administration Record (MAR)
  Lab/pathology report(s)
  Rehabilitation records
  Full detailed itemized bill indicating revenue code
  Coding query form, if applicable
  Quality Improvement Organization (QIO) letter, if applicable
  Itemized services billed on CMS UB-04 Claim Form
  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 Acute Inpatient Prospective Payment System (PPS) Hospital 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.