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:
| 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 |
|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)|
|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.
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: Additional Documentation Request (ADR)
- Comprehensive Error Rate Testing (CERT): CID Request
- Level One Appeal: Redetermination Request
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.