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
Physician/Non Physician Practitioner (NPP) order
Physician Certification or Physician Certification Statement (PCS)
Practitioner, nurse, and ancillary progress notes
  • Consultation notes
  • Treatment records
Physician consultations
Diagnostic tests, radiological reports, lab results, pathology reports, and other pertinent test results and interpretations, if applicable
Discharge Summary from Hospital
Emergency Room Records, if applicable
Operative/procedure report, if applicable
History and Physical reports (include medical history and current list of medications)
Medication Administration Record (MAR) and/or Infusion Flowsheet documenting the quantity administered include a dose, route, and frequency given
Beneficiary's medical records
  • Support for diagnosis codes billed
  • Support for medical necessity
Coding query form, if applicable
Quality Improvement Organization (QIO) letter, if applicable
Itemization of services
Advance Beneficiary Notice
Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services)
Facility process of how electronic signature is created if using electronic health record

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 May 15 , 2024

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.