IPPS Hospital Documentation Requirements - JE Part A
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
| |
| 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
| |
| 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.
- 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.
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.
