Preventive Services Documentation Requirements - JE Part A
Preventive Services 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:
- Signature logs and Signature Attestation Statement should be submitted when physician and/or clinician signatures are illegible
- If an electronic health record is used, the Electronic Order Signature Process Form should be submitted to verify provider's Electronic Ordering System is secure
- If the order for the preventive test is unsigned, there must be medical documentation (e.g. a progress note) by the treating physician that he/she intended the preventive test to be performed
- Documentation showing the intent that the test be performed must be authenticated by the author via a handwritten or electronic signature
- Anesthesia records, if applicable
- Recovery room records, if applicable
- Medication administration records, if applicable
- Most recent history and physical and/or physician clinic/progress notes pertaining to diagnosis/reason the service was completed
- Nurse notes, consultation reports, emergency room records, disposition/discharge reports and all other pertinent medical records as 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.
- Noridian Medical Review - Additional Documentation Request (ADR)
- Comprehensive Error Rate Testing (CERT) - CID Request
- Level One Appeal - Redetermination Request
View the Preventive Services 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.
