Sleep Medicine 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:
|Correct Beneficiary and Date of Service|
|Credentials of the physician interpreting the test results, the technician and the facility|
|Physician or Non-Physician Practitioner (NPP) Order and Intent (*Note intent [i.e. progress notes] should be properly authenticated by ordering provider)|
|Relevant and/or current records from physician's office, e.g., office notes, history and physical, labs, etc. as supporting documentation of medical necessity for service provided|
|Evidence of conservative measures, if applicable|
|Procedure notes and results for the service(s) rendered|
|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|
|Documentation contains valid signature of Physician (legible and complete)|
|Advance Beneficiary Notice of Noncoverage (ABN), if applicable|
|Completed Noridian Part A Signature Attestation Statement or Signature Log for illegible signature, if applicable. Access Forms.|
Multiple CMS contractors are charged with completing reviews of medical records. See the Who Reviewed My Claim webpage 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 Sleep Medicine 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.