Sleep Medicine Documentation Requirements

Polysomnography

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
  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.

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 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.