Spinal Fusion 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:
| Legible handwritten physician and/or clinician signatures |
| Valid electronic physician and/or clinician signatures |
|Physician or Non-Physician Practitioner (NPP) order(s) for the date of service (including admission order, if applicable)|
|Physician certification of medical necessity of admission, if applicable|
|Legible procedure note or report that includes sufficient detail to allow reconstruction of the procedure|
| Records of patient's condition before, during and after this billing period to support medical necessity and the reason the service was provided |
| Initial pre-procedural evaluation and/or the history and appropriately focused musculoskeletal physical examination including: |
| Documentation supporting unsuccessful and reasonable attempt at conservative therapy (non-surgical medical management), if appropriate. Examples include, but are not limited to: |
| Pre-procedure radiological reports and other pertinent diagnostic test results to support need/medical necessity for procedure |
|Medication Administration Records (MAR)|
|Observation orders and daily progress notes, if applicable|
| Rehabilitation records: |
|Disposition/discharge notes/hospital discharge summary|
|Full detailed itemized bill indicating revenue code|
|Coding query form, if applicable|
|Quality Improvement Organization (QIO) letter, if applicable|
|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|
|Advance Beneficiary Notice of Noncoverage (ABN), if 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.
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. To review situations that may arise where a spinal fusion is approved without conservative treatment being clearly documented, see "Documentation Errors" section of the SPINAL FUSION Services: Documentation Requirements Coverage Article.
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.