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Evaluation and Management Documentation Requirements

It is expected that patient's medical records reflect the need for care/services provided. Such records are not routinely submitted; however, they must be available upon request. They shall include:


Brief Description


Correct Beneficiary and Date of Service


Office and/or progress notes - Emergency Room (ER) records, Order for admission, Hospital History & Physical, Consultation reports, Notes supporting any invasive procedures, Disposition/discharge notes


Diagnostic test results - Lab/pathology reports, Imaging reports, Electrocardiogram (EKG) reports/tracings


Procedure reports


Physician orders and intent*


Time based codes - Send documentation to support this time and time frame. Examples: Critical Care, prolonged service codes, or any E/M codes billed with counseling and/or coordination of care dominating more than 50 percent of visit


Exam details


Legible signature (handwritten or electronic)


Signature validation (includes electronic)


Completed Noridian Part B Signature Attestation Statement [PDF] or Signature Log for illegible signature, if applicable


*It is important that the physician intent, physician decision, and physician recommendation to provide services is derived clearly from the medical record and properly authenticated.

Multiple CMS contractors are charged with completing reviews of medical records. See Identifying Which Entity Completed a Part B 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.

View the Evaluation and Management (E/M) webpage for more information and resources. 

Last Updated Apr 06, 2016

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.


Last Updated Aug 08, 2017