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:
Beneficiary identification, date of service, and provider of the service should be clearly identified on each page of the submitted documentation
Practitioner, nurse, and ancillary progress notes
Physician/non physician (NPP) order or evidence of intent to order
Beneficiary's medical records (which may include practitioner medical records, hospital records, nursing home records, home care nursing notes, physical/occupational therapy notes) that support the item(s) provided is/are reasonable and necessary
Medical documentation detailing prior course of treatment, including all interventions and/or evaluations
Current adjunctive treatment
Operative/procedure report
Records of conservative measures trialed for treatment of service provided
Full text peer reviewed articles
Full itemization of services
Documentation supporting the diagnosis code(s) required for the item(s) billed
Documentation to support the code(s) and modifier(s) billed
List of all non-standard abbreviations or acronyms used, including definitions
Any other supporting/pertinent documentation
Documentation to support national coverage determination (NCD), local coverage determination (LCD) and/or policy article
Signatures are required for medical review for the following purposes: 1) to satisfy specific signature requirements in statute, regulation, national coverage determination (NCD) or local coverage determination (LCD); and 2) to resolve authenticity concerns related to legitimacy of falsity of the documentation
If an electronic health record is utilized, include your facility's process of how the electronic signature is created. Include an example of how the electronic signature displays once signed by the physician.
Advance Beneficiary Notice of Non-coverage (ABN)/notice of Medicare non-coverage (NOMNC)
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/supplier 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 Amniotic and Placental-Derived Product LCD webpage for additional information and resources.
