Blepharoplasty / Visual Fields 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:

Check Brief Description
  Documentation supporting a comprehensive eye exam
  Comprehensive preoperative ophthalmologic evaluation including but not limited to examination/testing, best corrected Snellen visual acuity and corrected vision with glasses or contacts
  All Visual Field Testing
  Visual field measurement / documentation
  Visual Fields Studies
  Photographs showing visual impairment
  Diagnostic Studies, including visual acuity and glare tests
  Visual fields report (Taped and untapped)
  Operative / procedure report
  Beneficiary name and date of service on all documentation
  Documentation as required in LCD or NCD
  Any additional documentation to support the reasonable necessity of the service(s) performed
  Advance Beneficiary Notice
  Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services)
  Signature attestation and credentials of all personnel providing services
  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


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.


Last Updated Wed, 08 Jul 2020 20:49:03 +0000