Dental 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:

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Brief Description
Office/progress notes supporting the reason for items/services rendered. Examples: dental exam, radiographic imaging results, treatment plan.
If associated with a primary medical service-including office/progress notes supporting connection with primary medical service. Examples: consultation notes referral form, medical records from coordinating medical provider
If procedural/surgical, the operative report records describing the type of services performed including which dental structures. Documentation of tooth (teeth) treated using standard identification, tooth surface treated (if appropriate) and missing teeth documented.
Diagnostic/other tests and results
Copies of articles from peer-reviewed medical journals supporting the clinical utility of the service and/or association with primary medical service
Signature and credentials of all personnel providing services. Include a signature log or signature attestation for any missing or illegible signatures within the medical record.
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 it to the appropriate contractor according to the request received. Select the request below to view the appropriate submission instructions.

View the Dental webpage for additional information and resources.

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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.