EM Documentation Requirements - JE Part B
Evaluation and Management Documentation Requirements
This checklist applies to the following E&M services:
- Complex/Chronic Care Management (CCM)
- Critical Care
- Discharge
- Emergency Room
- Home/Domiciliary Care/Rest Home/Assisted Living
- Inpatient Hospital
- Nursing Home/Skilled Nursing Facility
- Observation
- Office Visits
- Prolonged Services
- Transitional Care Management (CCM)
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:
All E&M Services
| Check box if submitted | Requested Records (as applicable) |
|---|---|
| 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 | |
| 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 | |
| Other pertinent information | |
| Documentation to support National Coverage Determination (NCD), Local Coverage Determination (LCD) and/or Policy Article | |
| 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 | |
| Advance Beneficiary Notice of Non-Coverage (ABN)/Notice of Medicare Non-Coverage (NOMNC) |
In addition to the items noted above, refer to the applicable E&M categories below:
Complex/Chronic Care Management (CCM)
99487 – 99491
| Check box if submitted | Requested Records (as applicable) |
|---|---|
| Signed Consent Form | |
| Proof of phone calls | |
| Treatment team, person-centered active treatment plan, and coordination of services | |
| Documentation to support time in/out or actual time spent. | |
| History and Physical reports (include medical history and current list of medications) | |
| Documented pharmacologic management to include prescription and dosage adjustment/changes | |
| Vital sign records, weight sheets, care plans, treatment records | |
| All records that justify and support the level of care received |
Critical Care
99291 – 99292
| Check box if submitted | Requested Records (as applicable) |
|---|---|
| Documentation to support time in/out or actual time spent. | |
| History and Physical reports (include medical history and current list of medications) | |
| Documented pharmacologic management to include prescription and dosage adjustment/changes | |
| Vital sign records, weight sheets, care plans, treatment records | |
| Diagnostic tests, radiological reports, lab results, pathology reports, CT Coronary Angiography report, and other pertinent test results and interpretations | |
| All records that justify and support the level of care received |
Discharge
99238 – 99239 & 99315 – 99316
| Check box if submitted | Requested Records (as applicable) |
|---|---|
| Discharge summary/s from hospital, skilled nursing, Continuous care, and/or respite care facilities | |
| Discharge summary from acute care | |
| Discharge orders | |
| Documentation to support time in/out or actual time spent. | |
| History and Physical reports (include medical history and current list of medications) | |
| Vital sign records, weight sheets, care plans, treatment records |
Emergency Room
99281 – 99288
| Check box if submitted | Requested Records (as applicable) |
|---|---|
| Emergency Room records | |
| Documentation to support time in/out or actual time spent. | |
| History and Physical reports (include medical history and current list of medications) | |
| Vital sign records, weight sheets, care plans, treatment records | |
| Diagnostic tests, radiological reports, lab results, pathology reports, CT Coronary Angiography report, and other pertinent test results and interpretations | |
| All records that justify and support the level of care received |
Home/Domiciliary Care/Rest Home/Assisted Living
99324 – 99337 & 99341 – 99350
| Check box if submitted | Requested Records (as applicable) |
|---|---|
| Physician/Non Physician (NPP) Admission Orders | |
| Admission initial assessment | |
| Homebound/not homebound status | |
| Documentation to support virtual service(s) provided: Telehealth, E-Visit(s), Virtual Check-In | |
| Documentation to support time in/out or actual time spent. | |
| History and Physical reports (include medical history and current list of medications) | |
| Documented pharmacologic management to include prescription and dosage adjustment/changes | |
| Vital sign records, weight sheets, care plans, treatment records | |
| All records that justify and support the level of care received |
Inpatient Hospital
99221 – 99233
| Check box if submitted | Requested Records (as applicable) |
|---|---|
| Physician/Non Physician (NPP) Admission Orders | |
| Admission initial assessment | |
| Initial hospital inpatient care | |
| Subsequent hospital inpatient care | |
| Documentation to support time in/out or actual time spent. | |
| History and Physical reports (include medical history and current list of medications) | |
| Documented pharmacologic management to include prescription and dosage adjustment/changes | |
| Vital sign records, weight sheets, care plans, treatment records | |
| Diagnostic tests, radiological reports, lab results, pathology reports, CT Coronary Angiography report, and other pertinent test results and interpretations | |
| All records that justify and support the level of care received |
Nursing Home/Skilled Nursing Facility
99304 – 99310
| Check box if submitted | Requested Records (as applicable) |
|---|---|
| Physician/Non Physician (NPP) Admission Orders | |
| Admission initial assessment | |
| Initial nursing facility visit | |
| Subsequent Nursing Facility Visit(s) | |
| Interdisciplinary Group (IDG) Reviews | |
| Interdisciplinary Team/Group (IDG/IDT) meeting notes | |
| Documentation to support virtual service(s) provided: Telehealth, E-Visit(s), Virtual Check-In | |
| Documentation to support time in/out or actual time spent. | |
| History and Physical reports (include medical history and current list of medications) | |
| Documented pharmacologic management to include prescription and dosage adjustment/changes | |
| Vital sign records, weight sheets, care plans, treatment records | |
| All records that justify and support the level of care received |
Observation
99217 – 99220
| Check box if submitted | Requested Records (as applicable) |
|---|---|
| Emergency Room records | |
| Physician/Non Physician (NPP) Admission Orders | |
| History and Physical reports (include medical history and current list of medications) | |
| Diagnostic tests, radiological reports, lab results, pathology reports, CT Coronary Angiography report, and other pertinent test results and interpretations | |
| All records that justify and support the level of care received |
Office Visits
99202 – 99215
| Check box if submitted | Requested Records (as applicable) |
|---|---|
| Documentation to support virtual service(s) provided: Telehealth, E-Visit(s), Virtual Check-In | |
| Documentation to support time in/out or actual time spent. | |
| History and Physical reports (include medical history and current list of medications) | |
| Documented pharmacologic management to include prescription and dosage adjustment/changes | |
| Vital sign records, weight sheets, care plans, treatment records | |
| Diagnostic tests, radiological reports, lab results, pathology reports, CT Coronary Angiography report, and other pertinent test results and interpretations | |
| All records that justify and support the level of care received |
Prolonged Services
99354 – 99359
| Check box if submitted | Requested Records (as applicable) |
|---|---|
| Documentation to support time in/out or actual time spent. | |
| History and Physical reports (include medical history and current list of medications) | |
| Vital sign records, weight sheets, care plans, treatment records |
Transitional Care Management
99495 – 99496
| Check box if submitted | Requested Records (as applicable) |
|---|---|
| Proof of phone calls | |
| Treatment team, person-centered active treatment plan, and coordination of services | |
| Documentation Supporting Clinical /Facility Hours of Operation | |
| Proof of communication via direct contact, telephone or electronic means within two business days of discharge or attempts to communicate | |
| Documentation to support a face-to-face visit within 14 calendar days of discharge (moderate complexity) or within 7 calendar days of discharge (high complexity) | |
| Documentation to support that the beneficiary has medical and/or psychosocial problems that require moderate or high complexity medical decision making | |
| History and Physical reports (include medical history and current list of medications) | |
| Documented pharmacologic management to include prescription and dosage adjustment/changes | |
| Vital sign records, weight sheets, care plans, treatment records | |
| Diagnostic tests, radiological reports, lab results, pathology reports, CT Coronary Angiography report, and other pertinent test results and interpretations | |
| All records that justify and support the level of care received |
*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.
- Noridian Medical Review - Automated Development System (ADS) Letter
- Comprehensive Error Rate Testing (CERT) - CID Request
- Level One Appeal - Redetermination Request
View the Evaluation and Management (E/M) webpage for more information and resources.
Last Updated Wed, 01 Sep 2021 14:15:11 +0000
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.