Evaluation and Management 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 |
|---|---|
| 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.
- 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 Feb 08, 2019
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.