EM Documentation Requirements - JE Part B
Evaluation and Management Documentation Requirements
[Discharge, Emergency Room, Nursing Home/Skilled Nursing Facility, Complex/Chronic Care Management (CCM), Office Visits, Critical Care, Home/Domiciliary Care/Rest Home/Assisted Living, Observation, Prolonged Services, and 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:
These items apply to all E&M services unless otherwise noted.
| Check | Brief Description |
|---|---|
| Discharge orders – Discharge Codes |
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| Discharge summary from acute care – Discharge Codes |
|
| Discharge Summary/s from Hospital, Skilled Nursing, Continuous Care, and/or Respite Care facilities – Discharge Codes |
|
| Documentation identifying the rendering physician was present and personally performed the services – Observation Codes |
|
| Documentation to support patient consent for services – Complex/Chronic Care Management (CCM) Codes |
|
| Documentation to support the time element in the critical care code(s) – Critical Care Codes |
|
| Documentation to support the time element of the code when billing level of service based on time | |
| Documentation to support time in/out or actual time spent – Complex/Chronic Care Management (CCM) Codes |
|
| Emergency Room Records – Emergency Room & Observation Codes |
|
| Forms, reports, documents referred to in the note (if applicable) | |
| History and Physical reports (include medical history and current list of medications) | |
| Initial hospital inpatient care – Inpatient Hospital Codes |
|
| Initial nursing facility visit – Nursing Home & Skilled Nursing Facility Codes |
|
| Order for observation services – Observation Codes |
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| Physician/Non-Physician (NPP) Admission Orders - Inpatient Hospital, Nursing Home & Skilled Nursing Facility Codes |
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| Practitioner, nurse, and ancillary progress notes | |
| Review of beneficiary prior and current medical and functional conditions and comorbidities – Complex/Chronic Care Management (CCM) Codes |
|
| Signed and dated overall plan of care including, short and long term goals with any updates to the plan of care – Complex/Chronic Care Management (CCM) Codes |
|
| Subsequent hospital inpatient care – Inpatient Hospital Codes |
|
| Subsequent Nursing Facility Visit – Nursing Home & Skilled Nursing Facility Codes |
|
| Treating practitioner's written order | |
| Treatment team, person-centered active treatment plan, and coordination of services – Complex/Chronic Care Management (CCM) Codes |
|
| Proof of communication via direct contact, telephone or electronic means within two business days of discharge or attempts to communicate – Transitional Care Management Codes |
|
| 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) – Transitional Care Management Codes |
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| Documentation to support that the beneficiary has medical and/or psychosocial problems that require moderate or high complexity medical decision making – Transitional Care Management Codes |
|
| Diagnostic tests, radiological reports, lab results, pathology reports, and other pertinent test results and interpretations | |
| Office/other outpatient setting or inpatient/observation visit requiring direct patient contact beyond the usual service – Prolonged Service Codes |
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| Notes to support the documentation of start and stop times – Prolonged Service Codes |
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| 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 |
*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 Tue, 07 Jul 2020 21:05:57 +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.