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.

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.