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Nerve Conduction Studies and Electrophysiology Testing 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 box if submitted Brief Description
  History and Physical reports (include medical history and current list of medications)
  Practitioner, nurse, and ancillary progress notes
  Physician / Non Physician (NPP) order or evidence of intent to order
  Physician referral (prescription, treatment or diagnostic test)
  The reason for referral and a clear diagnostic impression are required for each study.
  Test results
  Normal findings and abnormalities uncovered during the study should be documented with the muscles tested, the presence and type of spontaneous activity, as well as the characteristics of the voluntary unit potentials and interpretation.
  The data gathered should reflect the actual numbers (latency, amplitude, etc.), preferably in a tabular (not narrative) format.
  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
  Beneficiary name and date of service on all documentation

 

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.

 

Last Updated Tue, 26 Oct 2021 15:35:47 +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.