Nerve Conduction Studies and Electrophysiology Testing Documentation Requirements - JE Part B
Browse by Topic
- Advance Beneficiary Notice of Noncoverage (ABN)
- Appeals
- Claims
- Clinical Trials
- Compliance Program
- Documentation Requirements
- Drugs, Biologicals and Injections
- Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS)
- Electronic Data Interchange (EDI)
- Emergencies and Disasters
- Fraud and Abuse
- Home Health
- Hospice
- Incentive Programs
- Incident To
- Medicare Secondary Payer (MSP)
- Modifiers
- Non-Covered Services
- Noridian Medicare Portal (NMP)
- Observation
- Overpayment and Recoupment
- Preventive Services
- Remittance Advice (RA)
- Telehealth
- Wound Care
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.
- Noridian Medical Review - Automated Development System (ADS) Letter
- Comprehensive Error Rate Testing (CERT) - CID Request
- Level One Appeal - Redetermination Request
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.