Preventive Services 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:

Initial Preventive Physical Examination (IPPE)

Check Brief Description
  Correct Beneficiary and Date of Service
  Office and/or progress notes detailing elements listed below
  Beneficiary's medical, family and social history
  Beneficiary's potential risk factors for depression, including current or past experiences with depression or other mood disorders
  Beneficiary's functional ability and level of safety
  Physical Assessment – Height, weight, body mass index and blood pressure; visual acuity screen; other factors as deemed appropriate based on medical, family and social history and current clinical standards
  End-of-life planning, on agreement of the beneficiary
  Educate, counsel and refer based on previous 5 components of medical, family and social history; potential risk factors for depression and other mood disorders; functional ability and level of safety; exam; and end-of-life planning
  Educate, counsel and refer for other preventive services – Brief written plan for other appropriate screenings
  Advance Beneficiary Notice of Noncoverage (ABN), if applicable
  Completed Noridian Part B Signature Attestation Statement [PDF] or Signature Log for illegible signature, if applicable

Annual Wellness Visit (AWV)

Check Brief Description
  Correct Beneficiary and Date of Service
  Exam Details
  Office and/or progress notes detailing elements listed below
  Health Risk Assessment (HRA) – Demographic data; Self-assessment of health status; Psychosocial risks; Behavioral risks; Activities of Daily Living (ADLs), including, but not limited to: dressing, bathing, and walking; and Instrumental ADLs, including, but not limited to: shopping, housekeeping, managing own medications, and handling finances
  List of beneficiary current providers and suppliers
  Beneficiary medical, family and social history
  Beneficiary potential risk factors for depression, including current or past experiences with depression or other mood disorders
  Beneficiary functional ability and level of safety
  Beneficiary Physical Assessment - Height, weight, body mass index (or waist circumference, if appropriate), blood pressure and other routine measurements as deemed appropriate based on medical and family history
  Beneficiary cognitive impairments, if applicable
  Beneficiary's written screening schedule, such as a checklist for next 5 to 10 years, as appropriate
  List of risk factors and conditions for which primary, secondary, or tertiary interventions are recommended or underway for beneficiary
  Personalized health advice to beneficiary and a referral, as appropriate, to health education or preventive counseling services or programs
  Advance Beneficiary Notice of Noncoverage (ABN), if applicable
  Completed Noridian Part B Signature Attestation Statement [PDF] or Signature Log for illegible signature, if applicable

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 Preventive Services webpage for more information and resources.
 

Last Updated Fri, 08 Feb 2019 11:48:22 +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.