Total Knee, Hip, and Shoulder Surgeries

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 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
Operative/procedure report
Documentation of the devices, implants, biological products used
Anesthesia records (including pre- and post-anesthesia).
History and Physical reports (include medical history and current list of medications)
Vital sign records, weight sheets, care plans, treatment records
Preoperative evaluations including anesthesia evaluation
Documentation of pain level and activities of daily living (ADL) limitations, for example Roland Morris Disability Questionnaire.
Medical record documentation of knee exam with objective description of joint laxity (e.g., Varus/valgus instability, Lachman test, anterior/posterior Drawer test)
Medical record documentation that describes and supports other treatment(s)/medication(s) was tried and failed or was considered and ruled out
Diagnostic tests, radiological reports, lab results, pathology reports, CT Coronary Angiography report, and other pertinent test results and interpretations
Medical clearance
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)

 

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 Surgery webpage for additional information and resources.

 

Last Updated Wed, 11 Aug 2021 20:57:54 +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.