Cardiac Services Documentation Requirements

General Outpatient

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:

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Brief Description
Physician/Non Physician (NPP) order or evidence of intent to order
Procedure or testing report
  • Anesthesia records, if applicable
  • Recovery room records, if applicable
  • MAR, if applicable
Practitioner progress notes
  • Support medical necessity
  • Support LCD and NCD requirements, if applicable
  • Results of prior testing to support medical necessity, if applicable
Office visit/E&M documentation if billed on same date of service under review
Itemization of services
Advance Beneficiary Notice
Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services)
Facility process of how electronic signature is created if using electronic health record

Multiple CMS contractors are charged with completing reviews of medical records. See Identifying Which Entity Completed a Part A 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.

Implantable Automatic Defibrillator (ICD)

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
Brief Description
Legible handwritten physician and/or clinician signatures
Valid electronic physician and/or clinician signatures
Physician or Non-Physician Practitioner (NPP) order for date of service
Legible procedure note or report that includes sufficient detail to allow reconstruction of ICD insertion
Records of patient's condition before, during and after this billing period to support medical necessity and reason service was provided
  • History and physical, progress notes, office visit notes, cardiology consultations and all other pertinent medical records
Documentation to support patient does not have irreversible brain damage from preexisting cerebral disease
Documentation to support a covered indication for secondary prevention as indicated in the National Coverage Determination (NCD) 20.4, if applicable
  • Documented episode of cardiac arrest due to ventricular fibrillation (VF), not due to a transient or reversible cause
  • Documented sustained ventricular tachyarrhythmia (VT), either spontaneous or induced by an electrophysiology (EP) study, not associated with an acute myocardial infarction (MI) and not due to a transient or reversible cause
Documentation to support a covered indication for primary prevention as indicated in the National Coverage Determination (NCD) 20.4, if applicable
  • Documented familial or inherited conditions with a high risk of life-threatening VT, such as long QT syndrome or hypertrophic cardiomyopathy
  • Coronary artery disease with a documented prior MI, a measured left ventricular ejection fraction (LVEF) = 0.35, and inducible, sustained VT or VF at EP study
  • Documented prior MI and a measured LVEF = 0.30
  • Patients with ischemic dilated cardiomyopathy (IDCM), documented prior MI, NYHA Class II and III heart failure, and measured LVEF = 35%
  • Patients with non-ischemic dilated cardiomyopathy (NIDCM) >9 months, NYHA Class II and III heart failure, and measured LVEF = 35%
  • Patients who meet all current CMS coverage requirements for a cardiac resynchronization therapy (CRT) device and have NYHA Class IV heart failure
  • Patients with NIDCM >3 months, NYHA Class II or III heart failure, and measured LVEF = 35%
If ICD was inserted for primary prevention, documentation to support patient is enrolled in either a Food and Drug Administration (FDA)-approved category B investigational device exemption (IDE) clinical trial (42 CFR §405.201), a trial under the CMS Clinical Trial Policy (National Coverage Determination (NCD) Manual §310.1) or a qualifying data collection system including approved clinical trials and registries
If ICD was inserted for primary prevention, documentation to support patient does not have:
  • Cardiogenic shock or symptomatic hypotension while in a stable baseline rhythm
  • Had a CABG or PTCA within the past 3 months
  • Had an acute MI within the past 40 days
  • Clinical symptoms or findings that would make them a candidate for coronary revascularization
  • Any disease, other than cardiac disease (e.g., cancer, uremia, liver failure), associated with a likelihood of survival less than 1 year
Diagnostic test results/reports to support any applicable cardiac findings such as ventricular arrhythmia, the LVEF, a prior MI or prior cardiac intervention
  • Angiography
  • Echocardiography
  • Electrocardiogram (ECG)
  • Electrophysiology (EP) studies
  • Holter monitor readings
  • Nuclear stress tests
  • Radionuclide scanning
  • Telemetry strips
  • When no official imaging report is available, the following components must be present within medical records: date(s) imaging was completed, type(s) of imaging/exam and detailed findings
Documentation to support rationale for a device other than a single lead device
  • If rationale is missing from record, use of a dual chamber or bi-ventricular device will be denied
Documentation to support indications and/or criteria as specified in Local Coverage Determinations (LCDs), National Coverage Determinations (NCDs), or coverage article for service(s) billed, if applicable
Office visit and/or evaluation and management (E&M) documentation, if billed on same date(s) of service under medical review
Itemization of services
Advance Beneficiary Notice of Noncoverage (ABN), if applicable

Multiple CMS contractors are charged with completing reviews of medical records. See Identifying Which Entity Completed a Part A 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.

Pacemaker

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
Brief Description
Legible handwritten physician and/or clinician signatures
Valid electronic physician and/or clinician signatures
Physician or Non-Physician Practitioner (NPP) order for date of service
Legible procedure note or report that includes sufficient detail to allow reconstruction of pacemaker insertion
Records of patient's condition before, during and after this billing period to support medical necessity and reason service was provided
  • History and physical, progress notes, office visit notes, cardiology consultations and all other pertinent medical records
Documentation to support a covered indication as indicated in the National Coverage Determination (NCD) 20.8.3
  • Non-reversible symptomatic bradycardia due to sinus node dysfunction
  • Non-reversible symptomatic bradycardia due to second degree and/or third degree atrioventricular block
Documentation to support contractor covered indications for Single Chamber and Dual Chamber Permanent Cardiac Pacemakers - Coding and Billing
  • Documentation to support appropriate KX or SC modifier
Documentation to support rationale for dual chamber device verses a single chamber device
Diagnostic test results/reports to support any applicable cardiac findings
  • Angiography
  • Echocardiography
  • Electrocardiogram (ECG)
  • Electrophysiology (EP) studies
  • Holter monitor readings
  • Nuclear stress tests
  • Radionuclide scanning
  • Telemetry strips
  • When no official imaging report is available, the following components must be present within medical records: date(s) the imaging was completed, type(s) of imaging/exam and detailed findings
Documentation to support indications and/or criteria as specified in Local Coverage Determinations (LCDs), National Coverage Determinations (NCDs), or coverage article for service(s) billed, if applicable
Office visit and/or evaluation and management (E&M) documentation, if billed on same date(s) of service under medical review
Itemization of services
Advance Beneficiary Notice of Noncoverage (ABN), if applicable

Multiple CMS contractors are charged with completing reviews of medical records. See Identifying Which Entity Completed a Part A 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.

Single Photon Emission Computed Tomography (SPECT)

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
Brief Description
Legible handwritten physician and/or clinician signatures
Valid electronic physician and/or clinician signatures
Physician or Non-Physician Practitioner (NPP) order for date of service
  • If the order for clinical diagnostic test be unsigned, there must be medical documentation (e.g. a progress note) by treating physician that he/she intended clinical diagnostic test to be performed
  • Documentation showing intent that test be performed must be authenticated by author via a handwritten or electronic signature
Legible diagnostic test report and results for date(s) of service billed that includes sufficient detail to allow reconstruction of SPECT scan
Records of patient's condition before, during and after this billing period to support medical necessity and reason service was provided
  • Most recent history and physical and/or physician clinic/progress notes pertaining to diagnosis/reason the SPECT scan was completed
  • Nurse notes, consultation reports, emergency room records, disposition/discharge reports, if applicable
Documentation to support a covered indication as indicated in the National Coverage Determination (NCD) 220.12
  • Stress fracture
  • Spondylosis
  • Infection (e.g., discitis)
  • Tumor (e.g., osteoid osteoma)
  • Analyze blood flow to an organ, as in case of myocardial viability
  • Differentiate ischemic heart disease from dilated cardiomyopathy
Documentation to support prior diagnostic testing including lab/pathology reports or X-ray/imaging reports if related to SPECT scan
  • SPECT scans may not be used following an inconclusive fluorodeoxyglucose (FDG)- positron emission tomography (PET) performed to evaluate myocardial viability
Documentation to support indications and/or criteria as specified in Local Coverage Determinations (LCDs), National Coverage Determinations (NCDs), or coverage article for service(s) billed, if applicable
Office visit and/or evaluation and management (E&M) documentation, if billed on same date(s) of service under medical review
Itemization of services
Advance Beneficiary Notice of Noncoverage (ABN), if applicable

Multiple CMS contractors are charged with completing reviews of medical records. See Identifying Which Entity Completed a Part A 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 Outpatient Prospective Payment System (OPPS) webpage for additional information and resources.

Last Updated May 15 , 2024

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.