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:

Brief Description
Legible handwritten physician and/or clinician signatures
Valid electronic physician and/or clinician signatures
Physician or Non-Physician Practitioner (NPP) order for the date(s) of service
  • If the order for the preventive test is unsigned, there must be medical documentation (e.g. a progress note) by the treating physician that he/she intended the preventive test to be performed
  • Documentation showing the intent that the test be performed must be authenticated by the author via a handwritten or electronic signature
Legible procedure note or preventative test report and results for the date(s) of service billed that includes sufficient detail to allow reconstruction of the service
  • Anesthesia records, if applicable
  • Recovery room records, if applicable
  • Medication administration records, if applicable
Records of patient's condition before, during and after this billing period to support medical necessity and the reason the preventive service was provided
  • Most recent history and physical and/or physician clinic/progress notes pertaining to diagnosis/reason the service was completed
  • Nurse notes, consultation reports, emergency room records, disposition/discharge reports and all other pertinent medical records as applicable
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

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 Preventive Services webpage for additional information and resources.

Last Updated Jun 18 , 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.