Article Detail - JF Part B
Surgery Documentation Requirements
It is expected that patient's medical records reflect the need for care/services provided. Such records are not routinely submitted; however, they must be available upon request. They shall include:
| Check | Brief Description |
|---|---|
| Procedure note or documentation for the service(s) rendered | |
| Relevant and/or current records from the physician's office, e.g., office notes, history and physical, labs, etc. as supporting documentation of medical necessity for the service that was provided | |
| Documentation to support the indications and/or criteria as specified in Local Coverage Determinations (LCDs), National Coverage Determinations (NCDs), or coverage article for the service(s) billed, if applicable | |
| Evidence of conservative measures, if applicable | |
| Correct Beneficiary and Date of Service | |
| Advance Beneficiary Notice of Noncoverage (ABN), if applicable | |
| Documentation contains valid signature of Physician (legible and complete) | |
| 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.
- Level One Appeal - Redetermination Request
- Comprehensive Error Rate Testing (CERT) - CERT: CID Request
- Noridian Medical Review - Automated Development System (ADS) Letter
View the Surgery webpage for additional information and resources.
Last Updated Dec 09 , 2023
