Expedite Review with Labeled Documentation
Providers and Suppliers are encouraged to label/tab submitted documentation. This voluntary effort will help providers/suppliers validate that all requested records are submitted and to ensure reviewers can easily identify such elements within the medical record.
The following list may be used as reference guides, when submitting documentation to Medicare. Each charge on a claim should be supported with the following:
- Documentation and Coding that Demonstrates Medical Necessity
- Documentation proving the service/procedure was performed
Documentation Requirements webpages will not be created for every possible situation or provider type.
Specialty/Topic Specific Requirements
- Ambulatory Surgical Center (ASC)
- Anesthesia and Pain Management
- Drugs, Biologicals and Injections
- End Stage Renal Disease (ESRD) / Dialysis
- Evaluation and Management (E/M) (Care Plan Oversight, Chronic Care Management, Critical Care, Transitional Care Management)
- Mental Health
- Outpatient Therapy
- Podiatry Services
- Preventive Services
- Radiation Therapy
- Radiology Services
Additional General Resources
Last Updated Oct 19, 2018
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.