ASC 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:

Check
Brief Description
Correct Beneficiary and Date of Service
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 service that was provided in ASC
Documentation contains valid signature of Physician (legible and complete)
Ambulatory Service Center identification (i.e name of ASC) on documentation to identify billing ASC
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
Advance Beneficiary Notice of Noncoverage (ABN), if applicable
Completed Noridian Part B Signature Attestation Statement 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. Select the request below to view the appropriate submission instructions.

View the Ambulatory Surgical Center (ASC) webpage for more information and resources.

Last Updated Jul 03 , 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.