Blepharoplasty / Visual Fields 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 box if submitted Brief Description
  Beneficiary name and date of service on all documentation
  Practitioner, nurse, and ancillary progress notes
  Diagnostic Studies, including visual acuity and glare tests
  Operative / procedure report
  Visual field measurement / documentation
  Photographs showing visual impairment
  Documentation to support that the service provided was medically necessary and not cosmetic
  Copy of Prior Authorization decision letter which includes assigned UTN
  The topical corticosteroid(s) given previously to beneficiary for ocular inflammatory condition prior to current treatment
  The diagnosis of neovascular (wet) macular degeneration has been firmly established (fluorescein angiogram)
  Ocular Photodynamic Therapy (OPT) treatment notes, including initial and subsequent treatments
  Documentation supporting the diagnosis code(s) required for the item(s) billed
  Documentation to support the code(s) and modifier(s) billed
  List of all non-standard abbreviations or acronyms used, including definitions
  Documentation to support National Coverage Determination (NCD), Local Coverage Determination (LCD) and/or Policy Article
  Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services)
  If an electronic health record is utilized, include your facility's process of how the electronic signature is created. Include an example of how the electronic signature displays once signed by the physician
  Advance Beneficiary Notice of Non-Coverage (ABN)/Notice of Medicare Non-Coverage (NOMNC)


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/supplier 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.


Last Updated Dec 09 , 2023