Botulinum Toxin (Botox) Injections 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
  Operative / procedure report
  Practitioner, nurse, and ancillary progress notes
  Physician consultations
  Documentation supporting the diagnosis code(s) required for the item billed
  For chronic migraine: documentation to support a history of migraines occurring most days of the month
  The clinical indication/medical necessity for the injection
  Medication Administration Record (MAR) and/or Infusion Flowsheet documenting the quantity administered include a dose, route, and frequency given
  Specific site(s) injected
  Documentation supporting wastage of medication
  Records of conservative measures trialed for treatment of service provided
  Conservative measures are not required for focal dystonia, hemifacial spasm, orofacial dyskinesia, blepharospasm, severe writer's camp, laryngeal spasm, or dysphonia
  Diagnostic tests, radiological reports, lab results, pathology reports, and other pertinent test results and interpretations
  Records to support clinical effectiveness of the injections (for continuous treatment)
  Beneficiary name and date of service on all documentation
  Documentation as required in LCD or NCD
  Any additional documentation to support the reasonable necessity of the service(s) performed
  Advance Beneficiary Notice
  Signature log or signature attestation for any missing or illegible signatures within the medical record (all personnel providing services)
  Signature attestation and credentials of 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


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.


Last Updated Dec 09 , 2023

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.