Dental Services 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 identification, date of service, and provider of the service should be clearly identified on each page of the submitted documentation
  Dental records including office/progress notes supporting the reason for items/services rendered (Examples: Dental exam, radiographic imaging results, treatment plan)
  If associated with a primary medical service, include office/progress notes supporting connection with primary medical service (Examples: consultation notes, referral form, medical records from coordinating medical provider)
  If procedural/surgical, the operative report record describing the type of services performed including which dental structures. Documentation of tooth (teeth) treated using standard identification, tooth surface treated (if appropriate), and missing teeth documented
  Diagnostic other/tests and results
  Itemized statement/bill/invoice
  Copies of articles from peer-reviewed medical journals supporting the clinical utility of the service and/or association with primary medial service, of if this is a new unlisted procedure, category III code, usual frequency for a service, or off-labeled indication
  If a not otherwise classified (NOC) code was billed for any portion of the service under review two separate types of documentation will be required to support the claim:
  • The documentation that supports the medical necessity of the service provided and
  • A separate statement outlining specifically for what the NOC code was used
  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
  Any other supporting/pertinent documentation
  Signature and credentials of all personnel providing services. Include a signature log or signature attestation for any missing or illegible signatures within the medical record
  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 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 webpages for additional information and resources.

Last Updated Apr 05 , 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.