Drug Administration Documentation Requirements - JF Part B
Drug Administration 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 |
|---|---|
| Physician order for the medication(s) administered with valid physician signature, including date, dose, route and frequency | |
| Medication administration record (mar) and/or infusion flowsheet documenting the quantity administered include a dose, route, and frequency given. | |
| Documentation to support drug wastage billed | |
| If the dosage for the drug under review is outside the allowed amount per the drug compendium, submit documentation to support the medical necessity of this dose variance (i.e. Clinical trial, article, studies, etc.) | |
| Documentation supporting the diagnosis for the medication administered which may include authenticated physician notes, diagnostic testing or previous laboratory testing | |
| Operative / procedure report | |
| Listing of most current beneficiary medications | |
| 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/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.
- Noridian Medical Review - Automated Development System (ADS) Letter
- Comprehensive Error Rate Testing (CERT) - CID Request
- Level One Appeal - Redetermination Request
View the Drugs, Biologicals and Injections webpage for additional information and resources.
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.
