Evaluation and Management Documentation Requirements

This checklist applies to the following E/M services:

  • Complex/Chronic/Principal Care Management (CCM, PCM)
  • Critical Care
  • Discharge
  • Emergency Room
  • Home/Domiciliary Care/Rest Home/Assisted Living
  • Inpatient Hospital/Observation
  • Nursing Home/Skilled Nursing Facility
  • Office Visits
  • Prolonged Services
  • Transitional Care Management (TCM)

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:

All E/M Services

Check
Brief Description
Beneficiary identification, date of service, and provider of the service should be clearly identified on each page of the submitted documentation
Practitioner, nurse, and ancillary progress notes
History and Physical reports (include medical history and current list of medications)
Documented pharmacologic management to include prescription and dosage adjustment/changes
Vital sign records, weight sheets, care plans, treatment records
Diagnostic tests, radiological reports, lab results, pathology reports, and other pertinent test results and interpretations
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
Documentation to support National Coverage Determination (NCD), Local Coverage Determination (LCD) and/or Policy Article
Signatures are required for medical review for the following purposes: 1) To satisfy specific signature requirements in statute, regulation, National Coverage Determination (NCD) or Local Coverage Determination (LCD); and 2) To resolve authenticity concerns related to legitimacy of falsity of the documentation
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)

In addition to the items noted above, refer to the applicable E/M categories below:

Complex/Chronic/Principal Care Management (Complex CCM, CCM, PCM)
99487, 99489, 99490–99491, 99437, 99439, 99424–99427, G3002–G3003

Check
Brief Description
All applicable items listed items under "All E/M Services"
Medical record documentation to support beneficiary having two or more chronic conditions (expected to last at least 12 months) with significant risk of death, functional decline, exacerbation, or decompensation
Annual Wellness Visit (AWV), Initial Preventive Physical Exam (IPPE) or comprehensive Evaluation and Management (E/M) performed prior to billing CCM services for a beneficiary new to Chronic Care Management (CCM) or for beneficiaries not seen by the billing provider within the last 12 months
Verbal consent or a written consent signed by beneficiary or caregiver and must include the following; description of the Chronic Care Management (CCM) services, ability to revoke/right to stop CCM services, responsibility for cost sharing and if verbal consent obtained for CCM, documentation to support narrative discussion and prior permission acceptance
Comprehensive care plan with measurable goals was established, implemented, revised, or significantly monitored and a copy was provided to the beneficiary and/or caregiver
Medical record documentation to support time spent on services for the CPT level of code billed
Chronic and Principal care management is based on time
Documentation of medical decision making (MDM) to support the level of service billed
Complex chronic care management is based on MDM and time

Critical Care
99291-99292

Check
Brief Description
All applicable items listed items under "All E/M Services"
Medical record documentation to support time spent on services for the CPT level of code billed
Documentation to support critical illnesses or injuries, defined as those with impairment to one or more vital organ systems with an increased risk of rapid or imminent health deterioration

Discharge
99234–99236, 99238–99239, 99315–99316

Check
Brief Description
All applicable items listed items under "All E/M Services"
Discharge summary/s from hospital, skilled nursing, Continuous care, and/or respite care facilities
Discharge summary from acute care
Discharge orders
Medical record documentation to support time spent on services for the CPT level of code billed
Discharge from hospital/observation or nursing facility, discharge day management is based on time
Documentation of medical decision making (MDM) to support the level of service billed
Discharge from hospital/observation, admission and discharge on same day is based on MDM or time

Emergency Room
99281 - 99288

Check
Brief Description
All applicable items listed items under "All E/M Services"
Emergency Room records
Documentation of medical decision making (MDM) to support the level of service billed

Home/Domiciliary Care/Rest Home/Assisted Living
99341–99342, 99344–99345, 99347–99350

Check
Brief Description
All applicable items listed items under "All E/M Services"
Medical record documentation to support time spent on services for the CPT level of code billed
Documentation of medical decision making (MDM) to support the level of service billed
A home/ domiciliary care/ rest home/ assisted living visit is based on MDM or time
Documentation to support homebound status

Inpatient Hospital/Observation
99221–99223, 99231–99233

Check
Brief Description
All applicable items listed items under "All E/M Services"
Physician or Non-Physician (NPP) Admission Orders
Initial hospital inpatient care
Subsequent hospital inpatient care
Medical record documentation to support time spent on services for the CPT level of code billed
Documentation of medical decision making (MDM) to support the level of service billed
A hospital / observation visit is based on MDM or time

Nursing Home or Skilled Nursing Facility
99304 - 99310

Check
Brief Description
All applicable items listed items under "All E/M Services"
Physician or Non-Physician (NPP) Admission Orders
Initial nursing facility visit
Subsequent Nursing Facility Visit(s)
Medical record documentation to support time spent on services for the CPT level of code billed
Documentation of medical decision making (MDM) to support the level of service billed
A nursing facility visit is based on MDM or time

Office Visits
99202–99205, 99212–99215

Check
Brief Description
All applicable items listed items under "All E/M Services"
Medical record documentation to support time spent on services for the CPT level of code billed
Documentation of medical decision making (MDM) to support the level of service billed
An office visit is based on MDM or time
Documentation to support virtual service(s) provided: Telehealth, E-Visit(s), Virtual Check-In

Prolonged Services
G2212, G0316 - G0318

Check
Brief Description
All applicable items listed items under "All E/M Services"
Medical record documentation to support time spent on services for the CPT level of code billed
Documentation to support virtual service(s) provided: Telehealth, E-Visit(s), Virtual Check-In

Transitional Care Management
99495 - 99496

Check
Brief Description
All applicable items listed items under "All E/M Services"
Proof of interactive contact (or attempts) with the patient or their caregiver by phone, email, or face-to-face within 2 business days after the patient’s discharge
Documentation to support a face-to-face visit within 14 calendar days of discharge (moderate complexity) or within 7 calendar days of discharge (high complexity)
Documentation to support virtual service(s) provided: Telehealth, E-Visit(s), Virtual Check-In
Description of the non-face-to-face- services provided
Documentation of medical decision making (MDM) to support the level of service billed

*It is important that the physician intent, physician decision, and physician recommendation to provide services is derived clearly from the medical record and properly authenticated.
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 Evaluation and Management (E/M) webpage for more information and resources.

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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.