Evaluation and Management Documentation Requirements

[Discharge, Emergency Room, Nursing Home/Skilled Nursing Facility, Complex/Chronic Care Management (CCM), Office Visits, Critical Care, Home/Domiciliary Care/Rest Home/Assisted Living, Observation, Prolonged Services, and Transitional Care Management (CCM)]

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:

These items apply to all E&M services unless otherwise noted.

Check Brief Description
  Discharge orders
– Discharge Codes
  Discharge summary from acute care
– Discharge Codes
  Discharge Summary/s from Hospital, Skilled Nursing, Continuous Care, and/or Respite Care facilities
– Discharge Codes
  Documentation identifying the rendering physician was present and personally performed the services
– Observation Codes
  Documentation to support patient consent for services
– Complex/Chronic Care Management (CCM) Codes
  Documentation to support the time element in the critical care code(s)
– Critical Care Codes
  Documentation to support the time element of the code when billing level of service based on time
  Documentation to support time in/out or actual time spent
– Complex/Chronic Care Management (CCM) Codes
  Emergency Room Records
– Emergency Room & Observation Codes
  Forms, reports, documents referred to in the note (if applicable)
  History and Physical reports (include medical history and current list of medications)
  Initial hospital inpatient care
– Inpatient Hospital Codes
  Initial nursing facility visit
– Nursing Home & Skilled Nursing Facility Codes
  Order for observation services
– Observation Codes
  Physician/Non-Physician (NPP) Admission Orders
- Inpatient Hospital, Nursing Home & Skilled Nursing Facility Codes
  Practitioner, nurse, and ancillary progress notes
  Review of beneficiary prior and current medical and functional conditions and comorbidities
– Complex/Chronic Care Management (CCM) Codes
  Signed and dated overall plan of care including, short and long term goals with any updates to the plan of care
– Complex/Chronic Care Management (CCM) Codes
  Subsequent hospital inpatient care
– Inpatient Hospital Codes
  Subsequent Nursing Facility Visit
– Nursing Home & Skilled Nursing Facility Codes
  Treating practitioner's written order
  Treatment team, person-centered active treatment plan, and coordination of services
– Complex/Chronic Care Management (CCM) Codes
  Proof of communication via direct contact, telephone or electronic means within two business days of discharge or attempts to communicate
– Transitional Care Management Codes
  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)
– Transitional Care Management Codes
  Documentation to support that the beneficiary has medical and/or psychosocial problems that require moderate or high complexity medical decision making
– Transitional Care Management Codes
  Diagnostic tests, radiological reports, lab results, pathology reports, and other pertinent test results and interpretations
  Office/other outpatient setting or inpatient/observation visit requiring direct patient contact beyond the usual service
– Prolonged Service Codes
  Notes to support the documentation of start and stop times
– Prolonged Service Codes
  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

 

*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.

 

Last Updated Tue, 07 Jul 2020 21:05:45 +0000

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.