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
  • Nursing Home/Skilled Nursing Facility
  • Observation
  • Office Visits
  • Prolonged Services
  • 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:

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
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
Other pertinent information
Documentation to support National Coverage Determination (NCD), Local Coverage Determination (LCD) and/or Policy Article
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
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 (CCM, PCM)
99487, 99489, 99490, 99491, 99437, 99439, 99424-99427

Check
Brief Description
Signed Consent Form
Proof of phone calls
Treatment team, person-centered active treatment plan, and coordination of services
Documentation to support time in/out or actual time spent. Include communication with patient, family, caregiver, community agencies or services.
Measurable treatment goals, assessment and support for treatment regimen
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
All records that justify and support the level of care received

Critical Care
99291 - 99292

Check
Brief Description
Documentation to support time in/out or actual time spent.
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, CT Coronary Angiography report, and other pertinent test results and interpretations
All records that justify and support the level of care received

Discharge
99238 - 99239 & 99315 - 99316

Check
Brief Description
Discharge summary/s from hospital, skilled nursing, Continuous care, and/or respite care facilities
Discharge summary from acute care
Discharge orders
Documentation to support time in/out or actual time spent.
History and Physical reports (include medical history and current list of medications)
Vital sign records, weight sheets, care plans, treatment records

Emergency Room
99281 - 99288

Check
Brief Description
Emergency Room records
Documentation to support time in/out or actual time spent.
History and Physical reports (include medical history and current list of medications)
Vital sign records, weight sheets, care plans, treatment records
Diagnostic tests, radiological reports, lab results, pathology reports, CT Coronary Angiography report, and other pertinent test results and interpretations
All records that justify and support the level of care received

Home/Domiciliary Care/Rest Home/Assisted Living
99341 - 99350

Check
Brief Description
Physician or Non-Physician (NPP) Admission Orders
Admission initial assessment
Homebound/not homebound status
Documentation to support virtual service(s) provided: Telehealth, E-Visit(s), Virtual Check-In
Documentation to support time in/out or actual time spent.
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
All records that justify and support the level of care received

Inpatient Hospital
99221 - 99233

Check
Brief Description
Physician or Non-Physician (NPP) Admission Orders
Admission initial assessment
Initial hospital inpatient care
Subsequent hospital inpatient care
Documentation to support time in/out or actual time spent.
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, CT Coronary Angiography report, and other pertinent test results and interpretations
All records that justify and support the level of care received

Nursing Home or Skilled Nursing Facility
99304 - 99310

Check
Brief Description
Physician or Non-Physician (NPP) Admission Orders
Admission initial assessment
Initial nursing facility visit
Subsequent Nursing Facility Visit(s)
Interdisciplinary Group (IDG) Reviews
Interdisciplinary Team/Group (IDG/IDT) meeting notes
Documentation to support virtual service(s) provided: Telehealth, E-Visit(s), Virtual Check-In
Documentation to support time in/out or actual time spent.
History and Physical reports (include medical history and current list of medications)
Documented pharmacologic management to include prescription and dosage adjustment or changes
Vital sign records, weight sheets, care plans, treatment records
All records that justify and support the level of care received

Observation (same as hospital codes)
99221 - 99233

Check
Brief Description
Emergency Room records
Physician or Non-Physician (NPP) Admission Orders
History and Physical reports (include medical history and current list of medications)
Diagnostic tests, radiological reports, lab results, pathology reports, CT Coronary Angiography report, and other pertinent test results and interpretations
All records that justify and support the level of care received

Office Visits
99202 - 99215

Check
Brief Description
Documentation to support virtual service(s) provided: Telehealth, E-Visit(s), Virtual Check-In
Documentation to support time in/out or actual time spent.
History and Physical reports (include medical history and current list of medications)
Documented pharmacologic management to include prescription and dosage adjustment or changes
Vital sign records, weight sheets, care plans, treatment records
Diagnostic tests, radiological reports, lab results, pathology reports, CT Coronary Angiography report, and other pertinent test results and interpretations
All records that justify and support the level of care received

Prolonged Services
G2212, G0316 - G0318, G0513 - G0514

Check
Brief Description
Documentation to support time in and out or actual time spent.
History and Physical reports (include medical history and current list of medications)
Vital sign records, weight sheets, care plans, treatment records

Transitional Care Management
99495 - 99496

Check
Brief Description
Proof of phone calls
Treatment team, person-centered active treatment plan, and coordination of services
Documentation Supporting Clinical or Facility Hours of Operation
Proof of communication via direct contact, telephone or electronic means within two business days of discharge or attempts to communicate
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 that the beneficiary has medical and/or psychosocial problems that require moderate or high complexity medical decision making
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, CT Coronary Angiography report, and other pertinent test results and interpretations
All records that justify and support the level of care received

*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 Sep 17 , 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.