Mental Health 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:
|Correct Beneficiary and Date of Service|
|Relevant and/or current records from physician's office, e.g., office notes, history and physical, labs, etc. as supporting documentation of medical necessity for service provided|
|Physician or Non-Physician Practitioner (NPP) Order and/or Intent (*Note intent [i.e. progress notes] should be properly authenticated by ordering provider)|
|Time based codes - Send documentation to support time spent and /or time frame. Example: Psychotherapy (Because time is indicated in code descriptor for psychotherapy CPT codes, it is important for providers to clearly document in patient's medical record time spent providing psychotherapy service rather than entering one time period including E&M service.)|
|Documentation contains valid signature of every attendant and Physician (legible and complete)|
|Documentation to support indications and/or criteria as specified in Local Coverage Determinations (LCDs), National Coverage Determinations (NCDs), or coverage article for service(s) billed, if applicable|
|Advance Beneficiary Notice of Noncoverage (ABN), if applicable|
|Completed Noridian Part B Signature Attestation Statement [PDF] or Signature Log for illegible signature, if applicable|
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.
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 Mental Health webpage for additional information and resources.
See also the Psychotherapeutic Services and Documentation Requirements webpage.
Last Updated Feb 08, 2019
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.