Surgery and Procedure Services Documentation Requirements - JF Part B
Surgery and Procedure Services 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 | 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 | |
| Operative/procedure report | |
| Documentation of the devices, implants, biological products used | |
| Anesthesia records (including pre- and post-anesthesia). | |
| History and Physical reports (include medical history and current list of medications) | |
| Vital sign records, weight sheets, care plans, treatment records | |
| Preoperative evaluations including anesthesia evaluation | |
| Pictures where necessary | |
| Medical record documentation that describes and supports other treatment(s)/medication(s) was tried and failed or was considered and ruled out | |
| Diagnostic other/tests and results | |
| Medical clearance | |
| 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 | |
| Signature and credentials of all personnel providing services. Include a signature log or signature attestation for any missing or illegible signatures within the medical record | |
| 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) |
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.
- Noridian Medical Review - Automated Development System (ADS) Letter
- Comprehensive Error Rate Testing (CERT) - CID Request
- Level One Appeal - Redetermination Request
View the webpages for additional information and resources.
Last Updated Wed, 28 Sep 2022 17:47:30 +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.