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Documentation Tips
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Medical record documentation must:
- Support the services billed according to Medicare guidelines,
- Support the medical necessity of the services, and
- Be legible for the contractor to complete a fair review
In cases where the provider signature is illegible, the provider should send a signature log or attestation statement. If the documentation is missing a provider signature, the provider must include an attestation statement with the submitted documentation.
Please note, it is the billing provider's responsibility to obtain additional supporting documentation from a third party (hospital, nursing home, etc.), as necessary. Do not refer a Medicare contractor to a third party to obtain these records.
Below are documentation tips for services commonly billed to Medicare. Please be aware that this list is not all-inclusive.
Allergy Services Documentation
Allergy Testing Documentation
- Clear indication of patient name, date of birth, and date of service
- Documentation supporting the medical necessity and diagnosis codes billed
- Prior to performance of allergy testing, evidence in the patient's record that the provider obtained a history, indicating the possible presence of allergy. The history should attempt to narrow the area of investigation so that the minimal number of necessary skin tests might deliver a diagnosis.
Allergy Immunotherapy Documentation
- Clear indication of patient name, date of birth, and date of service
- Medical history, examination, and results of diagnostic testing (including allergy testing) upon which the provider-based need for the treatment
- A plan of treatment and dosage regimen
- When billing an evaluation and management service on the same day as allergen immunotherapy (by the same physician), document the separately identifiable service
- Documentation must support the use of the code (e.g., number of venoms, number of vials)
- Evaluation and management codes are separately reimbursable on the same day as allergen immunotherapy only when performed as a significant, separately identifiable service
Ambulance (Air or Ground) Documentation
For a full list, see Ambulance Documentation Requirements.
Anesthesia Services Documentation
- Clear indication of patient name, date of birth, and date of service
- Documentation supporting diagnosis billed
- Pre anesthetic exam and evaluation
- Intra operative report with documentation of anesthesia time
- Operative report
- Post-anesthesia report
Assistant at Surgery Services Documentation
Surgeons document assistant at surgery services in the operative report. The assistant at surgery does not need to sign the operative report. The operative report shows the additional skilled services required based on the patient’s medical needs and provided by the assistant at surgery. The operative report documentation must also show the medical necessity for the assistant at surgery services billed to Medicare and the patient.
For more information, see Assistant at Surgery Services Documentation Requirements.
Cardiovascular Stress Tests Documentation
- Clear indication of patient name, date of birth, and date of service
- Signed physician order or signed progress note supporting intent for the service
- Test results
- Copy of radiological report if available
- Interpretation of physician’s cardiac stress test
- History and Physical
- Documentation of physician involvement
- Provide documentation to support all services/treatments as billed
- Reason (diagnosis or signs and symptoms) for test
- For pharmacologic stress testing
- The patient's record must document and clearly indicate:
- The patient is unable to exercise
- The reason(s) why the patient cannot undergo exercise stress testing
- Documentation of medication administration, including any contrast material given
- The patient's record must document and clearly indicate:
Cataract Surgery Documentation
- Operative report signed by the surgeon with informed consent.
- Documentation should show:
- The patient is having symptoms such as blurred vision and visual distortion
- Symptoms are affecting the patient’s lifestyle
- Glasses do not provide enough relief
- The patient has a diagnosis of cataracts, and surgery will improve the patient’s condition.
- Pre-op diagnostic testing reports and progress note supporting the medical necessity
Changing Patient’s Status from Inpatient to Outpatient Documentation
- If a patient’s status changes from inpatient to outpatient based on utilization review, the outpatient claim will include condition code 44. Documentation must show:
- Orders and notes indicating why the facility is changing the patient status
- Medical reason for care furnished to the beneficiary
- Names of participants involved in decision making change to the patient’s status
- Information on the use of condition code 44 is available in the CMS Internet-Only Manual (IOM) Publication 100-04, Chapter 1 , Section 50.3
Chemotherapy and Other Drug Administration Documentation
- Clear indication of patient name, date of birth, and date of service
- Name and dosage of drug administered
- Infusion stop times and length of infusion time to determine correct administration code
- Signed and dated physician order for drug(s) administered, dosage, frequency, and treatment duration
- Progress notes to support medical necessity of the treatment
- If performed to facilitate the chemotherapy infusion or injection, the following services are included in the chemotherapy administration and are not separately billable:
- Use of local anesthesia;
- IV access;
- Access to indwelling IV, subcutaneous catheter or port;
- Flush at conclusion of infusion;
- Standard tubing, syringes, and supplies; and
- Preparation of chemotherapy agent(s).
- If the provider performs a significant separately identifiable evaluation and management (E/M) service, the provider should report an appropriate E/M code using modifier 25 in addition to the chemotherapy code.
- Medicare does not require a different diagnosis for an E/M service provided on the same day.
- Documentation to support frequent monitoring for the patient receiving chemotherapy or other highly complex biologic agent
Chiropractic Manipulation Documentation
The history recorded in the patient record should include the following:
- Family history if relevant
- Past health history (general health, prior illness, injuries, or hospitalizations; medications; surgical history)
- Mechanism of trauma
- Quality and character of symptoms/problem
- Onset, duration, intensity, frequency, location, and radiation of symptoms
- Aggravating or relieving factors
- Prior interventions, treatments, medications, secondary complaints
Chiropractic Manipulation Initial Visit Documentation
- Clear indication of patient name, date of birth, and date of service
- History as stated above
- Description of the present illness including:
- Mechanism of trauma
- Quality and character of symptoms/problem
- Onset, duration, intensity, frequency, location, and radiation of symptoms
- Aggravating or relieving factors
- Prior interventions, treatments, medications, secondary complaints
- Symptoms causing patient to seek treatment
- Evaluation of musculoskeletal/nervous system through physical examination
- Diagnosis: The primary diagnosis must be subluxation, including the precise level of subluxation
- Either so stated or identified by a term descriptive of subluxation
- Such terms may refer either to the spinal joint condition involved or the position direction assumed by the particular bone named
- Either so stated or identified by a term descriptive of subluxation
- Treatment Plan: The treatment plan should include the following:
- Recommended level of care (duration and frequency of visits)
- Specific treatment goals
- Objective measures to evaluate treatment effectiveness
- Date of the initial treatment
Chiropractic Manipulation Subsequent Visit Documentation
- Clear indication of patient name, date of birth, and date of service
- Review of chief complaint
- Changes since last visit
- System review if relevant
- Physical exam
- Exam of area of spine involved in diagnosis
- Assessment of change in patient condition since last visit
- Evaluation of treatment effectiveness.
- Legible documentation of treatment given on day of visit
- Upon request, notes for all dates of service six months prior to date billed
Electrocardiogram (EKG) Documentation
- Clear indication of patient name, date of birth, and date of service
- Signed physician order or signed progress note supporting intent for the service
- History and physical
- Medical diagnosis
- Signs and symptoms (rationale for EKG diagnosis)
- Copy of EKG report or physician's interpretation
- Documentation of any prior and current assessments
- Documentation to support the medical necessity for the EKG
Evaluation and Management (E/M) Services Documentation
Documentation must support the level of service billed and the medical necessity for the level billed. Below are additional tips for services which commonly incur CERT error findings for insufficient documentation.
Critical Care Visits Documentation
- Clear indication of patient name, date of birth, and date of service
- Signed progress note which includes documentation of the total time the physician spent evaluating, providing care, and managing the critically ill or injured patient's care
- Documentation to support the service provided was medically necessary and meets the critical care definition as:
- The direct delivery by a physician(s) medical care for a critically ill or critically injured patient.
- A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening change in the patient's condition.
- Reminder: The billing provider is responsible for providing medical records upon request
Established patient office visit - CPT 99211 Documentation
- Clear indication of patient name, date of birth, and date of service
- Documentation that the service is medically necessary for the diagnosis and treatment of an illness or injury
- If billed in addition to blood draws, lab services, etc., documentation must show that a separately identifiable face-to-face E/M service took place
- Medicare requires a face-to-face encounter with a patient consisting of elements of both evaluation and management
- The evaluation portion is substantiated when the record includes documentation of a clinically relevant and necessary exchange of information between provider and patient
- The management portion is substantiated when the record demonstrates an influence on patient care (ex.; medical decision making, patient education, etc.).
Hospital Discharge Day Management Documentation
- Clear indication of patient name, date of birth, and date of service
- Signed progress note which includes documentation of required face-to-face encounter with the patient
- As applicable; note should also include documentation of:
- Patient’s final examination
- Discussion of hospital stay
- Instructions to caregivers, and
- Preparation of discharges records, prescriptions, and referral forms
- Documentation of time spent providing services - imperative if billing for more than 30 minutes (CPT code 99239)
- Reminder: The billing provider is responsible for providing medical records upon request
Skilled Nursing Facility Care Documentation
- Clear indication of patient name, date of birth, and date of service
- Signed and legible physician progress note that documents a face-to-face encounter with the patient occurred
- Documentation that supports the specific level of E/M visit billed
- Signed and dated physician orders if applicable
- Reminder: The billing provider is responsible for providing medical records upon request
Subsequent Hospital Visits Documentation
- Clear indication of patient name, date of birth, and date of service
- Signed and legible physician progress notes for all dates billed
- Physician progress note must document a face-to-face encounter with the patient took place
- Documentation must support level of evaluation and management service billed
- Signed physician orders as applicable
- Reminder: The billing provider is responsible for providing medical records upon request
Foot Care Documentation
- Clear indication of patient name, date of birth, and date of service
- The provider should use the following class finding modifiers with G0127, 11055, 11056, 11057, 11719, 11720, 11721, when applicable:
- A Class A finding (Modifier Q7)
- Two of the Class B findings (Modifier Q8); or
- One Class B and two Class C findings (Modifier Q9).
- Documentation to support the medical necessity for services as indicated within the "Indications and Limitations of Coverage" section of the Policy
- Documentation includes relevant medical history, physical examination, and results of pertinent diagnostic tests or procedures
- The provider must maintain documents supporting medical necessity, such as:
- Physical and/or clinical findings consistent with a diagnosis involving a severe peripheral condition in the patient record
- Physical findings and services must be precise and specific (e.g., left great toe, or right foot, 4th digit.)
- The provider must maintain documentation of co-existing systemic illness
- Adequate medical documentation to demonstrate the need for routine foot care services.
- This documentation may be:
- Office records
- Physician notes or
- Diagnoses characterizing the patient's physical status as being of such severity to meet the criteria for exceptions to the Medicare routine foot care exclusion.
- This documentation may be:
Injections Documentation
- Clear indication of patient name, date of birth, and date of service
- Name of drug injected
- Dosage of injection given
- Route of administration
- Signed and dated physician order to include the drug name, dosage, route of administration and duration of treatment
- Progress notes to support the medical necessity of treatment
- Reminder: Documents required for previous conservative therapies that failed for certain injection procedures (i.e., epidural steroid injections)
Laboratory Services Documentation
- Clear indication of patient name, date of birth, and date of service
- Lab results for date(s) of service billed
- Signed and dated physician order or progress/clinic/visit notes that clearly document the specific service(s) to be performed
- Documentation to support the medical necessity of ordered test(s)
- Medical diagnosis
- Signs and symptoms (rationale for lab performed)
- If the provider bills for travel allowance for specimen collection:
- Number of collections performed per trip (for Medicare patients) to compute the Medicare prorated fee
- Documentation of miles travelled
- Documentation supporting that patient is homebound or nursing home bound
Psychiatric Services Documentation
- Clear indication of patient name, date of birth, and date of service
- Legible and signed daily individual or group notes for dates of service requested
- Documentation for timed codes must indicate the time spent in the psychotherapy encounter
- Physician certification/re-certification
- Current individualized, multidisciplinary treatment plan to include weekly or monthly treatment summaries that update/revise the plan
- Documentation of target symptoms; goals of therapy and methods of monitoring outcomes; and why the chosen therapy is the appropriate treatment modality
- Documentation to support medical necessity which includes relevant medical history, physical examination, results of pertinent diagnostic tests or procedures
- Psychiatric history/assessment by a physician
- Diagnosis with date of onset
- Psychosocial evaluation/assessments and all other assessments or consultations
- Medicare will only reimburse for psychotherapy sessions lasting longer than 90 minutes if the report is supported by the medical record documenting the face-to-face time spent with the patient and the medical necessity for the extended time
Radiation/Oncology Services Documentation
- Clear indication of patient name, date of birth, and date of service
- Supporting documentation for all services billed
- Documentation of history of illness being treated
- Level of clinical management involved
- Signed physician order(s) for treatment including current dosage and planned course of therapy
- Type and delivery of treatment
- Dosimetry reports
- Physicist reports
- Simulation reports
- Oncology reports
- Documentation of each treatment billed
- Ongoing documentation of any changes in course of treatment
- Copy of radiological report or physician's interpretation
- Documentation of any contrast material provided
- The provider must maintain a patient referral with diagnostic information and request for consultation for radiation oncology in the patient's record for treatment devices, designs, and construction (CPT codes 77332-77334)
- Medicare may allow additional sets only when documentation explains why new or additional devices are necessary (e.g., lesion size changes, patient is repositioned, different volume of interest is treated, etc.)
Radiology Services Documentation
- Clear indication of patient name, date of birth, and date of service
- Signed and dated physician order or progress/clinic/visit notes that clearly document the specific service(s) to be performed
- Signs and symptoms (rationale for radiology test performed)
- Medical diagnosis
- Signed copy of physician interpretation of the results
- Documentation of any contrast material provided and the administration route for contrast material (e.g., orally, IV, IA, IJ, or intrathecal)
- Note: When administering general anesthesia, the pre-operative chest x-ray should include documents that supports the patient’s medical condition which may pose a risk factor
Therapies (Physical, Occupational and Speech) Documentation
- Clear indication of patient name, date of birth, and date of service
- Evidence of the need for care and that the patient is under the care of a physician
- Signed and dated certification by physician or signed order which includes a plan of care
- Documents should be legible and signed for all services provided on date(s) of service
- Actual minutes provided to support timed services/HCPCS provided
- Date of evaluation
- Start of care date
- Medical diagnosis
- Treatment diagnosis
- Onset date
- Current level of function
- Prior level of function
- Treatment plan with long- and short-term goals
- Previous therapy administered to include:
- Date
- Diagnosis for treatment
- Modalities administered
- Progress notes detailing service provided for each date of service billed
- Grid reflecting service/HCPCS provided
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LICENSE FOR USE OF CURRENT DENTAL TERMINOLOGY (CDT™)
These materials contain Current Dental Terminology (CDTTM), Copyright © 2010 American Dental Association (ADA). All rights reserved. CDT is a trademark of the ADA.
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- Subject to the terms and conditions contained in this Agreement, you, your employees and agents are authorized to use CDT only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. Use of CDT is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials.
- Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CDT for resale and/or license, transferring copies of CDT to any party not bound by this agreement, creating any modified or derivative work of CDT, or making any commercial use of CDT. License to use CDT for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. Applications are available at the American Dental Association web site, http://www.ADA.org/.
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- CMS DISCLAIMER. The scope of this license is determined by the ADA, the copyright holder. Any questions pertaining to the license or use of the CDT should be addressed to the ADA. End Users do not act for or on behalf of the CMS. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT. CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL COVERED BY THIS LICENSE. IN NO EVENT SHALL CMS BE LIABLE FOR DIRECT, INDIRECT, SPECIAL, INCIDENTAL, OR CONSEQUENTIAL DAMAGES ARISING OUT OF THE USE OF SUCH INFORMATION OR MATERIAL.