What Documents are Needed

Table of Contents

What Documents are Needed
Supporting Medical Records

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What Documents are Needed

You are required to submit all necessary medical documentation to support the services billed on your claim, you must submit a complete medical record when requesting an appeal. If documentation was previously submitted to the Medical Review Department or another contractor, for example the RA, CERT or UPIC, those medical records will be included in the file reviewed by the Appeals department.

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Supporting Medical Records

Below are some of the types of services you may appeal, as well as a list of medical records that may assist in supporting that the services billed are coverable by Medicare.

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Ambulance

Justification for ambulance transport
Itemization for charges—charge for loaded, unloaded
Mileage for each ambulance trip
Ambulance transport report
Reason for transport between health care facilities
Discharge note from transferring facility
Admission note from receiving facility
Physician’s certification of need for ambulance transport in scheduled and unscheduled nonemergency transports
Run sheets
ABN (if issued): The written notice issued to the beneficiary by the provider of services when they believe that Medicare will not pay for the services on the basis that the services are not reasonable or necessary

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Ambulatory Surgery, Operating Room, Lithotripsy and Preadmission Testing

Physician’s history and physical
Physician’s orders
Surgical reports
All records pertaining to services under review
Medical justification for services under review
Evaluations
Physician’s notes
Nurses’ notes
Test results
Anesthesia report
Medication administration records
Pre- and postoperative notes
ABN (if issued): The written notice issued to the beneficiary by the provider of services when they believe that Medicare will not pay for the services on the basis that the services are not reasonable or necessary
Visual fields and pictures for eye surgeries
Pathology report for breast reduction
Itemized bill

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Cardiac Rehabilitation

Cardiac history/physical
Diagnosis for cardiac rehabilitation and date of onset
Initial/third month stress test report and cardiac perfusion studies
Rhythm strips or documentation to support patient monitoring
Physician’s order, progress notes, attendance records
Medical justification for extension of program beyond 12 weeks
Initial evaluation and reevaluation
Plan of care
Session notes for each session billed
ABN (if issued): The written notice issued to the beneficiary by the provider of services when they believe that Medicare will not pay for the services on the basis that the services are not reasonable or necessary
Itemized bill

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Clinic and Therapeutic Services

Clinical notes signed by provider of services (include credentials)
Physician’s history and physical
All records pertaining to services rendered

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Covered Screenings

Physician order
Procedure report
ABN (if issued): The written notice issued to the beneficiary by the provider of services when they believe that Medicare will not pay for the services on the basis that the services are not reasonable or necessary
Itemized bill

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Computer Tomography and Magnetic Resonance Imaging

Physician order
Procedure notes
Procedure report
Physician notes
ABN (if issued): The written notice issued to the beneficiary by the provider of services when they believe that Medicare will not pay for the services on the basis that the services are not reasonable or necessary
Itemized bill

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Demand Bill

Physician’s orders
Physician’s history and physical
All medical records pertaining to the services billed
ABN (if issued): The written notice issued to the beneficiary by the provider of services when they believe that Medicare will not pay for the services on the basis that the services are not reasonable or necessary

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Dental

Physician order
Physician procedure notes
Physician progress notes
Itemized billing

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Diagnostic Studies

Physician’s history and physical
Physician’s orders
Reports of all studies billed
Medical justification to support services

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Dialysis

Physician’s history and physical
Physician’s orders
Progress notes, treatment records, flow sheets
Medical justification for treatments in excess of three times a week
Medical justification for backup treatment when patient is on IPDCAPD/CCPD
Lab reports and medical justification including hematocrit and hemoglobin
Medical justification for all services billed
Medication administration notes/records
ABN (if issued): The written notice issued to the beneficiary by the provider of services when they believe that Medicare will not pay for the services on the basis that the services are not reasonable or necessary
Itemized bill

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Education and Training

Physician’s orders, evaluations, and referrals
Documentation of type of program
Initial and updated treatment plan goals
Attendance records
Program notes and progress to date
Expected achievement date
History and physical
ABN (if issued): The written notice issued to the beneficiary by the provider of services when they believe that Medicare will not pay for the services on the basis that the services are not reasonable or necessary
Itemized bill

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Emergency Room/Emergency Room Records

All records pertaining to services rendered
Reports of all diagnostic studies performed
History and physical
Physician notes
Nurses’ notes
Therapy notes
Evaulations
Reports for all laboratory, x-rays, and procedures billed
Itemized bill

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Erythropoietin/End-Stage Renal Disease Pharmacy

Physician’s history and physical;
Physician’s orders (include standing orders);
Medication administration records
Treatment records/flow sheets
Pertinent lab reports to justify erythropoietin (EPO) or other pharmacy
Diagnosis to justify the drug
Medical justification for doses above 10,000 units per administration
Medical justification for EPO when hematocrit (HCT) is above 33
Hemoglobin and/or HCT levels for the time period in question
ABN (if issued): The written notice issued to the beneficiary by the provider of services when they believe that Medicare will not pay for the services on the basis that the services are not reasonable or necessary
Itemized bill

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Erythropoietin/Non End-Stage Renal Disease Pharmacy

Physician’s history and physical
Physician’s orders (include standing orders)
Medication administration records
Treatment records and flow sheets
Pertinent lab reports to justify EPO or other pharmacy
Diagnosis to justify the drug
Medical justification for doses above 10,000 units per administration
Medical justification for EPO when HCT is above 33
Hemoglobin and/or HCT levels for the time period in question
ABN (if issued): The written notice issued to the beneficiary by the provider of services when they believe that Medicare will not pay for the services on the basis that the services are not reasonable or necessary
Itemized bill

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Gastrointestinal Services

Physician’s orders
Procedure reports
Consultation reports
Medical justification for procedure

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Hyperbaric Oxygen Therapy

Physician’s orders, history, and physical notes
Diagnosis for HBO therapy and all related services—include date of onset of diagnosis
Initial evaluation and re-evaluations
Progress/attendance records for each visit billed
Plan of treatment relative to this claim period
All pertinent radiology and laboratory reports per HBO LCD
All documentation pertaining to skin grafting if applicable

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Home Health

Oasis form for the dates of service in question
Skilled nursing visit notes for previous month and date of service in question
Current plan of care signed and dated by the MD
Any additional MD orders for the date of service in question, signed and dated by the MD
Therapy initial evaluation, reevaluations, and treatment visit notes for previous month and date of service in question, social worker notes as applicable
Home health aide visit notes for date of service in question

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Hospice

Initial certification, dually signed by hospice MDdirector and primary MD supporting terminal diagnosis (six months or less)
Recertifications (if appropriate) for the date of service under review
Notes supporting routine, continuous, general inpatient, or physician services billed

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Inpatient Hospital and Hospital Ancillary

Emergency room records/report
Hospital discharge summary
Physician’s admission history and physical notes
Physician’s orders
Physician’s progress notes
Surgical reports
Diagnostic study reports
Rehabilitation records pertaining to this claim period
Include initial evaluation, all reevaluations, plan of treatment, progress notes, attendance records for physical therapy, occupational therapy, and/or speech therapy if applicable.
Documentation of DRG
Nurses’ notes
Medication administration records
Social service notes
Therapy evaluations/reevaluations and plan of care
Documentation that patient requested a private room if applicable
ABN (if issued): The written notice issued to the beneficiary by the provider of services when they believe that Medicare will not pay for the services on the basis that the services are not reasonable or necessary
Itemized bill

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Inpatient Procedure (W7018 Outpatient Code Editor Edit)

Physician’s orders
Physician’s history and physical
Medical justification to support the services billed
All medical records to support services billed
If the claim processed with a billing error, please submit a hard-copy UB-04 (corrected claim) with the correct HCPCS along with all medical records, which support and correspond with this correction

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Inpatient Rehabilitation Facility

Preadmission screening
Physician’s orders, history, and physical/discharge summary and progress notes for the IRF stay
Individualized plan of care
Therapy assessments, treatment records, and daily progress notes
Nursing assessments, care plans, notes, and flow sheets
Medication records and laboratory results
IRF-PAI
Evidence of an interdisciplinary team approach

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Intraveneous Therapy

Physician’s orders
Current progress notes
Intravenous administration record

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Laboratory and Pathology Services

Physician’s order
Physician’s progress notes/clinic record
Physician’s history and physical
Laboratory/pathology report
Specific ICD-10-CM code
Medical justification to support laboratory service
ABN (if issued): The written notice issued to the beneficiary by the provider of services when they believe that Medicare will not pay for the services on the basis that the services are not reasonable or necessary
Itemized bill

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Mammography

Physician’s history and physical
Physician’s orders (not required for screening)
Mammogram report
Date/report of last mammogram
Medical justification if diagnostic mammogram

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Magnetic Resonance Angiography/Positron Emission Tomography

Physician order
Physician notes
Evaluation
History and physical
Documentation to support the diagnosis supporting medical necessity of the test
Procedure report
ABN (if issued): The written notice issued to the beneficiary by the provider of services when they believe that Medicare will not pay for the services on the basis that the services are not reasonable or necessary
Itemized bill

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Oncology and Therapeutic Radiology

Physician’s history and physical
Physician’s orders
All records pertaining to services rendered

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Pap Smear

Physician’s history and physical
Physician’s orders (not required for screening services)
Pap smear report
Date/report of last pap smear
Medical justification for pap smear

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Pharmacy and Unclassified Drug J3490

Physician’s history and physical
Physician’s orders
Medication administration records
Itemized list of pharmacy charges
If applicable:
- Clear documentation of the unclassified drug billed
- Medical justification for the unclassified drug billed
- Medication administration record
- Notes to show that the supplies were utilized
- Documentation to support diagnosis billed

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Physical, Occupational, Speech, and Respiratory Therapy

Physician’s initial order or referral
Diagnosis for therapy services including date of onset
Initial evaluation and all reevaluations
Plan of treatment pertaining to this claim period
Progress notes and attendance records pertaining to this claim period to support total minutes of actual treatment and number of minutes for each modality
Clinic progress notes
Laboratory, radiology, and any other diagnostic reports pertinent to services billed
ABN (if issued): The written notice issued to the beneficiary by the provider of services when they believe that Medicare will not pay for the services on the basis that the services are not reasonable or necessary
Itemized bill

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Psychiatric Services, Partial Hospitalization Program, and Alcohol/Drug Rehabilitation

Certification/recertification form if billing partial hospitalization program (PHP)
Initial evaluation
Treatment plan (initial/updated)
Physician’s orders and progress notes and clinic notes
Medication administration record and attendance record
Progress notes for group therapy, activity therapy, family therapy, individual therapy, education, MD visits and all other psychiatric services billed
Itemization of pharmacy charges
Laboratory, radiology, and any other diagnostic reports pertinent to services billed
Counseling session start and stop times
Modalities and frequency of treatment rendered
Diagnosis, functional status, symptoms, prognosis, and progress to date

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Pulmonary Rehabilitation

Physician order and referral and recertification every 30 days
Physical examination by referring physician within 90 days of program
Physician evaluation/assessment by facility MDDO or MD/DO overseeing program; initial evaluation and reevaluations
Treatment plan
Daily progress notes and attendance records
Physician signed and dated progress reports
Documentation to support all related services (i.e., pulmonary function tests)
ABN (if issued): The written notice issued to the beneficiary by the provider of services when they believe that Medicare will not pay for the services on the basis that the services are not reasonable or necessary
Itemized bill

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Skilled Nursing Facility

Hospital discharge summary
Hospital transfer referral form
Social service notes
Physician’s admission history and physical notes
Physician’s consultation report
Physician’s orders
Physician’s progress notes
Nurse’s progress notes
Rehabilitation records must include the initial evaluation, all reevaluations, plan of treatment, progress notes, and log/time sheets showing minutes of services rendered for physical, occupational, speech, and/or nursing rehabilitation records
If applicable:
- Medical records for 30 days prior to each MDS assessment reference date applicable to the billing period
- Medical records through the end of the claim period(s) billed to support all services including the observation and look back period(s)
- Medicare remittance advice
- Medication administration notes
- Test results
- ABN (if issued): The written notice issued to the beneficiary by the provider of services when they believe that Medicare will not pay for the services on the basis that the services are not reasonable or necessary
- Itemized bill

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Treatment, Observation, and Cast Rooms

All records pertaining to services billed
Treatment and procedure records
Documentation to support observation room hours if applicable
Medical justification for services billed
Physician order
History and physical
Physician notes
Nurses’ notes
Emergency room notes
Laboratory and procedure reports
Consult reports
Evaluations
ABN (if issued): The written notice issued to the beneficiary by the provider of services when they believe that Medicare will not pay for the services on the basis that the services are not reasonable or necessary
Itemized bill