WPS Medicare Provider MAC Information - Medicare Areas - MR - Part A

Documentation Guidelines Full Listing - Part A

Note: Documentation should be submitted to our office no later than 30 days from the date of the request. If a response to our documentation request is not received within 45 days of the date of the request, the claim will be denied. Please be sure to attach either the hardcopy request letter or a remote cover sheet to the top of each set of medical records to expedite handling.

Ambulance (Air or Ground)

Physician written order for transport (if non-emergency physician ordered)
Trip record to include:
Detailed statement of the condition necessitating the ambulance
Point of origin (identify place and complete address)
Detailed documentation of condition during transfer
Point of destination (name of facility, complete address)
Number of loaded miles/cost per mile/mileage charge
Minimal or base charge and charge for special items or services with an explanation
Statement if patient was admitted as an inpatient
Certification and rationale of necessity for non-emergent transfers
Certification of bed confinement if applicable

Any further documentation that supports medical necessity of air and/or ground ambulance transport (i.e. emergency room report)

Blood Glucose

Results of each blood glucose/Accucheck billed
Physician notification of each blood glucose result
Documentation that the physician utilized these results to modify the plan of care
History and physical
Physician orders and progress notes
Nurses notes
Detailed itemization of charges

Cardiac Rehabilitation

Physician order(s)
Diagnosis from physician with date of onset and documentation to support this diagnosis
Physician progress notes
Start of care date
Most recent history and physical
Initial evaluation for cardiac rehabilitation services
Electrocardiogram (EKG) strips for each session
Number of sessions to date
Documentation reflecting that service is Phase II
Individual session notes for each day of service provided
Documentation supporting diagnosis billed

Cardiac Stress Tests

History and Physical
Physician order(s)
Documentation of physician involvement
Documentation to support all services/treatments were provided as billed
Reason (diagnosis or signs and symptoms) for test
Documentation of medication administration, including any contrast material given
A detailed itemization for all services billed
Test results
Copy of radiological report if available
Copy of physician's interpretation of cardiac stress test

Cataract Surgery

Preoperative history and physical
Operative report of surgery
Statement of degree of functional impairment
Documentation listing symptomatology
Documentation indicating preoperative correctable acuity test

Chest X-Ray

Physician order(s)
Signs and symptoms (rationale for radiology test performed)
Medical diagnosis
Copy of radiology test performed
Emergency room records or clinic records to support medical necessity (if applicable)

Note: Pre-operative chest x-ray should have documentation that supports the patient has a medical condition, which may pose a risk factor with the administration of general anesthesia.

Demand Bills - Skilled Nursing Facility (SNF)

SNF ABN (Formerly known as: Notice of Non-Coverage): The notice reflects the reason for denial. It is signed and dated by the beneficiary or authorized representative. **If the notice is not signed and dated, please include documentation indicating the date and method of notification that was used. This may include, but is not limited to; telephone notification followed by a certified letter and/or social services notes that document the date and method of notification. [Medicare Claims Processing Manual, Pub. 100-4, Chapter 30, Section 70]
Name and telephone number of a SNF contact person
Completed MDS documentation relating to dates of service billed
Completed MDS documentation just prior to the SNF ABN or Notice of Non-Coverage (if available)
Documentation to support the reason that services were denied for Medicare coverage - Please include:
Hospital and/or admission history and physical
Hospital discharge summary
Physician orders
Physician progress notes
Therapy progress notes
Treatment logs to identify therapy minutes provided
Nursing notes and admission assessment
Medication and IV administration records
Treatment administration records
Skin/wound documentation
All other documentation supporting the determination of non-coverage of services

Please refer to the Medicare Program Integrity Manual Pub100-8, Chapter 6, Section 6.1.3 http://www.cms.hhs.gov/manuals/downloads/pim83c06.pdf

Dental Surgery

Physician order(s)
Diagnosis (rationale for surgery)
History and physical
Operative report
Nurse's notes
Medication administration record
Radiology Report (if applicable)
All documentation for date(s) of service

Electrocardiogram (EKG)

Physician order(s)
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

Emergency Room/Cardiac Arrest

Itemization of 250 & 270 revenue code charges to include:
Number of units billed for each item
Dollar amount of each item
Identification of each item
Revenue code billed under
Documentation of ER time billed under 450 revenue code
Physician report/orders
Progress notes of interventions performed and reflecting utilization of items billed
Medication sheet/code sheet showing medications billed and administered
Emergency room record

Hemodialysis and Peritoneal Dialysis (End Stage Renal Disease)

Extra lab tests (not included in or over amount allowed in composite):
Physician order(s)
Signs and symptoms
Prior lab values indicating the need for additional testing
Extra treatments (over amount allowed in composite):
Documented signs and symptoms of fluid overload (mental status changes, shortness of breath, etc.)
Pre and post dialysis weights in kilograms
Physician order(s)
X-rays and EKG's (over amount allowed in composite):
Signs and symptoms or rationale for x-ray/EKG
Physician order(s)
Drugs (not included in or over amount allowed in composite):
Physician order(s)
Itemization of pharmacy charges billed to include:
  – Number of doses of each medication administered
  – Dollar amount of each medication
  – Identification of each medication
  – Revenue code billed under
Documentation showing amount/dosage administered
Laboratory test results supporting medical necessity of the drug
Signs and symptoms
Hepatitis B immunizations: send anti-hepatitis B core and anti-hepatitis B surface tests results

Hyperbaric Oxygen (HBO)

Physician progress notes that describe the physical findings, type(s) of treatment(s) provided, number of treatments provided, the effect of treatment(s) received, and the assessment of the level of progress made toward achieving the completion of established therapy goals;
For treatment of soft tissue radionecrosis- documentation of a history of radiation therapy including date and anatomical site of radiation treatments
Documentation supporting date of skin graft and compromised state of graft site;
An initial assessment which includes:
History and physical
Prior medical, surgical &/or previous HBO
Prior antibiotic therapy and surgical interventions
Any adjunctive treatment currently being rendered;
Procedure (logs) including ascent time, descent time, and pressurization level
Lab reports (culture or gram stains) confirm the diagnosis of necrotizing fasciitis
Any Physician to physician communications
X-Ray findings and/or bone cultures confirming the diagnosis of osteomyelitis
Previously unsuccessful antibiotic treatment (if applicable)
Lab and/or x-ray reports to support the presence of gas gangrene
HBO treatment record showing wound progress
Documentation of direct physician supervision

Inpatient Psychiatric Facility Services (IPF)

Certification/Recertification
Initial psychiatric evaluation to include:
Chief complaint;
Description of acute illness or exacerbation of chronic illness requiring admission;
Current medial history, including medications and evidence of failure at or inability to benefit from a less intensive, outpatient program;
Past psychiatric and medical history;
History of substance abuse;
Family, vocational and social history;
Mental status examination, including general appearance and behavior, orientation, affect, motor activity, thought content, long and short term memory, estimate of intelligence, capacity for self harm and harm to others, insight, judgement, capacity for activities or daily living (ADL's)
Physician order(s)
Plan of treatment
Progress notes
Physician progress notes
Discharge plan

Inpatient Rehab Facility Prospective Payment System (IRF PPS)

Pre-Admission Assessment
Acute Care Documentation
Acute care discharge summaries
Physician discharge summary as well as discharge summaries for any and all disciplines
IRF-Patient Assessment Instrument (PAI)
Physician documentation to include:
Admission history and physical including pertinent information from prior acute stay
Physician admit and discharge summaries
Physician orders
Physician progress notes
Therapy documentation to include:
Initial therapy assessment
Therapy reassessments
Documentation of actual therapy minutes provided
Therapy summaries
Any therapy grids
Copies of therapy notes and/or discharge summaries from any previous outpatient therapy or any therapy in another less intensive setting
Team conference notes and/or careplans
Team conference notes must contain dated participants signatures and professional designations
Nursing documentation to include:
Any nurses notes and narratives
Any nursing treatment sheets
Discharge summaries for any and all disciplines

Lab

Physician order(s)
Medical diagnosis
Signs and symptoms (rationale for lab performed)
Lab results for date of service billed
Itemization of each lab item billed to include:
How many labs drawn
Dollar amount of each lab
HCPC code for each lab
Revenue code billed under

Medical /Surgical Supplies

Physician order(s) and Progress Notes
Detailed itemization which specifically identifies all supplies billed under 27X (Medical Surgical Supplies) and/or 62X (Medical Surgical Supplies-Extension of 27X) revenue code(s):
Itemization of each supply billed to include:
  –Identification of each item
  –Number of supplies utilized
  –Dollar amount of each item
  –Revenue code billed under
Documentation that supports that each procedure(s) and/or service(s) was provided as billed which may include Medication and/or Treatment Administration Records
Diagnosis with date of onset
History and physical
Progress notes detailing service provided for each date of service billed
Operative/Procedure/Progress Notes detailing debridement services and/or Wound Care relevant to the dates of service billed
Wound Care records including measurements, if applicable

Non-End Stage Renal Disease (ESRD) EPO

Physician order(s)
Current history and physical indicating diagnosis for EPO usage
Progress notes describing and supporting the indications for initiation and subsequent use of EPO
Laboratory results (hemoglobin or hematocrit test results done for at least three months prior to the billing period, as well as any other available results)
Medication administration records

Observation

Nurse's notes including clock time admitted to observation
Physician order(s) including admission to observation and clock time of discharge orders
Physician progress notes
History and physical
Diagnosis
Signs and symptoms that warrant observation services
Medication administration records
Diagnostic tests and results
Supporting documentation of all services billed

Observation Service > 48 Hours

Nurse's notes including clock time of admission to observation bed
Physician order(s) including admission to observation and clock time of discharge
Physician progress notes
History and physical
Diagnosis
Signs and symptoms for observation status
Medication administration records
Diagnostic tests and results
Rationale for observation over 48 hours
Supporting documentation of all services billed

Open Biopsy

Physician order(s)
History and physical
Diagnosis
Operative Report
Procedure code for biopsy
Pathology report

Pharmacy

Physician order(s)
Diagnosis
Signs and symptoms
Physician progress notes
Medication log reflecting administration
Itemization of each pharmacy item billed to include:
Number of doses of each medication administered
Dollar amount of each medication
Identification of medication
Revenue code billed under

Psychiatric Services

Physician order(s)
Physician certification/re-certification
Current individualized, multidisciplinary treatment plan to include weekly or monthly treatment summaries that update/revise the plan
Psychiatric history/assessment by a physician
All progress notes
Diagnosis with date of onset
Medical history and physical
Psychosocial evaluation/assessments and all other assessments or consultations
All daily individual and group notes for dates of service
All electroconvulsive therapy (ECT) records (if service provided)

Note: Hospital Partial Hospitalization Program claims must be submitted with a condition code 41 to reflect PHP. If condition code 41 is not present, the claim is considered outpatient services.

Pulmonary Services

Physician order(s)
Pulmonary Rehab orders need to specify which therapies are ordered, such as PT, OT, and RT
Diagnosis with date of onset
Start of care date
Signs and Symptoms
Physicians History and physical
Prior level of function
Current level of function
Psychosocial status
Progress notes detailing service provided for each date of service billed
Short and long term goals for all therapy regimens
Treatment plans for all therapy regimens
Pulmonary function tests results (PFT's)
Number of sessions to date
All treatment session notes, which include date, time, procedure or modality and signature with clinician's credentials.

Questionable Covered Procedure

(Reproductive Services, Blepharoplasty, Breast Reconstruction, Bariatric Surgery, Transplant Services, etc.)

Physician order(s)
Diagnosis (rationale for surgery)
History and physical
Operative report
Nurse's notes
Medication administration record
All documentation for date(s) of service
Visual Fields to support any Blepharoplasty performed
Actual photograph(s) (if applicable)
Amount of tissue removed from each breast for breast reduction surgery
Body Mass index > or = to 35 to support any bariatric surgery

Radiation Therapy

A detailed itemization and supporting documentation for all services billed
Documentation of history of illness being treated
Documentation of physician involvement
Physician order(s) for treatment including current dosage
Documentation to support all services billed were provided
Dosimetry reports
Physicist reports
Simulation reports
Oncology reports
Documentation of each treatment billed
Copy of radiological report or physician's interpretation
Documentation of any contrast material provided

Radiology Services (X-ray, CT Scan, MRI and Ultrasound)

Physician order(s)
Signs and Symptoms (rationale for radiology test performed)
Medical diagnosis
Copy of radiology test performed with physician interpretation of the results
Detailed itemization to support revenue code 25X, 27X and/or 62X for the date(s) of service billed in cases which contrast medication material is utilized and/or supplies are used along with radiological examinations
Documentation of any contrast material provided

Recovery Room

History and Physical
Physician pre-operative notes including diagnosis and orders
Operative records
Anesthesia records
Post operative care records (nursing records and physician notes)
Patient's time in and out of recovery room
Disposition of patient (discharged, sent to observation, or inpatient care)

NOTE: Ambulatory Surgical Recovery Room services will not be covered for excluded services such as dental and cosmetic surgery. If these services are needed for complications of dental or cosmetic procedures, then they may be covered.

Respiratory Services

Physician order(s)
Diagnosis with date of onset
History and physical
Signs and symptoms
Progress notes detailing service provided for each date of service billed

Rural Health Clinic

Identification and social data, evidence of consent forms, pertinent medical history, assessment of the health status and health care needs of the patient and a brief summary of the episode, disposition, and instructions to the patient
Reports of physical examinations, diagnostic and laboratory test results, and consultative findings
All physician's or midlevel providers (MLP) (PA, NP, CNM) orders, reports of treatments and medications, and other pertinent information necessary to monitor the patient's progress
Signatures of the physician or other health care professional such as the MLP's
Documentation requiring the patient met the definition of the evaluation and management (E & M) code used

Skilled Nursing Facility Prospective Payment System (PPS)

Documentation to support the dates of service billed
Hospital Documentation to include:
Hospital discharge summaries
Transfer forms
Medication administration records
Documentation to support each of the HIPPS code(s) billed, including notes related to each of the assessment reference date(s) (ARD)
Minimum Data Set (MDS) Documentation to include:
A hardcopy version of each MDS related to the billing period being reviewed
Documentation to support each of the look back periods requested and documentation to support each of the look back periods which may fall outside of the billing period (The lookback or observation period is the 7, 14 or 30-day period prior to and ending on the ARD date)
Physician Documentation to include:
Physician Certifications and Re-certifications for skilled care
– Including physician signature and date
– Re-certifications must include the need for continued skilled care
Physician orders, including admission orders
Physician progress notes
Physician History and Physical
Nursing Documentation to include:
Nursing notes and admission assessment
Patient care plans
Vital sign records
Medication & IV administration records
Any nursing treatment sheets such as:
– Skin care/wound care treatment sheets
– Respiratory treatments and O2 therapy records
Rehabilitation Documentation to include:
Initial therapy evaluations and re-evaluations:
– Objective and measurable prior level of function and current level of function to support functional decline
Rehabilitation therapy notes including progress notes
Treatment records, grids or logs
Actual therapy minutes provided
All other documentation supporting the beneficiaries need for and delivery of the skilled services being provided in the SNF

SPECT Scan (Single Photon Emission Computed Tomography)

Physician order
Diagnosis with date of onset
Signs and/or symptoms to support medical necessity
History and Physical
Copy of SPECT scan performed
Documentation of any contrast material provided
Documentation to support any first line tests performed prior to SPECT scan
Documentation to support the medical necessity of using SPECT as a first line study

Therapies (Physical, Occupational and Speech)

700/701 Evaluation forms or in-house equivalent to include:
Physician order(s)
Signed and dated certification by physician
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
Actual minutes provided to support each timed service/HCPCS provided

Note: When submitting records for interim claims for continuous patients, please include the initial evaluation. If a summary of the progress from the previous billing period is available, it is helpful to include that information also.

Wound Care

Physician order(s) for physical therapy (PT)/wound care services
Initial evaluation of PT/wound care services
Wound characteristics such as diameter, depth, color, presence of exudates or necrotic tissue
Previous wound care services administered to include date and modalities of treatment
Plan of treatment for PT/wound care services
Weekly progress notes to include current wound status, measurements (including size and depth), and the treatment provided
Description of instrument used for selective or sharp debridement (i.e. forceps, scalpel, scissors, tweezers, high-pressure water jet, etc.)
Treatment grid/log reflecting PT HCPCS billed
Certification/recertification for PT/wound care services
Detailed itemization for any 27X (Supplies) or 62X (Supplies) charges
Actual minutes provided to support each timed service/HCPCS provided

Note: If patient is continued from one billing period to another, include initial evaluation and progress notes/summary of wound progress prior to the service dates billed

Long Term Acute Care Hospital (LTCH) Documentation Request

Short Term Acute Care Hospital (STCH) Documentation Request

Page Last Updated: Wednesday, 31-Dec-2008 10:48:52 CST