Documentation Requirements for Appeals

As part of their participation agreement, providers are required to submit all medical documentation to support the services billed on their claim. Providers must submit a complete medical record when requesting an appeal. The following alphabetical listing identifies the types of services that a provider may appeal. Click on the type of service for a comprehensive list of medical records that should accompany the appeal request for that type of service.

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

Advance Beneficiary Notice(s) (ABNs) (if issued)—the written notice given to the beneficiary from the provider of services when the provider believes that Medicare will not pay for the services on the basis that the services are not reasonable or necessary)

Ambulatory surgery, operating room, lithotripsy, anesthesia, recovery room, 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
• Visual fields and pictures for eye surgeries
• Pathology report for breast reduction
• Itemized bill)

Audiology

• Physician’s order/referral for audiology services
• Physician’s history and physical (including patient history, diagnosis, and date of onset of hearing problems)
• Physician’s consultation report related to hearing problems
• All records related to services rendered
• Diagnostic reports related to hearing problems)

Blood glucose monitoring

• Physicians’ order
• Blood glucose results
• Documentation physician was notified of results
• Documentation of follow up action related to abnormal results
• Nurses’ notes
• Physician progress notes
• ABN(s) if issued—the written notice given to the beneficiary from the provider of services when the provider believes that Medicare will not pay for the services on the basis that the services are not reasonable or necessary
• Itemized bill

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 re-evaluation
• Plan of care
• Session notes for each session billed
• ABN(s) if issued—the written notice given to the beneficiary from the provider of services when the provider believes that Medicare will not pay for the services on the basis that the services are not reasonable or necessary
• Itemized bill

Clerical error and omission reopening request

• Submit Clerical Error/Omission Reopening Request Form
• A note/remark indicating what is to be corrected
• A copy of the corrected UB-92
• Documentation to support the new diagnosis (refer to specific service under Documentation Requirement for Appeals by type of service)
• Documentation to support that the denied service was rendered
• Itemized bill

Clinic and therapeutic services

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

Covered screenings

• Physician order
• Procedure report
• ABN(s) if issued—the written notice given to the beneficiary from the provider of services when the provider believes that Medicare will not pay for the services on the basis that the services are not reasonable or necessary
• Itemized bill

Computer tomography (CT) and magnetic resonance imaging (MRI)

• Physician order
• Procedure notes
• Procedure report
• Physician notes
• ABN(s) if issued—the written notice given to the beneficiary from the provider of services when the provider believes that Medicare will not pay for the services on the basis that the services are not reasonable or necessary
• Itemized bill

Demand bill

• Physician’s orders
• Physician’s history and physical
• All medical records pertaining to the services billed
• ABN(s) if issued—the written notice given to the beneficiary from the provider of services when the provider believes that Medicare will not pay for the services on the basis that the services are not reasonable or necessary

Dental

• Physician order
• Physician procedure notes
• Physician progress notes
• Itemized billing

Diagnostic studies

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

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 pt is on IPD/CAPD/CCPD
• Lab reports and medical justification including hematocrit and hemoglobin
• Medical justification for all services billed
• Medication administration notes/records
• ABN(s) if issued—the written notice given to the beneficiary from the provider of services when the provider believes that Medicare will not pay for the services on the basis that the services are not reasonable or necessary
• Itemized bill

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(s) if issued—the written notice given to the beneficiary from the provider of services when the provider believes that Medicare will not pay for the services on the basis that the services are not reasonable or necessary
• Itemized bill

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

EPO/end-stage renal disease (ESRD) pharmacy

• Physician’s history and physical;
• Physician’s orders (include standing orders);
• Medication administration records
• Treatment records/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 hematocrit (HCT) is above 33
• Hemoglobin and/or HCT levels for the time period in question
• ABN(s) if issued—The written notice given to the beneficiary from the provider of services when the provider believes that Medicare will not pay for the services on the basis that the services are not reasonable or necessary
• Itemized bill

EPO/non-ESRD 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(s) if issued—the written notice given to the beneficiary from the provider of services when the provider believes that Medicare will not pay for the services on the basis that the services are not reasonable or necessary
• Itemized bill

Gastrointestinal services

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

Hyperbaric oxygen (HBO) 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 local coverage determinations (LCD)
• All documentation pertaining to skin grafting if applicable

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, re-evaluations, 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

Hospice

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

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 re-evaluations, plan of treatment, progress notes, attendance records for physical therapy, occupational therapy, and/or speech therapy if applicable.
• Documentation of diagnosis related group (DRG)
• Nurses’ notes
• Medication administration records
• Social service notes
• Therapy evaluations/re-evaluations and plan of care
• Documentation that patient requested a private room if applicable
• ABN(s) if issued—the written notice given to the beneficiary from the provider of services when the provider believes that Medicare will not pay for the services on the basis that the services are not reasonable or necessary
• Itemized bill

Inpatient procedure (W7018 OCE edit)

• 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 Healthcare Common Procedure Coding System (HCPCS) along with all medical records, which support and correspond with this correction

Inpatient rehabilitation facility (IRF)

• Physician’s orders, history, and physical/discharge summary and progress notes for both the acute inpatient hospitalization and the IRF stay
• Therapy assessments, treatment records, and daily progress notes
• Nursing assessments, care plans, notes, and flow sheets
• Medication records and laboratory results
• IRF—patient assessment instrument (IRF-PAI)
• Social service/master of social work (MSW) records, if any

Intraveneous (IV) therapy

• Physician’s orders
• Current progress notes
• Intravenous administration record